Is risk of cord prolapse ever really a good reason for a c-section?

[eastendjenn]

This pregnancy has been such a rollercoaster for me in terms of care and birth plans. I started off being seen by midwives, but at our 20 week ultrasound was diagnosed with a complete placenta previa and referred to OB care. After 11 weeks of angst about what that meant for my baby and my birth, we returned for another ultrasound at 31 weeks and found that i did not in fact have a previa, but instead have a uterine synechiae - essentially a band if scar tissue stretching across my uterus. It was not covering the cervix. The high risk specialist told us that he would not perform a version on our then transverse baby, because of the risk of tearing the tissue by forcing her around, but that if she turned head down on her own, we were all clear for a vaginal birth. I did all the breech/transverse positions/activities, including moxibustion, and sure enough, she was head down at our 35 week ultrasound. BUT, this synechiae is blocking her head from getting to my cervix. It is literally stretched across my uterus, front to back, just to the right of my cervix, and her head is pressed up against it. Unless it breaks, she will not be able to make it to the birth canal (at least not with her head).

So we thought we'd just keep watching it, and hope it broke at some point. However, today (36 weeks) my regular OB did another ultrasound and saw that the cord is right over my cervix. He is very concerned about a cord prolapse, and recommending an amnio and c-section if her lungs are mature as soon as Saturday, because without her head to serve as a cork, there is a greater risk of cord prolapse, which could be fatal. I am dilated 2.5 cm already (not that that affects whether my membranes might rupture, but it could make prolapse more likely if they did.)

If we follow his recommendation, we are taking on all the risks of amnio, premature birth, and c-section. But if we don't, we run the risk of prolapse, which is much smaller, but much much graver. There appears to be a very low risk of my membranes rupturing this early, and I don't have any risk factors for that, but if it happened and I was in that very small percentage . . . well, it just doesn't matter if the risks were small if you are the one or two percent affected. And if I was in the small percentage of women whose membranes rupture early, I AM at much greater risk for a prolapsed cord.

I'm just so upset that we got so far from the type of care and birth I wanted, that we fought so hard to get back to that and almost did, and here we are again, facing an early c-section. I am honestly really worried right now, and I just don't know whether that's reasonable or just me being susceptible to the fear-mongering of conventional medicine. I could really use some perspective here. Any thoughts are welcome.

[thefreckledmama]

I honestly don't think I'd do a c-section in your situation. That cord could have moved away from your cervix 5 minutes after that US, KWIM? If it's really that big of a concern, I would go in at the first sign of labor, let them do another US, and then evaluate from there.

I definitely wouldn't go for a c-section until at least 38/39 weeks, but even still as a first time mama, the likelihood that you wouldn't go beyond your due date is slim.

[Plummeting]

But if she can't descend, then how would a cord prolapse be fatal? If the cord comes out and no baby parts follow to compress the cord, then the cord will just keep functioning like it always has until you can get to the hospital for an section, without needing to schedule one in advance.

I honestly have no idea whether your situation warrants a planned cesarean, but that is the first question that pops into my mind, since it's not the fact that the cord comes out that causes the problem, but that the baby's body compresses it once the baby tries to follow it out. I would ask your OB to explain that to you, then base your decision on the explanation. Good luck to you!

[mwherbs]

well the name for uterine synechiae - is Asherman's syndrome and most of the medical lit is about it being discovered before pregnancy/infertility treatment and how often treatment results in a baby. the causes are associated with D&C and other uterine surgeries (like previous c-section),and a variety of infections including TB, there are some other causes like endometrial ablation and fibroids-
Your risk of ending up with a c-sections is over 40%, I would say most likely this high rate is because if the infertility work done to bring about a pregnancy in most cases .
maternal complications from having Asherman's is a higher rate of placenta accreta and risk of more scare tissue /adhesions forming in the postpartum period .
So you could get a second opinion from a different perinatologist group. there is a higher risk of cord prolapse if your baby is not enguaged and you have artificial rupture of membranes or spontaneous rupture of membranes-
that your baby turned seems like a good sign to me and it just depends on how extensive and deep the scaring is and if there is cervical stenosis - in the end of pregnancy you have lots of hormone changes that effect connective tissue and elasticity and it may help to release the scar tissue and allow for a vaginal birth. I think it is up to you to weigh out what the docs are telling you, I would say try to take a friend with you to an appointment- warn the doc ahead of time you want a sit-down information appointment and then take a list of questions and things you want to communicate or have clairified by the doc -just how extensive is your scar tissue? what are the plans if any for postpartum treatment? I am sure you have more questions...
you know I read in the lit about 1000 IU vitamin E supplementation improving fertility and endometrial thickness in women with Asherman's - and I am connecting that to how vitamin E has long been recommended for helping with scar tissue and thinking maybe some vitamin E supplementation for women with scar tissue would be helpful in pregnancy as well but I don't have any studies on that- just a thought.

[MegBoz]

Originally Posted by Plummeting

But if she can't descend, then how would a cord prolapse be fatal?

OR, what I was thinking is, if the cord prolapses, why can't you handle it like any other woman - just get on your hands & knees, head down, butt up in the air to prevent the head from slipping down & compressing the cord. Then transfer for a CS. It is an emergency that requires immediate CS, BUT - if that emergency occurs, all you need to do is be aware, get in that position & go in for the CS. It's an emergency that can be resolved. At least that's what I thought - I could be grossly ignorant of other things involved here.

[Kailey's mom]

I'd follow the doctors plan at this point, if I were in your shoes.. I'd be scared not to, so even if I tried other things, I'd be freaking out. Hugs

[laohaire]

Originally Posted by MegBoz

OR, what I was thinking is, if the cord prolapses, why can't you handle it like any other woman - just get on your hands & knees, head down, butt up in the air to prevent the head from slipping down & compressing the cord. Then transfer for a CS. It is an emergency that requires immediate CS, BUT - if that emergency occurs, all you need to do is be aware, get in that position & go in for the CS. It's an emergency that can be resolved. At least that's what I thought - I could be grossly ignorant of other things involved here.

What are the outcome statistics in this scenario? I'm aware of this procedure but it's not preventative of a problem, it's just what you do to mitigate a problem while seeking emergency help. I'm sure some women do this and everything turns out peachy keen but probably for a significant (even if minority, I don't know the numbers) number of cases there is some oxygen deprivation.

My comments aren't a response to the OP - honestly I don't know what I'd do. But I do know I wouldn't rest totally assured that "hey, if prolapse happens, I'll just get my butt in the air, no problem." Oh, another issue is that you don't necessarily instantly know when prolapse happens. So even if you relieve the compression immediately and successfully when it's discovered, it might be a couple minutes before it IS discovered.

But all the same that doesn't address the stats on that particular risk happening in the first place, nor the risk/benefit scenario of taking that chance versus the amnio/cesarean, etc.

[Cheshire]

I've been that one percent you mention, and, you're right, statistics don't mean squat when you're the one affected. My son died due to cord issues.

If you don't like what you doc is telling you get a second and third opinion. If all other opinions agree you have to decide what is best for your family. This is your child and you are the one that will live with the consequences, good or bad, of your decision. It is not fear mongering when there is a real risk to your baby - you've been given a gift with an early diagnosis and the opportunity to weigh your options.

Support here is great but medical advice should come from those you know and trust IRL. Find good doctors who have a vested interest in the outcome of your pregnancy and ask them as many questions as you need to until you are at peace with whatever decision you make.

Best wishes!

[Plummeting]

Originally Posted by laohaire

Oh, another issue is that you don't necessarily instantly know when prolapse happens. So even if you relieve the compression immediately and successfully when it's discovered, it might be a couple minutes before it IS discovered.

But the issue, IMO, is whether or not cord compression is even possible, given that the doctor is saying the band of scar tissue prevents the baby from descending. Is it likely that the cord will get compressed between the baby's head and some other part of the uterus or is it likely that the baby will descend somehow or other and compress the cord on the way out?

I guess I wasn't actually answering the proper question in my first post...or this one. Sorry, eastendjenn. I was thinking of whether the possibility of a prolapse necessitated a planned cesarean, versus waiting until labor begins on its own and then doing a section. It seems to me that if the cord is in front of the head at the time labor begins, then a c-section is going to have to happen one way or the other - either because the baby can't descend, in which case the risk of cord compression is crazy low, or because the baby can descend and obviously will compress the cord in that case. I don't know all the ins and outs of prolapse and cord compression though, so maybe I'm wrong. I would definitely find out from your doctor why you would need to plan a c-section, though, rather than just wait until you go into labor. Planning one seems unnecessary to me if there's no risk of compression, but I obviously have no idea if there is a risk of that or not.

[laohaire]

Originally Posted by Plummeting

But the issue, IMO, is whether or not cord compression is even possible, given that the doctor is saying the band of scar tissue prevents the baby from descending. Is it likely that the cord will get compressed between the baby's head and some other part of the uterus or is it likely that the baby will descend somehow or other and compress the cord on the way out?

I agree. I was just saying I wouldn't make this decision (either way) based on figuring I could solve it if prolapse did indeed happen.

[noobmom]

Originally Posted by Cheshire

I've been that one percent you mention, and, you're right, statistics don't mean squat when you're the one affected. My son died due to cord issues.

If you don't like what you doc is telling you get a second and third opinion. If all other opinions agree you have to decide what is best for your family. This is your child and you are the one that will live with the consequences, good or bad, of your decision. It is not fear mongering when there is a real risk to your baby - you've been given a gift with an early diagnosis and the opportunity to weigh your options.

Support here is great but medical advice should come from those you know and trust IRL. Find good doctors who have a vested interest in the outcome of your pregnancy and ask them as many questions as you need to until you are at peace with whatever decision you make.

Best wishes!

First, .

Second, I really like this answer. If it were just a cord prolaspe question, I think that one thing. But your situation is more complicated and most people here don't have experience with it. Personally, I would talk to the high-risk OB and get his opinion as well. Chances are your regular OB isn't as well-versed in your condition and he may be overly cautious.

[justKate]

Originally Posted by mwherbs

well the name for uterine synechiae - is Asherman's syndrome and most of the medical lit is about it being discovered before pregnancy/infertility treatment and how often treatment results in a baby. the causes are associated with D&C and other uterine surgeries (like previous c-section),and a variety of infections including TB, there are some other causes like endometrial ablation and fibroids-
Your risk of ending up with a c-sections is over 40%, I would say most likely this high rate is because if the infertility work done to bring about a pregnancy in most cases .
maternal complications from having Asherman's is a higher rate of placenta accreta and risk of more scare tissue /adhesions forming in the postpartum period .
So you could get a second opinion from a different perinatologist group. there is a higher risk of cord prolapse if your baby is not enguaged and you have artificial rupture of membranes or spontaneous rupture of membranes-
that your baby turned seems like a good sign to me and it just depends on how extensive and deep the scaring is and if there is cervical stenosis - in the end of pregnancy you have lots of hormone changes that effect connective tissue and elasticity and it may help to release the scar tissue and allow for a vaginal birth. I think it is up to you to weigh out what the docs are telling you, I would say try to take a friend with you to an appointment- warn the doc ahead of time you want a sit-down information appointment and then take a list of questions and things you want to communicate or have clairified by the doc -just how extensive is your scar tissue? what are the plans if any for postpartum treatment? I am sure you have more questions...
you know I read in the lit about 1000 IU vitamin E supplementation improving fertility and endometrial thickness in women with Asherman's - and I am connecting that to how vitamin E has long been recommended for helping with scar tissue and thinking maybe some vitamin E supplementation for women with scar tissue would be helpful in pregnancy as well but I don't have any studies on that- just a thought.

OP, I know how you feel. I had "something strange" appear in an 18 wk u/s that ended up being a uterine band per a 25 wk u/s. It was at the top of my uterus and the peri, my OB, and my midwife agreed that it shouldn't present a problem for a natural birth. I was surprised--no prior D&C or surgery, fertility treatments, or anything. Another surprise came when DD would not descend b/c she was wrapped up in the cord--I ended up with a c/s because her heart rate kept accelerating. I won't stress you with the rest of the details.

I would definitely get a second opinion from a different peri if you can, or have a "sit down" with yours. I haven't seen a lot of info on this, but IME it may (or may not) have been the cause of my DD's difficult birth. I think if I had known the 40% stat the PP cited I might have had more realistic expectations for DD's birth.

Not sure that helps, but wanted to let you know you're not the only one. I'd love to get more info on this myself, so that I can be more prepared for any future pregnancies.

ETA: mwherbs, I'm really interested in learning more about this. Can you share links or sites for info? Esp. re. subsequent pregnancies? TIA.