UPDATE post #12 Help me think through the risks of transverse lie (x-posted in DDC)

[msmiranda]

Just when I thought I'd gotten everything squared away finally ... met with my new OB yesterday, who is great.  Very patient choice oriented.  Very supportive of natural birth, doulas, the whole nine.  Avoids episiotomies "like the plague."  Supports delayed cord clamping and any position you want to push in.  30-40% of the births he does are without epidurals, which for an OB is rare.  He's a perfect fit for me.

And then I find out the baby is transverse lie.  At 35w2d.  At first I didn't think much of it, figured it was a fluke and he would certainly turn.  But I am a worrier by nature, so that sanguine attitude didn't last long.  Got home, started doing research, and here's where I am:

* I hope by the time I go in next week he has turned head down.  I believe that he has been moving between transverse and vertex for several weeks now, based on where I feel movements.  Sometimes he's more oblique (diagonal).  I never feel movements that indicate breech -- his head is always in the lower half of the uterus.  But my other babies were firmly head down by this point.  According to Dr. Google, the fact that I no longer have abs of steel is probably to blame for giving him too much room to lay sideways.  I don't have any of the other risk factors (placenta previa, tumors, multiples, prematurity).  Okay, you got me there, I never had abs of steel.  And now in my third pregnancy I really, really don't.

* Even if he has turned, though, who's to say he couldn't turn back?  (the dreaded "unstable lie").  So I feel like I have to go into my next appointment with a suggested course of action. 

* The crux of the problem with transverse lie is the high risk of cord prolapse should my water break before labor begins (7-15% chance of cord prolapse is what I have read).  OTOH, of women who have a transverse fetus at 37 weeks, under 20% of them will still be transverse during labor (e.g. 80% or so turn vertex on their own).  So I want to give him every possible chance to turn and stay head down since that is most likely what he will do.  But, the risk of cord prolapse is scary.  We live an hour from the hospital I am planning to birth at, where this OB delivers.  The closest hospital to my house is 10 minutes away, though ... but even that distance (I think it is 6-7 miles as the crow flies) worries me for something like a cord prolapse.  If I was going to have to have a c-section, I would rather it be with my doctor.  But, I certainly don't want to schedule one at 38 weeks, which is standard of care for transverse lie.  (Note: this is not what he said to me that he would want to do -- he said, make that baby turn and we'll check again next week, so he is not that worried yet.  I am just thinking out loud about what if the baby is still transverse next week and the following week). 

So I guess right now my thinking is this:  if baby stays transverse for the next two weeks, my suggestion to the doctor will be to schedule a version for 39 weeks, and then an immediate induction if it works (and if it doesn't, I don't know ... a scheduled c/s at 40 weeks maybe?).  That means my natural birth is out the window, but it's a damn sight better than a c-section, which I would prefer to avoid for many reasons.  And of course if at the time of the version appointment he was head down then I would just go home. 

In the time between 37 and 39 weeks, though, I am worried about my water breaking.  If there was a cord prolapse the baby could easily die if I was at home alone with my two kids, as I usually am during the week (between calling 911, waiting for them to get here, getting to the hospital and getting into an OR, that seems like too many minutes to me, and I wouldn't have anyone to help me hold the baby off the cord while we were waiting for EMS).  I would be more comfortable being at the hospital that whole time, although I am not sure that my insurance would pay for it because of the availability of elective c-section.  So maybe the version/induction should be scheduled at 38 weeks?  I don't know.  (For reference my previous LOs were born at 39w6d and 38w6d respectively, so I am not worried about the baby being majorly preterm at either 38 or 39 weeks, and it is why I am worried about my water breaking around this point). 

Any thoughts?  (please no suggestions for spinning babies, chiropractic, moxibustion, or any of the usual suspects -- I am just trying to think through what I will do if the baby does NOT turn).

[2sweetboysmom]

Those same 'not so steel-y abs' will easy accomodate your little one turning vertex right up until birth, so take heart!!

Spontaneous rupture of membranes causing prolapse is less likely than AROM causing prolapse. Do the studies and  percentages you are studying take that into account?  Frequently waters will leak, giving you some warning/time.  Did your other labors start with your water breaking? 

I would wait and watch and pray. Oh, and pound down the vitamin C.  

What you decide you feel comfortable with now will likely change over the next few weeks.  You clearly understand the potential risks.  Listen closly to your mama voice of intuition.  Can you arange to be closer to the hospital of your choice from 39w0d?  Are there moms or neighbors you can ask to help out if need be? 

[Monkey Keeper]

I dealt with unstable lie with my DS several months ago, and your worries were mine as well. (FTR, he kept flipping from breech to oblique to kinda-sorta-vertex but not at all engaged)  First of all, do whatever you can to get him head down. Secondly, if he gets there, see if you can bind your belly to keep him there. My doula said they see unstable lie a lot in the Amish population because of closely spaced pregnancies--so there's your abs theory!  Third, don't feel pressured into anything. Statistically, your water breaking to begin labor is not that likely.

Still, I was SO afraid of the possibility. I had a long talk with my doula who also happens to be a midwife. We came up with a plan that made me feel comfortable--it helped that she lives very nearby.  

[XanaduMama]

Originally Posted by msmiranda 

In the time between 37 and 39 weeks, though, I am worried about my water breaking.  If there was a cord prolapse the baby could easily die if I was at home alone with my two kids, as I usually am during the week (between calling 911, waiting for them to get here, getting to the hospital and getting into an OR, that seems like too many minutes to me, and I wouldn't have anyone to help me hold the baby off the cord while we were waiting for EMS).

If your water breaks while he's still transverse, call 911 and immediately go hands-and-knees with your butt in the air. At least gravity will keep baby's weight off the cervix (and thus, possibly, the cord). Or, alternatively, rather than contemplating being in hospital for all those weeks, why not get someone to come and stay with you--someone who could at least watch your other kids while you're waiting for the ambulance, and/or drive you to hospital. And ITA with PPs' suggestions: pound the vitamin C, get tested for asymptomatic BV or yeast, which can also weaken your bag of waters.

BUT: sending you vertex vibes and hoping all this is irrelevant! Still plenty of time for him to turn. If he does, drop and start squatting ASAP to try to lock that head into place!

[MsFortune]

I would not do anything to risk my baby's life, even if it meant a c section.  So I'd do the scheduled c-section if the baby does not turn.  Nothing is worth risking my baby's life for.

Here's hoping LO turns!

[Monkey Keeper]

Originally Posted by MsFortune 

I would not do anything to risk my baby's life, even if it meant a c section.  So I'd do the scheduled c-section if the baby does not turn.  Nothing is worth risking my baby's life for.

Here's hoping LO turns!

I understand your position, I really do.  The thing is, WHEN? Because her water could break *today*, unexpectedly, with the same outcome.  Having been in this situation, it's not just about the scheduled c/s. You have this fear hovering over you for quite literally weeks when you don't know what position your baby will be in or if your BOW will just *wham* rupture with no warning at all. You're not making a conscious choice to risk your baby's life--it's just a reality of your situation.

OP, I agree with the "butt in the air, call 911" advice. Could you find a mw/montrice to hire that is within just a few minutes who might be able to come and assess you if you water breaks?

[msmiranda]

I updated on the DDC thread (June 2011) that based on following his movements for the past few days, I am pretty sure that he is very mobile at this point.  He turns from vertex to oblique to transverse regularly.  He may turn breech sometimes, but I'm not sure about that -- I feel more foot-like movements either at the top or all the way down my right side.  Yesterday in the bath I found him lying completely transverse -- feet on my right side toward the bottom.  Today he has been vertex and oblique (diagonal) if my deductive reasoning is working correctly. 

So now the problem is not so much that he is transverse as that he is an unstable lie.  When exactly this gets diagnosed ... I have read 34 weeks, 36 weeks, and 37 weeks in various obstetrical and midwifery textbooks.  My OB said he would not worry until 37 weeks.  I will be 36 weeks on Saturday.  Most obstetrics guides that I have been able to find online suggest hospital admission at 37 weeks to ensure the availability of emergency care in the event of cord prolapse and/or water breaking with baby in transverse or oblique position, both of which of course necessitate an emergency c-section.  I do have family who could stay with my older kids in the event I was admitted, so that's not an issue. 

I have my next appointment on Monday.  I am keeping tabs on baby's movements in the meantime, but so far he's still all over the place.  On Monday I will be able to find out whether I have a lot of fluid, which can contribute to this problem and is the only unknown potential cause -- otherwise like I said it is just lax uterine/abdominal muscles (which the textbooks say is the most common cause anyhow, especially in a multip).  And I will discuss with my OB what his recommendations would be in a situation like this, whether he has experience with versions, whether he would recommend hospital admission, and whether there are any contraindications for a version in my situation (I do have an anterior placenta but I think it is high up -- not sure whether that is a contraindication or just something to be very careful of).  At the end of the day if a c-section is necessary, of course I'll go with that.  But I think there is a middle course between "schedule the C for 38 weeks" and "stay home and risk it until you go into labor" that is the place where I would feel comfortable ... which is close expectant management starting at term (preferably in or very near the hospital) and then if he does not turn head down and stay that way by 39 weeks, a version attempt with immediate induction if successful gives me the best odds of having a vaginal birth while still ensuring both his and my safety by having immediate access to emergency care.  If the version was unsuccessful, then I would have to think about whether to schedule a section or try to hold out until I went into labor on my own, again preferably in or very near the hospital, so as to give him a chance to turn at the last minute.  

I'm still hoping he will get with the program in the next week or two and settle into vertex position, but I like to have all eventualities thought out just in case.  Thanks so much for the responses!

[msmiranda]

Originally Posted by PinkBunch 

I understand your position, I really do.  The thing is, WHEN? Because her water could break *today*, unexpectedly, with the same outcome.  Having been in this situation, it's not just about the scheduled c/s. You have this fear hovering over you for quite literally weeks when you don't know what position your baby will be in or if your BOW will just *wham* rupture with no warning at all. You're not making a conscious choice to risk your baby's life--it's just a reality of your situation.

OP, I agree with the "butt in the air, call 911" advice. Could you find a mw/montrice to hire that is within just a few minutes who might be able to come and assess you if you water breaks?

Right, that's the thing about it -- you have this possibility of a Very Bad Thing happening, but you don't know when or if it would happen, so from a practical perspective a line has to be drawn somewhere, and it seems like most OBs draw it at 37 weeks because once you are at term your water is more likely to break ... but of course you are right that it *could* happen today!  Yet, there is not enough potential for that happening to do a section tomorrow.  So the question is definitely when.

I would of course do the butt in the air/911 thing today, but as a plan going forward from 37 to 40 weeks or beyond, I'm not comfortable with that being the answer because of the potential for disaster.  Closest hotel to the hospital (*my* hospital, with *my* doctor, NOT the closest hospital to my house, which is not someplace I would really want to go for a number of reasons) would even be better than just staying at home.  I know many people would be fine with staying home, and certainly the risk of death is statistically very low (only some people have their water break before labor begins, only a certain percentage of those would have cord prolapse, only a certain percentage of those would have compression, and so forth) but it is still too high for my personal comfort level. 

[Monkey Keeper]

You know, it's interesting--it seems your OB really is pressing you to make a decision with some scary scenarios whereas in your same situation (DS was breech--half complete, with the other leg stretched across my belly at 35w, head down at 36w-39w, breech again at 39w, and back to vertex/oblique the next day) I was not pressed with a decision at all. She mentioned the risk of prolapse--which also is the case if baby is not engaged breech which he was not. But never was it in a "we have to DO something" way.  I'm just puzzling through why for my own sake, I guess.

Aside from that, I did have an AFI estimate of 31cm at 41w. THAT caused my OB to put the pressure on. Good thing I went into labor the next day with a confirmed head-down babe ;)

Wishing you strength and wisdom, mama.

[msmiranda]

Originally Posted by PinkBunch 

You know, it's interesting--it seems your OB really is pressing you to make a decision with some scary scenarios

Not at all -- he did no such thing.  This is ALL me.  He hardly said anything at all about it, actually, except that he really wanted to help me have another natural birth.  I am a huge worrier and and a huge planner, which is a toxic combination when it comes to birth, lol. :)

[Monkey Keeper]

Okay!  I was beginning to wonder why my (IMO awesome) OB was not nearly as concerned. Now I get it ;)  Hang in there!

[msmiranda]

Today at my appointment the baby was head down.  Tonight I think he's breech, because I'm feeling hiccups at the top (which has never happened before today).  So we know that he's capable of being head down, and that he is still mobile.  My OB is not worried (of course I think he got a false sense of security from seeing him in the right position).  When I told him what I had read about being admitted to the hospital at 37 weeks for an unstable lie, he was like, "that is old school, where did you read that?"  LOL.  For now the plan is just to assess where he is next week and if I were to go into labor early, to go right in so they can assess his position.  Which is fine.  I hope he is just being stubborn and will turn the right way when the time comes.  The BPP showed a good level of amniotic fluid (not too little, not too much) and a very healthy baby, so that reassurance was nice to get. 

[L&K'smommie]

Originally Posted by msmiranda 

Today at my appointment the baby was head down.  Tonight I think he's breech, because I'm feeling hiccups at the top (which has never happened before today).  So we know that he's capable of being head down, and that he is still mobile.  My OB is not worried (of course I think he got a false sense of security from seeing him in the right position).  When I told him what I had read about being admitted to the hospital at 37 weeks for an unstable lie, he was like, "that is old school, where did you read that?"  LOL.  For now the plan is just to assess where he is next week and if I were to go into labor early, to go right in so they can assess his position.  Which is fine.  I hope he is just being stubborn and will turn the right way when the time comes.  The BPP showed a good level of amniotic fluid (not too little, not too much) and a very healthy baby, so that reassurance was nice to get. 

Yay for head down!  And I wanted to add that I have had to change my view on hiccups accurately telling position this pregnancy.  This LO has been head down a while now and he gets the hiccups all the time and I can feel them at the top of my belly and down low where the head is and sometimes the entire belly moves.  I guess I'm saying that hiccups aren't always accurate for telling if baby is head down or breech as you they can cause full body movement.  I hope he's still head down for you like my little guy(who gets hiccups daily)

[Monkey Keeper]

Wooohoooo! Awesome news!! Stay head down, dude :)  (I'm being optimistic that he's hiccuping so hard that his bum is moving!!)

[msmiranda]

I'm pretty sure that he was breech Monday, Tuesday and Wednesday, then in the middle of the night last night I felt him turn head down and he has been that way all day today.  So, who knows whether it will last or not ... The good news is that he has not been transverse that I have been able to tell for several days, so maybe there is no longer room for him to get in that position comfortably and his lie is now firmly longitudinal.  Next appointment on Tuesday ... 37 weeks on Saturday.  Hoping for the best ...