Friday, December 14, 2012


So I was recently asked about twins and vaginal delivery vs c/section so here goes. Twins can deliver vaginally if they are both head down. Twins are a complicated situation all around though because risk of preterm delivery (approx 50%) and other risks with twins such as monoamniotic and cord transfusion issues, but I won't get into those in this post. As far as delivery goes, if the twins are delivered preterm such as less than 32 weeks, and it is not a first vaginal delivery, it may be reasonable to deliver them breech or allow the head first one to deliver and the second one deliver breech if fetal heart tones on that twin are appropriate and the baby is descending the birth canal well on its own. Generally twins are taken by c/section if they are beyond 34 weeks and not head down though. The reason is because if the head becomes entrapped in the cervix after the rest of the body has delivered, they can become strangulated or end up with broken necks trying to maneuver them out that way. It is safer to just do the c/section. Even if one is head down and delivers vaginally, the other one may stay breech and is still a risk for head entrappment or other cord prolapse and problems in that transition period of waiting for the second twin to drop. Therefore, instead of having to hurry and prep mom for an emergency c/section after delivery through the vagina on the first, a c/section is performed from the beginning to ensure safety of both babies. However, if both babies present at term head down, they will likely stay that way and vaginal birth is reasonable as long as both babies are tolerating labor well. Sometimes twins don't tolerate things as well because of placental or cord issues and may warrant a c/section regardless.

Monday, October 22, 2012


I get a lot of questions from patients and potential patients about episiotomies (incision in perineal area to enhance opening during vaginal delivery). I would like to talk about why they are used and then why I generally avoid them all together, although there are rare circumstances where they may be necessary. Years ago episiotomy was used on a regular basis by many physicians and some midwives to expedite the delivery of the baby by making the vaginal opening larger. Many felt and some still do probably that a nice clean incision is better than a spontaneous vaginal tear that could be jagged, etc. There are some emergency situations that occasionally warrant an episiotomy. The first being shoulder dystocia. In the event that the head delivers and the shoulders get stuck, if it is really tight fit, the episiotomy can help make room for practitioners hand to reach in and help relieve the dystocia. The other time is if the head is crowning and has been for some time and fetal heart rate is dropping and having the ability to rapidly deliver for the safety of the baby may be a time that episiotomy is useful.
Now for the downfalls, and the reason why I almost never cut episiotomies. There is ample evidence that suggests that cutting an episiotomy even a lateral one increases the risk of third and fourth degree lacerations meaning the tear has extended through the anal sphincter and rectum. Cutting and episiotomy is like cutting material. When you make a cut, subsequent tearing is much easier and generally more severe than had that skin been left intact and only torn slighty naturally or not at all. There are consequences for women with third and fourth degree lacerations besides the pain of healing. These severe types of lacerations increase the risk for anal incontinence as well as other problems such as having fecal matter in the vagina if they are not repaired correctly. So, this is the reason why episiotomies are frowned upon generally. Plus, a little patience and allowing the perineal skin to stretch on it's own almost always leads to a safe delivery, less tearing, and better recovery for the mother.
Hope this answers any questions about episiotomy!!

Thursday, January 26, 2012

Bradley Method versus lamaze vs. hypno vs...whatever?

I often get asked by patients what the best method is for going "natural" during childbirth. Many patients are becoming more educated and realizing that often the things we "routinely" do in the hospital may pose added risk of c/section, infection, etc. Some of things such as pitocin use, rupturing membranes artificially, frequent vaginal checks, placement of monitoring tools internally, etc. have likely lead to some of the above mentioned interventions that are not preferable. Therefore, the trend is leaning once again toward self education and reliance that your body can do this without unnecessary interference. That being said, labor is still a painful process and is a lot of work for your body, and therefore, knowing the best option to help you cope and succeed with the delivery you desire is important!

So, first off, let's talk about the Bradley method. This came about many years ago by a Dr. Bradley and I believe it is the method most women will succeed with because it is the most normal and reasonable. I would estimate that >90% of my patients who use this method or take classes for this do succeed. It encompasses the attitude that labor and delivery are normal processes and don't usually require interevention unless necessary for the life of the mother and/or baby. Notice how I used the word "usually.." This method still requires intermittant monitoring of the baby and mom (vital signs, etc) and if abnormalities are noted, intervention may still be necessary. This method focuses much on nutrition and proper eating and weight gain for the mother. I believe this is crucial to pregnancy! They encourage 80-100 gms of protein per day...which I thought was a lot, but it certainly makes sense to help maintain sugars and help with weight gain and diabetes prevention. Plus, a normal weight infant is less likely to have or cause birth trauma than a very large one:) The Bradley method also focuses on knowing the mechanisms of labor and how your body functions, so it is less mysterious and scary. They focus on natural breathing vs lamaze which is very regimented breathing that sometimes leads to hyperventilation...which is not good for the mom or the baby. I think when you understand your body as a labor machine capable of doing this, and give it the proper diet and exercise to prepare this is the method you can and will succeed at!

Hypno birthing is also a popular method and there are many great classes and instuctors in this as well. It is more mediation, breathing, and hypnosis focused, although I've only ever had one patient I've delivered that I believe was truly "hypnotized" for her delivery. I think most women can't get that deep into their meditations and when they are not they sometimes panic and have no other information to pull from. Then they give in to medications or epidural. Both of which I think are reasonable options, but do have side effects that would not otherwise be present if they you still going "natural."
Lamaze is a bit old fashioned. Although relaxation and breathing are critical components to natural, certain altered chest breathing in rhythm and focusing on this so much is probably not the best. I think it often leads to hyperventilation which alters the blood gas of the baby and mother. This is what makes you feel "tingly" and "dizzy" both common complaints we see in hyperventilating patients. This typically leads your nurse to think you need more oxygen and they put an oxygen mask on you making the problem worse! You need to slooooow down, relax and breathe into a paper bag if necessary to take in less oxygen.
So in a nutshell, those are my thoughts on those options. I do have information on classes for all of these methods at my office if you would like more information on this.

And as always, I believe the birth experience is about you. If you choose epidural or other medications don't feel bad! Labor is hard work and exhausting and not all labors are the same. It is not a race or competition to see how much better or equal you are to anyone else who has done it. There is more than one right way to have a baby. Good Luck!