KandyKinz
Longtime Mama
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Turns out I'm not a know it all after all!!!! 
I desperately need some thoughts and insights. I'm feeling quite confuzzled
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. 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) 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
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
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....
) 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 
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 Cause again it can and will go cephalic... It just won't stay that way 
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......
I desperately need some thoughts and insights. I'm feeling quite confuzzled
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.
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
) 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
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
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....
) 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 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
Cause again it can and will go cephalic... It just won't stay that way 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......
) 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).
