Transverse baby - would you try an ECV and an induction to avoid repeat C?

[nina_yyc]

I'm 38wks with a 7lb-ish baby in there. Baby turned transverse @35 weeks, and I had one ECV @ 37 weeks, but it moved back. I haven't given up on the baby turning yet (will see chiro and homeopath this week) but am considering my doctor's proposed management plan: ECV at 39 weeks followed by immediate AROM to induce labor. The hospital has a 24 hour limit on labor after AROM. WWYD?

One other factor in this is that my treatment is somewhat out of my doctor's hands. She is a family practice physician with a hospital-based maternity clinic. She does not do ECVs or inductions (or c/s for that matter) but must refer those procedures to the attending OB.

The OBs have somewhat different comfort levels with ECVs on VBAC patients. Some will not do them, particularly this late in pregnancy. My doctor feels that I am a reasonable candidate for an ECV even on a scar because the baby is small, has been mobile, and I am not obese. She called ahead to confirm that the attending OB on call next Friday is comfortable with the ECV. She said I can put off the decision about induction until I talk to him on Friday.

Yesterday I experienced a pickup in Braxton Hicks contrax and I started to feel good about the induction plan...I think my body will be ready. My doula said that if I want to go ahead with the induction, have lots of sex to ripen my cervix and she will come to the ECV and help me try to get labor started if it doesn't start naturally.

ETA: Previous C was for FTP/heartbeat decels @ 6cm after 48 hours of labor @39w. Insufficient labor support/cascade of interventions was a factor, and I suspect that's what caused my c-section more so than a physical problem. There IS a physical problem contributing to the transverse lie (pelvic alignment) but I am already getting chiro to treat this and my chiro thinks the baby will turn when it's ready to be born. I believe I physically CAN get a baby out my vagina, it just needs to realize that there's no side door.

[jess152]

Why the rush to induce at 39 weeks? That could be 3 weeks early, according to baby's time table. Who knows when s/he is ready to come out? Three weeks is potentially lots of time for baby to turn on his own. I would not be in any rush. Not to rain on your parade, but the pick up in BH contractions doesn't necessarily mean impending labour. I've had them since about 25-27 weeks.

Did you go into labour with your first or was it an induction too? If it was an induction, then you clearly know the risks.

An approximately 7lb baby won't gain two more lbs in 2-3 weeks, so it's not like they couldn't try another version later if baby hasn't moved. It sounds to me like you have some good things on your side...I would be nervous to consent to AROM this early.

I don't know if there's much you can do to encourage baby to engage once you've had the ECV, but maybe squatting or spending lots of time on a yoga ball might open your pelvis enough that baby will drop in. Avoid the recliner! that's my 2 cents, anyway! Good luck!

[smeisnotapirate]

I agree with the PP - I wouldn't rush at this point. You're still early. I had lots of prodromal labor, and unfortunately it doesn't mean much of anything in terms of when you will actually go into labor.

I would seek out some chiropractic care in the meantime, work on your posture and what the PP said about the yoga ball and doing pelvic lifts, and see if the baby's still transverse at or past 40w if they'll do another ECV.

But yeah - no rush.

[catspage]

I don't think I would rush into the AROM. When the water is gone, it is harder for the baby to move and can get even more stuck. Have you checked out spinningbabies.com? Here is the link for transverse babies: http://spinningbabies.com/baby-posit...tions/sideways

Definitely visit the chiropractor though. I saw the chiro twice a week throughout most of my pregnancy. Good luck!

[kltroy]

Hmm.... if baby has an unstable lie then it seems reasonable to think about doing a version and then inducing before he/she can flip the wrong way again. I dunno... it's a tough choice but I can see merit to inducing or waiting. I'd ask lots of questions about the pros/cons of each and make the best decision you can. Certainly the ECV sounds like a good plan though.

[nina_yyc]

Originally Posted by smeisnotapirate

I would seek out some chiropractic care in the meantime, work on your posture and what the PP said about the yoga ball and doing pelvic lifts

I'm doing the chiropractic and the chiro thinks baby is just going to turn when it's ready to be born. Another adjustment Tuesday, wish me luck

Originally Posted by catspage

I don't think I would rush into the AROM. When the water is gone, it is harder for the baby to move and can get even more stuck. Have you checked out spinningbabies.com? Here is the link for transverse babies: http://spinningbabies.com/baby-posit...tions/sideways

I think that's the whole theory. If it can't move, it can't go transverse again I don't know. I don't love the idea of AROM (I had it to speed up labor last time and I think it contributed to the heart rate decels.)

I've been doing spinning babies for the last week Before that the little one was flipping on its own. Spinning babies suggests that if you don't flip the baby by 35w your uterus becomes shaped for a transverse lie Well, I couldn't flip the baby before 35 weeks because it was vertex. And my chiro and a previous ECV have gotten it to flip, it just won't STAY. Arghhhh.

Originally Posted by jess152

Why the rush to induce at 39 weeks? That could be 3 weeks early, according to baby's time table. Who knows when s/he is ready to come out? Three weeks is potentially lots of time for baby to turn on his own. I would not be in any rush. Not to rain on your parade, but the pick up in BH contractions doesn't necessarily mean impending labour. I've had them since about 25-27 weeks.

Did you go into labour with your first or was it an induction too? If it was an induction, then you clearly know the risks.

No, previous baby went into labor naturally. The doctors want to induce @ 39w because of the risk of cord prolapse if I go into labor naturally. My cervix isn't open at this point so I'm not too worried about cord prolapse. I'll see where I am Friday but it's definitely going to be part of the risk/benefit analysis on Friday.

I am aware of the risks of a failed induction, particularly being a VBAC since I'm likely to be treated more conservatively. I know all the bad. These are MY concerns about waiting past 39w:
1. Going into labor naturally with a transverse babe = definite c/s.
2. Finding a sympathetic OB who will attempt the ECV past 39w. My doctor said last week that the OB who did my version at 37w "gave her sh*t" for sending a VBAC for an ECV, because a scar is a "relative contraindication" to ECV. My Dr. was pissed about this because she knew about that but thought I was a good candidate anyway (small, mobile babe and not obese)....and the OB was unhappy anyway, even though he made the same judgement call when he examined me. What is up with that? I think my Dr. worked the system for me already a little bit just so I wouldn't end up with someone who thinks transverse babies belong on the operating table @ 38w (or maybe I am just basing that feeling on friends' experiences who did not deliver with these particular docs or hospitals???)

Obviously I need to talk this through with the OB on Friday, and I'm considering calling another OB to see if I can get at least a phone consult...I don't know if I can get myself referred to an OB (if I can find a sympathetic one) this late in the game, but maybe worth at try.

Originally Posted by kltroy

Hmm.... if baby has an unstable lie then it seems reasonable to think about doing a version and then inducing before he/she can flip the wrong way again. I dunno... it's a tough choice but I can see merit to inducing or waiting. I'd ask lots of questions about the pros/cons of each and make the best decision you can. Certainly the ECV sounds like a good plan though.

Planning to! Just in case there's something I haven't thought of, what would you ask?

[mamatolevi]

The doctors want to induce @ 39w because of the risk of cord prolapse if I go into labor naturally.

I think I'm not understanding something here. Are the drs talking about you going into labor on your own while the baby is still transverse? or you going into labor on your own after they turn the baby vertex? I can understand the worry if the baby is still transverse, but if the baby is turned to a vertex presentation, it stands to reason that breaking your water too soon if the baby is still high would be a greater risk of prolapse than waiting for labor to start after turning the baby.

Rather than breaking your water as a first option, would you/they consider a low dose pit first? very low dose and slow increase pit would at least keep you off the clock for a while and could be turned off if necessary. the risk of rupture does go up (doubles, in fact),but it's still fairly low in the scheme of things. risk of rupture in any vbac is .4 to .7%, so you're looking at .8 to 1.4% risk w/pit.

Another option might be to try getting you started using a foley bulb.

[MsBlack]

The risk of cord prolapse is greater with baby transverse--and if the baby is vertex and at least fairly low (even if not fully engaged), then risk of cord prolapse reduces to 'normal' levels (ie, cord prolapse is possible for most anyone--just rare when baby is vertex and egaged/low).

OP--along with chiro and spinning babies, have you considered using a belly binding? A wide wrap/belt around your lower belly (from your navel downward) can help keep baby in place. The wrap keeps your belly/uterus in a more funnel shape, giving baby less room to go sideways and making it far easier for baby to be comfortable and somewhat 'contained' in a vertex position--harder to continue to flip around so much. I would definitely suggest you try this as soon as you get chiro help to get baby vertex again. Then, keep the wrap on pretty much continuously--you *don't* want to take it off at night and give baby all those hours to wiggle out of vertex again.

Good luck~ many tranverse babies will slide head downward once active labor begins, but some don't. Doing all you can to encourage optimum positioning now is a great idea. I would avoid induction for the time being--see if you can't use the belly binding to help keep that baby in vertex--if it works, then you will likely go into labor in a timely way. If it doesn't work to keep baby's position stable, then perhaps induction would be advisable. But I agree with pp that I would NOT consent to AROM as part of induction, for a host of reasons.

[nina_yyc]

Originally Posted by mamatolevi

I think I'm not understanding something here. Are the drs talking about you going into labor on your own while the baby is still transverse? or you going into labor on your own after they turn the baby vertex? ....
Rather than breaking your water as a first option, would you/they consider a low dose pit first? very low dose and slow increase pit would at least keep you off the clock for a while and could be turned off if necessary. the risk of rupture does go up (doubles, in fact),but it's still fairly low in the scheme of things. risk of rupture in any vbac is .4 to .7%, so you're looking at .8 to 1.4% risk w/pit.

Another option might be to try getting you started using a foley bulb.

They are worried about cord prolapse if I go into labor on my own while baby is still transverse. They also think that if they don't do something they might lose the window to manipulate the baby from the outside. I understand that once you are in labor, a transverse baby is a c-section. Of course, it could flip at the start of labor too.

I didn't ask about other induction options. I assumed that the whole point of going straight to AROM was to get the baby stuck so it couldn't go transverse again. They seem to like AROM at this hospital...a friend of mine had it done for post-dates and my doula has had both her labors induced that way. I beleive pitocin could be an option, because my Dr. said they would likely start it if AROM didn't work. I don't know how long the window would be...apparently it's up to the discretion of the OB, some will give you 12hrs before pitocin, others say 24. On the good news angle, I'm GBS-.

I would really like to talk to this OB before Friday...maybe if I call L&D they can arrange a phone consult.

Originally Posted by MsBlack

The risk of cord prolapse is greater with baby transverse--and if the baby is vertex and at least fairly low (even if not fully engaged), then risk of cord prolapse reduces to 'normal' levels (ie, cord prolapse is possible for most anyone--just rare when baby is vertex and egaged/low).

OP--along with chiro and spinning babies, have you considered using a belly binding? A wide wrap/belt around your lower belly (from your navel downward) can help keep baby in place. The wrap keeps your belly/uterus in a more funnel shape, giving baby less room to go sideways and making it far easier for baby to be comfortable and somewhat 'contained' in a vertex position--harder to continue to flip around so much. I would definitely suggest you try this as soon as you get chiro help to get baby vertex again. Then, keep the wrap on pretty much continuously--you *don't* want to take it off at night and give baby all those hours to wiggle out of vertex again.

Good luck~ many tranverse babies will slide head downward once active labor begins, but some don't. Doing all you can to encourage optimum positioning now is a great idea. I would avoid induction for the time being--see if you can't use the belly binding to help keep that baby in vertex--if it works, then you will likely go into labor in a timely way. If it doesn't work to keep baby's position stable, then perhaps induction would be advisable. But I agree with pp that I would NOT consent to AROM as part of induction, for a host of reasons.

I understand that the risk of cord prolapse decreases once babe is vertex...it's just that the Drs don't believe that baby will STAY vertex.

I guess the good thing about my situation is that if I don't consent to a procedure and I piss off the OB, there's a pretty good chance that I will never see him again. My Dr. is not pressuring me either way. She says she trusts the OB but she gave me a lecture on the cascade of interventions, so I don't have to worry about being without care, either way.

Interesting on the belly binding. Good thing I am getting my Maya Wrap back from a friend tomorrow! Sometimes over the last couple weeks I haven't been able to tell if it is vertex or not. I knew it was vertex for sure twice, but I think it could have been as many as four times, just going by kick positioning. I think I will know this week though, since it is getting much tighter in there.

[MsBlack]

Nina__yyc--

Yeah, I figured YOU understood the link btwn cord prolapse and position...I was answering the pp who asked about it. You sound quite well informed on all this, just so you know I don't think *you* are missing anything.

And hurray for your regular doc! What a gem. Do see if your wrap can help--you might even search info on how to do this properly, maybe your chiro knows, or other moms in your community, a homebirth mw who might consult with you. I only make a general suggestion with the wrap, good idea to look into it for more particular info.

[flapjack]

For me, the one concern I have is that you haven't met this OB before. I think you need to talk to them (him?), let him have a look, a palpate and see what he thinks and feels.

For me, though, in your shoes, I wouldn't hesitate to take the AROM after the version. I think it's a safer option than c-section, and this is a damn good shot at a VBAC for you: possibly your best shot. I'd also consider a trial of induction with pitocin, have an epidural in place during the version, (when I had mine a decade ago, that was standard practice) but leave your waters intact so that you do have the option of walking away, if the version or induction doesn't work. I know of several multiparas who've had great success with AROM inductions, not so many first vaginal births- obviously, this is all anecdotal, though. I'd trust the ob's gut instinct, though.

[MsBlack]

Before I'd ever trust an OB's gut instinct I'd have to really trust that OB hugely. Mostly I don't trust what OBs say, because I've met so few that any knowledge of, and generally even less trust in, normal birth--not to mention being pressured w/liability, hospital routines, and all that.

Or Flapjack, do you mean the OP should trust her HCP, who is not an OB but a Fam PRactice MD~~?

And yes, it is important to differentiate between AROM in a multip and AROM in a first vag birth. Unless you are already pretty well effaced and starting to dilate, I would not go with AROM, particularly if baby's head is not very well engaged in the pelvis.

[nina_yyc]

On the first vaginal birth note...does it make any difference that I did labor the first time, was not a cold c/s? I have heard conflicting reports on this.

Any reason you would take the epidural as opposed to the uterine relaxant Flapjack? At my 37w version they gave me a nitroglycerin injection into the IV tube to relax the uterus.

ETA: On the OB...I'm finding out what I can via contacts in the natural birthing community and trying to get a phone consultation. I'm in Canada so liability and profit aren't as big a factor as they are in most states. Knowledge/trust of natural birth is potentially an issue, but also not as much as in the US. This hospital serves a lot of low-risk patients who deliver with family physicians and is where the homebirth MWs have privileges and deliver their VBAC/high risk/transfer patients, so they do SEE plenty of natural births...I just can't say if they trust them or not.

[cairomama]

I just had a uterine relaxor for my version for my VBAC baby. I did not have AROM. I went home and 3 weeks later I went into labor on my own and had a very easy birth.

[kltroy]

FWIW, here's the sort of questions I'd be asking....

1. What are the risks assoc. with ECV. Is there an advantage to doing it now versus later? If we don't do an ECV what are the possible outcomes? Is baby "stuck" transverse or still quite mobile? What is the risk of cord prolapse or other bad outcome of baby is transverse when I go into labor?
2. If the ECV is successful what are the risks of inducing right away versus waiting for labor to happen on its own? Given that you're a VBAC and prostaglandins are a nono, how likely is an AROM/foley/pitocin only induction to work? There should be some statistics on this from before prostaglandins were commonly used.
3. What alternatives are there to inducing after the version that might help you keep the baby pointed the right direction? Some women have a corset type thingy that they are told to wear. I have no idea whether it works or helps, but is there something like that that is an option?

Assuming your doc knows his/her stuff, he should be able to answer these questions for you or get answers for you in a timely manner. This is not an emergency, so there's no reason the discussion can't take place over the course of a couple days.

Best of luck,
karen

[Astraia]

My only thought after reading through this thread (I'm not a VBAC mom, sorry for crashing) is that if the baby is still spinning on his own and turned back after your last version, it's showing that he's very mobile and still capable of turning so there is a much higher chance of spinningbabies tricks working- or chiro, another ECV, or even just baby turning on his own. It's, to me, no indication that your uterus is shaped for a transverse baby.

I do think that belly binding after you get baby vertex is probably your best bet.

I would also seriously consider my bishop's score before consenting to AROM. It's one thing if your dr is fairly certain that AROM would be enough to get things moving, but if it's not looking favourable it might be best to consider other options.

[flapjack]

Originally Posted by MsBlack

Before I'd ever trust an OB's gut instinct I'd have to really trust that OB hugely. Mostly I don't trust what OBs say, because I've met so few that any knowledge of, and generally even less trust in, normal birth--not to mention being pressured w/liability, hospital routines, and all that.

Or Flapjack, do you mean the OP should trust her HCP, who is not an OB but a Fam PRactice MD~~?

And yes, it is important to differentiate between AROM in a multip and AROM in a first vag birth. Unless you are already pretty well effaced and starting to dilate, I would not go with AROM, particularly if baby's head is not very well engaged in the pelvis.

No, actually I meant the OB. Given that I spent last Friday discussing induction with an OB who is refusing to consider induction a scrap before 42 weeks, who reassured me that a baby who is frequently flipping at 36 weeks is not a foreshadow of anything other than a baby who is frequently flipping, reminded me that every labour is different and one precipitous labour does not mean that the next one won't take three days, that I could do it, and told me that he thought the whole process was wonderful, I really think you need to get out more. If I want a butcher, I'll go to one. When I want a doctor with a particular interest in obstretrics and childbirth, I'll go to an obstetrician. The two professions are, actually, different, honest.

Nina, my version was over 11 years ago now: the logic behind the epidural was that I'd had some bleeding during the pregnancy and the risk of a placental abruption was higher, therefore the likelihood of needing to go straight to surgery also higher. My understanding is that ECV is now safer than it used to be, but I don't know how your scar will affect it. I'd also point out that it might hurt quite a bit.

[jennay]

I had a transverse baby (every transverse position imaginable) from 36 weeks on. She kept flipping no matter what I did - chiro, pregnancy belt, birth ball, spinning babies, etc.

I was going for a VBA2C -(this was baby #4-I had a vbac with #2) My OBs were supportive of a vbac and waiting for her to turn on her own, but wouldn't attempt a version.

So I saw another OB at 39w5d and he agreed to try a version on Thursday afternoon (and that's on 2 scars!) But I went into labor early Wed. morning and when I got to the hospital she was transverse in yet another position (i felt her flip and thought she was going head down...) so it was c/s for me.

So, I would consider it especially if you have other signs of labor being imminent. I waited too long.

[nina_yyc]

Update
DH and I DTD and baby moved. I also saw a homeopath and my chiro yesterday. I believe baby is head down as of this morning, about 10 degrees oblique. I was having lots of prodromal labor but contrax are gone this morning, so we'll see. I will do the belly binding if I don't get any more contrax.

Off to call my doula and check spinning babies to see if I can do anything to get babe to engage...that will probably get my anxiety level down by 100%. I'm also going to drink some RRL tea and seduce DH again...contrax make ME more uncomfortable when babe is transverse so it's reasonable to think it's not pleasant for the baby either.

I can't get a phone consult with the OB, but I did talk to a nurse who works in my Dr.'s office and also in L&D...apparently one reason for the 39 wks is that babies are often hard to turn and the later you wait, the harder they are. My ECV @ 37 weeks was pretty easy but that might explain why an OB wouldn't want to wait.

[nina_yyc]

Originally Posted by flapjack

Nina, my version was over 11 years ago now: the logic behind the epidural was that I'd had some bleeding during the pregnancy and the risk of a placental abruption was higher, therefore the likelihood of needing to go straight to surgery also higher. My understanding is that ECV is now safer than it used to be, but I don't know how your scar will affect it. I'd also point out that it might hurt quite a bit.

Makes sense. My first ECV did hurt but without the risk of immediate surgery I don't know if I want the epi.

Originally Posted by jennay

I had a transverse baby (every transverse position imaginable) from 36 weeks on. She kept flipping no matter what I did - chiro, pregnancy belt, birth ball, spinning babies, etc.

I was going for a VBA2C -(this was baby #4-I had a vbac with #2) My OBs were supportive of a vbac and waiting for her to turn on her own, but wouldn't attempt a version.

So I saw another OB at 39w5d and he agreed to try a version on Thursday afternoon (and that's on 2 scars!) But I went into labor early Wed. morning and when I got to the hospital she was transverse in yet another position (i felt her flip and thought she was going head down...) so it was c/s for me.

So, I would consider it especially if you have other signs of labor being imminent. I waited too long.

Thanks for the BTDT perspective.

I am really hoping for some obvious answer to fall from the sky...like active labor with an engaged baby, or doing an ECV and finding out I'm already dilated to 3.