what would have happened at home?

[dnr3301]

I have a friend who just had a baby yesterday. (I'm a doula, but wasn't hers because I have a new one of my own, but I gave her lots of advice and was one of the first to hear how things went.) I'm wondering how this would have turned out differently at home or how she could have avoided her cesearean. Her water broke early Tuesday morning. She didn't start contracting until late Tuesday night, spent all day Wed at home, laboring (despite warnings from her mw's, she was GBS+), went in to the hospital at about 1am Thursday. She had her dh, her mother, and her MIL with her. All were very supportive of her choices to have a drug free birth; MIL had most of her babies at home and her mother had all of her kids sans drugs. I don't know all the details yet (will post more later), but the baby was "transverse arrest" and the c/s happened at about 11 am Thursday morning, a good 10 hours after getting to the hospital and about 2 days after her water broke. What happened? This baby was 41weeks (wed) and weighed 6lbs 7oz. The mom was also very small at birth. Any ideas? She asked me to help her process what could have been different.

[Persephone]

I'm still learning, but transverse means the baby was lying on it's side. And 'arrest' I assume means labor stalled because the baby wasn't in the right position. If the baby is transverse when labor starts, I don't think there is anything that can be done. The baby can come out if it's breech, but not transverse. I dunno, midwives, prove me wrong?

[JesseMomme]

Ok - not a mw here...

Transverse arrest. That's a new one...something fancy for "stuck in an awkward position and not progressing". What will they think of next. I'm glad to hear she had support from her dh and mom and mil for a drug free labor, but...

Was she getting really tired? was she allowed to move much at all, get out of bed? Was her movements restricted by an EFM, did she have a dextrose IV and/or an antibiotics drip for being GBS+? The ability to be Moving about instinctually is the best way to move a transverse baby. Case in point: a friend of mine was in labor and the baby was trans. When she had the urge to push she found herself arching her back (upright), sticking her tummy way out. The nurse scolded her, saying she was doing it "wrong" and had to lay back and "curl forward". My friend ignored her - and later found out that pushing like she did for a while was what turned the baby!

IMNSHO - hospital birth, no matter how "natural" or drug-free, can still wind up interfering with the process on a whole.

[Evergreen]

Well, if the baby really was transvese I am sure the homebirth midwife would have transported her and she would have had the c. anyway. Correct me if I am wrong, but I an pretty sure you can't vaginally birth a transverse baby.

[dnr3301]

I talked with my mom, who is a labor and delivery nurse, and she said that "Transverse arrest" is a head position. The baby had been OP for a long time, then apparently turned her head to be basically looking down the mom's leg, so presenting forehead first, but off-center. (BTW- my mom is a cool nurse, super supportive of natural childbirth, had all four of us at home, including me, her first, UC, and nursed my youngest sister for 4 years. She's not the normal L&D nurse.)

[Greaseball]

Forhead-first can be delivered vaginally. So can face-first. But if the whole baby is sideways, it can't come out that way. At home she might have been able to do things to make it turn, though.

[JesseMomme]

Wow dnr - I bet I wish I had your mom as an L&D nurse when I had my first two babies Then again my mother is a nurse too and she was there, but she's way more western medically minded so...I digress...

Ouch, the poor baby. That definately sounds like an awkward position. OP labors are really hard too, the pain the back is excrutiating (with mine at least).

I'm curious so I'm going to look more into it.

[JesseMomme]

Oh yeah, greaseball reminded me of a UC mom who homebirthed her 10 lb baby, he was totally face first.

[lilyka]

It sounds like the baby was in a akward position if not fully side ways and just was not coming. Sometimes c-sec is just nessecary. rarely but sometimes it just is. It sounds like she fought the good fight and did everything she could. poor mama. she worked really hard to have that baby natrually.

[LizD]

Transverse arrest doesn't mean the same thing as transverse presentation. I have attended a few cesareans for this reason. In my experience it has been another "failure to wait" situation. It refers to the baby's head descending rapidly enough for whoever is making the decision. You see it often with inductions because usually women are induced before the baby has moved into its optimal positioning and come down into the pelvis. When women are induced they usually have an epidural which restricts their movements and there is little they can do to bring the baby down. If there was no infection she might have been able to have antibiotics and wait longer, but there is no way to know after the fact whether the cesarean was necessary or not.

[MountainLovinMama]

I don't know the details of your friend's birth - our situtations and options may have been different, but my baby was also transverse arrest (facing my leg, body sideways) and ended up being born via c/sec. This was after 36 hours of drug-free labor (!), after dilating fully and pushing for four hours (!) with many different attempts to turn her. The baby always moved right back to her transverse position, and did not progress down the birth canal - did not budge throughout the four full hours of strenuous pushing. I was in a hospital setting, but I was not "medicalized" and was in a very warm and nurturing environment -- I was very comfortable walking around naked, using the birthing tub, using massage, etc, etc. I had a wonderful doctor and wonderful nurses, all completely supportive of our desires for a natural, intervention-free labor. We had a doula - also wonderful. In fact, when it came time to do a c/sec, it was against hospital regulations for our doula to come into the surgery room with us. My doctor (who was the one performing the c/sec) said flat out, "If she (the doula) doesn't go in, I don't go in." So, we had tons of support all the way through, even in surgery, and the c/sec was, in our case, a truly life-saving intervention.

[cottonwood]

Various interventions can bring the baby down before it can get into an ideal position for birth. How was her labor managed after she got to the hospital? Was she told when to push? On her back for 2nd stage? How was the baby's presentation determined? What was the deciding factor for doing the cesarean? There are a lot of clues missing here.

A brow presentation in itself should not necessitate a cesarean, but may make the labor longer and 2nd stage more difficult.

[pamamidwife]

Transverse arrest is very different from a face presentation. Brow presentation vaginal births are VERY RARE - and alot depends on the size of the baby, but it hardly ever happens. When I was a doula, I was at a homebirth with a local midwife and we transported for brow presentation for a cesarean. Face presentations, believe it or not, are successful vaginal births. Much easier to birth than a brow presentation.

Deep transverse arrest is when the baby is stuck at the widest part of the head (because of the posterior position) and has not rotated to more of a diaganal to fit though the ischial spines of the pelvis. I've heard of many babies at homebirths, after long hours (6+) of finishing dilating that last centimeter and pushing that transfer for a cesarean.

Of course, certain positions in late first stage and second stage are more conducive to helping baby rotate a particular way, but I'm not sure about this particular case and what happened with her freedom to move. It could have been an issue.

Deep transverse arrest is more common with posterior babies. With posterior babies, because their heads are not well-applied to the cervix, we typically see early rupture of membranes with no labor for awhile. It's like the bag of waters can fill up under the head and there's more pressure with the late braxton-hicks, early labor contractions to break it.

It's totally difficult to second-guess this sort of outcome. Surely, in a hospital, they could have tried forceps to rotate the baby when it became stuck. However, there is a risk of trauma to the baby applying the forceps in that position.

[dnr3301]

I went and visited her today. From what she and her dh said, it sounds like they were given a lot of leeway and time to make the decision. She labored for hours drug free at the hospital, pushed for 2 1/2 hours. She said the mw told her she could still have babies vaginally, but this one was wedged in wrong (sounds like what papamidwife was describing). After talking with my mom about it, it sounds like she had pretty good care. My mom mentioned that if the baby had been bigger (6lbs7oz), it's would have been less able to get into this position. My friend sounded like she was disappointed, but believes she had good care and this was a freak incident. She said that they didn't tell her there was something wrong with her body (ie her pelvis was too small or something like that), but that the baby was in a weird position and that if it hadn't been in that position, she would have been fine. I'm happy that she felt well-cared for and that she had so much support and help in the room. She said she wasn't sure which part was presenting. I think I was trying to figure it all out when I said forehead? Not sure where that came from .

[pamamidwife]

I'm so glad that she was well supported. I love hearing stories like that - and the confirmation about her ability to birth vaginally, etc. So many women hear horrible things after a cesarean.

I'm thrilled that she has you for a resource in her life, too.

[Elyssia]

pamamidwife

i have a question, are you saying the brow presentation and transverse arrest are the same thing??
my son was born brow presentation at home - second twin
i thought my head was going to blow off when i was pushing him, it took SOOO much more effort than my other kids
we didn't know b/c he was high up for an hour after baby A was born
then he just dropped down all at once and i started pushing
we were all wondering why it was so hard
then finally there came this big head, and then face - he was 8.11
my midwife told me that brow is very rare and gave me some reading material on it, so i am just wondering if it is the same thing

as to transverse presentation, both of my babies (the twins i mean) were transverse at onset of labor
and labor stalled for a little while until baby A presented finally (frank breech)
i got as far as i could get w/ just the water bag dilating me
i felt that i learned from that labor to be even more confident in my body's ability to work it out
but in your experience, do you find that malpresentations will right themselves given time and patience?? (i mean the transverse or oblique, the babies looking a little this way or that way, not the breech or posterior)

[pamamidwife]

brow presentation is common with posterior babies. however, posterior babies do not often have brow presentaitons. does that make sense?

transverse arrest is in reference to a head down baby. it happens alot with brow or military presentations and posterior babies because the widest part of the head is trying to fit through the smallest part of the pelvis.

some brow presentations are born vaginally, most are not. I've heard of a couple from homebirth midwives (one with a pushing stage of 15 hours), but they are indeed rare. There is something to consider in an obstructed labor - typically your rate of uterine rupture (I'm talking a virgin uterus - no surgical history) is much higher with these presentations.

I find that most babies do turn themselves with good posture and those stronger braxton-hicks/early labor contractions that occur in the last week(s) before active labor kicks in. I don't think that lying on your back or being in a bed is conducive to encouraging babies to settle in the pelvis properly. And, yep, patience is key.