# Need Advice



## KandyKinz

Turns out I'm not a know it all after all!!!! :haha:

I desperately need some thoughts and insights. I'm feeling quite confuzzled :wacko: Anyways, if you were in this situation what would you do and what would be your rational? And if anyone has any additional information or tips I'd be grateful. 

(Added: sorry for this being so incredibly long... I just needed to write out all my thoughts in attempts to try to figure things out. My support system at home is somewhat lacking hence my 'How do your partner's view birth' post and I couldn't sleep at all last night cause this has been on my mind.... OH's telling me to "just get over it" has proven to be not very effective!)

Anyways, as many of you are already aware by my previous whining, my little Peanut has declared itself a gymnast and has continued to do summersaults. Last week at my prenatal visit my suspicions were correct and my baby was breech. I had told the midwives that the baby moved quite alot and that it spent alot of time transverse but I don't think they truly grasped how much this baby liked to change position. They did however note that there seemed to be a fair amount of amniotic fluid present. I had a scan two days later and I knew baby had turned a couple of time since but went anyways. Sure enough baby was head down.... then went to oblique then transverse then to almost breech back down to cephalic and then transverse again. So essentially not much was confirmed in terms of Baby Peanut's position. :wacko: And as unreliable as estimated fetal weights are it was seen to be normal and the amniotic fluid volume was described as being normal as well. They refused to give me the actual AFI at the scan and they failed to mention it in the report as well so it could be anywhere between 6 and 24 but I'm guessing giving what it feels like through palpation it's closer to the 24 mark. 

Anyways, had my home visit on Tuesday (yesterday) and during the palpation Baby Peanut started out oblique and then moved to transverse. This is a very mobile baby and it took very little effort on the parts of the midwives or even myself to change the baby's position. 

So here I am at 36 weeks with a baby in an unstable lie who's really loving being transverse. 

I was and am still planning a homebirth though the reality of whether or not that will actually happen is now on the table. I still have a list of things I need to get (faucet adapter, shower curtain to protect the mattress, etc) that I'm suppose to have by friday (I'll be term then according to the midwives dates :wacko:) but I'm feeling very reluctant to purchase such items now. 

I've been reading and reading everything I can on shoulder presentations at term and the information I have found thus far, including that from popular obstetrical scientific journals, has been fairly limited, outdated and focused on third world countries in which quality maternity care is lacking :wacko:

The three main risks would be A) uterine rupture B) prolapsed cord C) fetal injury. Essentially if the baby's shoulder gets wedged into the pelvis the pressure of the contractions could cause nerve or skeletal damage to the baby. Also, in the event that that would happen the uterus would also likely become overly stimulated in order to overcome the obstacle and would become hypertonic. The pressure of the baby on the lower segment of the uterus in combo with the hypertonic contractions could make the uterine thin out abnormally to the point in which rupture would occur which is apparently the most common outcome of a neglected shoulder presentation. I have yet to discover what time frame would classify as a neglected shoulder presentation and how quickly such a thing would/could play out. And then in the even of SROM the chances of a prolapsed cord are much much higher then if baby is vertex or breech.

Then in terms of management, well there's really no consensus over what should be done in terms of prenatal management. The practice of performing ECV's on an unstable lie has little support as the baby will likely just move again. Some recommend that the mother be hospitalized at term until labour begins so that the women would be in a safe spot should her membranes rupture. This also allows them to attempt an ECV at the beginning stages of labour when it is most likely to be successful. Alternatively, the woman could stay at home and come into hospital or have her midwives go to her as soon as labour begins and ensure and or try to get the baby cephalic. And if in either case the ECV fails then cesarean would be the only option. Full term babies just don't come out sideway.... and if they do they're not living....... There's also several obstetricians and guidelines which suggest that doing an ECV at term and then immediately breaking the waters in a controlled environment which is ready for an emergent cesarean is the most practical approach and it avoids having to keep the woman in hospital for a long period of time or the risks of having her at home with a baby with a potential shoulder presentation. So that's certainly a reasonable approach, however there have been some well designed studies which have shown that 80% of babies who are cephalic at 37 weeks will spontaneously turn longitudinal by the time of delivery which in my eyes make the wait and see approach very reasonable as well. 80% is a very reassuring number! Then there's the transverse baby = straight to cesearan at term approach which I don't view as being a very favorable option. To complicate matters further apparently most cesareans for shoulder presentations require a vertical incision... There's supposedly some technique during surgery to manipulate the fetus out through a transverse cut but this technique has not been widely adopted and given the primitive old school nature and mindset of the OB's in my community I am highly doubtful in their knowledge, skill and ability to utlize such a maneuver that would reduce my risks of rupture in any future pregnancy should I decide to have more children.

Personally, I'd like to refrain from entering into the hospital if at all possible. The midwife I spoke to at my last appointment did mention the possibility of doing a controlled rupture at home, but quite frankly as much as I do desire a homebirth the thought of doing something like that makes me a tad bit nervous primarily due to the fact that I am a 45 minute drive away from the closest hospital. Apparently, the OB's at my hospital would not be too keen on that approach (they are the transverse baby = section at term type) and would be very unlikely to agree to do an ECV and having the controlled rupture done in hospital. And I'm thinking that once the midwife I spoke to speaks to the head midwife of the practice, that option will be a no go at home as well. So should I choose an ECV and ARM I would likely have to travel two hours to the next community where the practicing obstetricians are more progressive, more uptodate with current literature and who are a little more tolerable of the idea that women actually have thoughts and opinions and a capability to make their own deicisons. Traveling that distance to be induced is certainly not the picturesque birth I had in mind and would likely lead to some chaos in the postpartum especially in the event that a cesarean would be required in terms of OH having to take extra days off work which we can't really afford (having no postpartum support is another factor at play in terms of management.....) and childcare for my other children. And then if I did opt for an ECV and induction there would be the question of timing.... when? when? when? The thought of it makes me somewhat :sick:

Then there's the expectant management approach where I just wait to go into labour and hope that I will be one of those 80% of women who's babies turn longitudinal. Once I'm 37 weeks (according to the midwives dates which is this friday.... and here I thought dealing with the due date discrepency sucked.... :dohh:) I'm to page them immediately at the slightest sign that labour is beginning so they can get to me asap (again I'm in the middle of nowhere) and ensure baby is vertex or help to turn baby vertex and keep it there. It goes a little bit beyond the realm of homebirth normalcy and comfort but a huge part of me is leaning towards doing that. My main concern though is that it will likely take 30-45 minutes for my midwives to get to me.... and if at that time those contractions have wedged that baby's shoulder into my pelvis to such a degree that there's no moving baby I'll have to go to the hospital for an emergent cesarean which will take another 45 minutes. What damage is likely to be done to baby or my uterus in 2 hours? Again back to the fact that I can't find any information on the lenghts of labours with shoulder presentations and incidences of bad outcomes. Is uterine hypertonia and potential rupture something that's likely to happen BAM right away??? I do have a history of fairly rapid labours (4 1/2 hours both times, though they were both induced) or is this primarily something that occurs over an extended prolonged period of time? And if I'm in (early) labour and baby won't agree to be moved to a cephalic position would I be looking at an ambulance transfer in??? probably :shrug:

And then if my water breaks I've been instructed to get into the hands and knees position and page immediately so that they can check and make sure the cord hasn't prolapsed. I can certainly check myself but if I were to do that I could very well be cutting off the blood supply to baby if there were in fact a cord prolapse so it's probably best I don't.... Unless I can somehow manage to do so with my boobs on the ground and a** in the air but I don't think that even I am that talented. Once my waters break baby's head SHOULD and would in most cases just fall into my pelvis with the gush... But I imagine in the knee chest position gravity would not be so kind and would likely greatly reduce the likelihood of baby's head engaging.... Hopefully hopefully hopefully my membranes won't rupture prelabour cause I think if my waters did break first things in an uncontrolled environment without the presence of contractions things would likely go down hill quick...... 

In the meantime, I've been sitting on my birthing ball all day and have been taking periodic walks in -20C temps in hopes of bringing that baby down.... Hubby is to bring me some Pulsatilla on his way home from work and I will be attempting to belly bind tomorrow if baby will cooperate and stay cephalic for me for a few moments! From what I read so far the breech tilt (which I had been doing) is not very effective in my situation. Supposedly it's purpose it to dislodge the malpositioned fetus from the pelvis. My problem is that my uterine muscles are too lax and there's ample fluid.... Nothing's in my pelvis.... Same goes with the webster maneuver and moxibustion is supposedly useful as it makes the baby hyper thus stimulating them to move to a more ideal position.... My baby continues to do summersaults so I don't think increasing it's activity level would be of any use :shrug: Cause again it can and will go cephalic... It just won't stay that way :nope: Oh and another thing my midwife said was that sometimes constipation can impede the baby's space and make them stay out of the pelvis... While my constipation isn't at it's worst things could certainly improve in that area so I'm gonna try increasing my fiber and will be starting metamucil to get things moving more regularly just in case that may be in issue....

Again I'm very open to ideas......


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## sugarcube84

My friend had the same thing happen with her 3rd baby hadnt engaged at 37 weeks so they were worried about cord prolapse. They kept her in hospital for a week and when baby still hadnt engaged they decided to keep checking babies position untill he was correct and then they induced her and i think (sorry it was 5 years ago!) broke her waters so that if the cord did come out they could whip her straight off for a c section.

She has since said that although her labour was ok and she just had 1 shot of pethedine despite being on the hormone drip she wishes that she hadnt had the induction and had just sat it out and been monitored in hospital.

Sorry no help whatsoever to you, if it was me i would probably go with hospital so i was in the right place just in case my waters did go and the cord prolapsed but 80% chance of baby turning is very high. It must be so difficult!!


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## pinkmonki

I genuinely don't know what to suggest but didn't want to read and run so :hugs:

I think, for me, home birth has always been about weighing up the odds of anything untoward happening and having to be transferred into hospital.. If the odds of being transferred outweighed the odds of staying home then I think I'd opt to go to hospital and become the 'pain in the arse' patient by being there but steadfastly refusing medical intervention unless the situation warranted it. 

However, your situation is uniquely problematic in the 'what if' stakes, so I think if it were me, I would try the belly binding and if that didn't work I would opt for going to hospital with controlled induction. Since as we all know, whilst the desired result is always getting the baby out safely, it's also about feeling in control so if you make the choices, you're more in control of those choices than if it's all happening around you in an emergency setting.


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## PeanutBean

Hi Kandy. Funnily enough this is a timely post for me too. My baby has slipped round transverse now (not unstable lie). Byron was the same at the same stage and did turn by 34 weeks and start to engage. My anxiety then and now lies with diastasis recti. I had no anxiety this time (given how things went with Byron and having abdominal support this time) until the week of bronchitis doubled the gap in my muscles. :wacko:

Everything you've said in the post tallies with what I've read and heard about transverse and unstable lie. Most things I've seen give the impression that a section is preferred (perhaps necessary) for both for the reasons you've mentioned. I have also read about ECV followed by ARM induction for transverse to get the head down and engaged. I've read nothing positive anywhere (including in all the home and natural birthing things) to suggest there is any alternative in the case of a shoulder presentation.

I am not at all surprised your head is all over. Given the added issues of travelling time. For me I'm assuming she will turn and if she doesn't I'd be inclined to try ECV (given she is fairly stable) and failing that wait for labour to start and see if the contractions turn her. I'm only 15 mins from the hospital though. There are so many factors for you.

In the messy EDD issue, when do you think you're 37 weeks? I think I would wait until then to see what happens doing lots of the exercises and positions to encourage head down. I read something about hip inversion (I got the impression on one's back rather than knee chest) to discourage engaging when the position is unfavourable. It was a throwaway comment and I really don't know how it would relate to these sorts of circumstances, other than being helpful for ROM if the position is unfavourable whilst awaiting medical backup.

As I understand it subsequent babies can be later to get into position and engage. It could be a case of literally taking it a day at a time and see how the position is and how you are feeling etc. Perhaps set up the plans for going in under planned and emergency circumstances so are ready to act if a decision is made to go in.

I don't know....it's so complicated!

On the pulsatilla side of things, for homeopathy to work there are a couple of things you should avoid consuming - coffee and mint are two of them. I forget the others but basically it's a very strong taste thing. You should avoid eating at least 15 mins either side of taking it. Really it's best to avoid mint toothpaste too though I personally can't bring myself to do that this time. I am avoiding my favourite mint chocs though. :cry:

No idea if this post will help you at all!


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## KandyKinz

Thanks, it's definitly helpful to get the perspective of others. :hugs: And hopefully PeanutBean your little bundle will soon realize that cepahlic is the way to be!

I'm feeling a tad bit better... Spent yesterday shopping for the last of the baby items remaining on my 'Need to Get' list including the last few things I needed for my homebirth. Then I spent the remainder of the day at my mothers where I was forbidden to talk or think about anything negative which included the unco-operativeness of my baby... And I have to admit it was kinda nice to become distracted with other things for a little while.

And today I woke up and baby was breech.... but now it's transverse again. 

Diastasis recti is definitly playing a role with me. After my son the muscles somewhat went back together.... Then after my daughter there remained an inch gap seperation extending above my navel, so I definitly did not have the best abdominal support this time around.... Perhaps a belly band would have been useful to avoid it getting to this point :shrug:

I am currently planning to take the day by day approach unless I come across further information which changes my mind. I can't say I'm 100% comfortable with that approach, but I'm certainly not keen on the other options either. Today I'm 36+2 (according to my dates based on conception) and 37 weeks according to the midwives and I'm intending to test out my birth pool and get my bed prepped etc etc this morning for a potential homebirth. I'm also going to pay a little more attention to what's in my hospital bag :wacko:

I now have pulsatilla and am feeling quite hopeful. I don't use mint toothpaste (I'm a cinnamon kinda girl :D ) but I do drink a fair amount of tea. Would the caffeine in that effect the pulsatilla in the same way coffee would? (I drink primarily decaf green tea, which still has some caffeine, and the occasional orange pekoe).

My next midwifery appt is scheduled for Monday morning. Then the following week or perhaps even later next week I imagine they will be requesting that I see the consultants in regards to this matter at their 38 week mark. It's in their guidelines so they _have_ to make the appt and I understand but whether I go or not will be dependant on what consultant I get. Apparently, you don't get to choose :wacko: and while I feel the practices of both of them are overall quite dated there is one whom uses interventions a tad more conservatively and he actually has a good bedside manner and while I did my one month placement at this hospital he always talked to the women with respect, explained things to them. As an extra bonus while I was there he also treated me with respect, actually answered my questions and I have to admit though there were times our opinions conflicted he was one of the best teachers I had run into during my clinical practice. While our opinions may very likely conflict as to how this is to be managed I would appreciate to here his view, get a picture of what his previous experiences have been and get more details as to what exactly I should expect should I require transport to hospital in labour with a potentially compromised baby with a shoulder presentation...... I can't speak so highly of the other consultant as he was always very rude to his patients, would never make eye contact, would never listen to them, and if anyone were to ask him anything he'd reply with simple one worded answers or the infamous "If we don't do this the baby could die" line :nope: Going to see him would be an utter waste of my time in my mind.


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## PeanutBean

It's not the caffiene that's the issue, it's the strong coffee taste, so tea is fine. I am wondering about cinnemon though! Maybe google to check! I know anniseed is ok which I thought wasn't as it is so strong, so probably it's fine. I don't like either so only remember the things I do like. (Though having said that I don't drink coffee anyway...)

I'd have thought that stomach exercises might be uselss at this late stage but in case not there is an exercise you can do while pregnant, albeit very gentle. My physio showed it to me. Sitting upright put a hand under your bump just held loosely against the bottom (this doesn't need to be there, it's just for being able to tell if you're doing it right the first time). Then really all you do is breathe in fully deep into your abdomen so that your muscles contract a little and you will feel your bump raise off your hand underneath. It's very gentle!

I think that if the muscles are a problem now for this pregnancy, then a tubigrip will help stabilise the baby's position. If it's the fluid I don't know whether it would help. Mine covers my whole bump and is fairly snug. It needs to be quite tight to offer sufficient support but obviously not uncomfortably so (I find I don't need a wedge cushion if I lie on my side in the tubigrip). If you can't get one easily then (don't laugh) I got a couple of size 10 vests from H&M before getting pregnant and they were really weirdly long, past my bum! Now I'm pregnant they are actually almost as supportive as the tubigrip. I reckon two, on top of each other, if tight enough and covering your whole bump, would work as well as a tubigrip!


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