Wednesday, June 07, 2017

Breech and the art of obstetrics

Sometimes doing research is really, really boring. Other times I come across gems like this 1961 Lancet article titled "Management of Breech Presentation" by Leonard Lang. His humor and colorful language bring his words alive, contrasting with the dusty pages they now live on.

Also worth reading is his commentary on the last page about the trend towards increased cesarean for breeches.

The old masters in obstetrics of one or two generations ago—the mean who taught many of us—had a great deal of respect for the breech. Each of them had special technics and pet maneuvers that worked well in his particular hands. Each warned against certain dangers and pitfalls that should be anticipated, carefully searched for, and then properly handled, sometimes in rigid mechanical sequence. Many of these dedicated teachers had slogans and bits of advice that clearly expressed their concern. Dr. Williams often said that he could tell a really good obstetrician by the manner in which he conducted a breech delivery. Our old teacher, Dr. J. C. Litzenberg, liked to say that “any physician who said that he wasn’t afraid of a breech or never had trouble with a breech was either someone who didn’t do any work in obstetrics or was an ‘outright’ liar, and he could choose his own category!” Another exhorted the medical student to always be friendly with his competitor across the street, “because you may need him to help you with a breech some time!” They were acutely aware of the dangers inherent in breech delivery. They had to be. They had to depend upon their hands and keen mechanical sense which experience developed into a type of intuitive perception and manipulation that DeLee liked to call the “art of obstetrics.” They couldn’t readily resort to cesarean section once delivery from below was chosen. They didn’t have blood banks, antibiotics, and highly trained anesthesiologists.

No doubt our old teachers are turning in their graves as they contemplate upon the number of cesarean sections we are doing for breech today. We can only hope that St. Peter has tried to explain why things have changed. That might help a little but I’m sure that it wouldn’t completely satisfy that fine group of “Old-Timers.”


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