When I was in my Residency at Tulane Medical School the Chairman of our Obstetrical department was doubly board certified in Maternal fetal medicine and Internal Medicine and had written volumes on High risk Obstetrics and breech deliveries.
Due to the high risk of possible neurological complications to the fetus....all of our breech pregnancies were delivered by C-section! Unless when the patient came in and the feet or the breech were already exposed at the introitus! Then it was necessary to deliver vaginally since the baby could not be "pushed back up"!
The risk is that the biggest part of a new born is the head and not the breech.!
If the feet or the buttocks were presenting...which by definition are much smaller in diameter than the head.. then the head could get entrapped in the cervix. The "pointy"part of the baby's head ( the soft spot) is what dilated the cervix during labor and the chin is "tucked in" against the baby's chest....in a breech presentation the head may extend as it passes through the cervix in "military" position i.e.having the baby's chin pointing "up" instead of being tucked onto the baby,chest...this causes that the widest part of the baby's head as the presenting part instead of the narrowest part called the Vertex ( soft spot) and this can and does get trapped in the vaginal canal !!
This is mayor Obstetrical emergency and can cause fetal death and or permanent neurological injury to the baby!!!
It was for this reason that in our training program any breech that delivered vaginally we had to be in our Chairman's office to discuss the "why" and "where for" of the delivery and the out come. This is the reason most Obstetricians proceed with a Cesarean section....especially if this is the patient's FIRST pregnancy !!
First time pregnancies have what we refer to as "an unproven pelvis"....i.e. there is no documentation as to how big a baby she can safely have vaginally....no documentation if her pelvis is of an adequate size to have a vaginal delivery...and many other important criteria that have not been documented by the patient not having had a prior pregnancy and vaginal birth.
For these reasons it is my opinion that if this is her first pregnancy and the baby is breech she should have a Primary Cesarean section.
A pudendal block is NO guarantee that she will have a safe and healthy baby at the end!!
Joseph A. Pineda, MD
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