Wednesday, April 18, 2018

Dates, dates, the magical (dried) fruit

I had my 37w (36w5d) BPP this week.  Baby is still head down (whooh!), my blood pressure is still good, and I am slowly but steadily getting ready to release this kiddo.  1 cm dilated, 25% effaced.  Although I’m not sure I am going to ask for / consent to anymore of these cervical checks—they are pretty unpleasant, and it sounds like not really good for much in the way of predicting baby’s arrival anyway.  (I have a memory of being natural earth mama last time around and saying no to most or all of the offers for them last time around.  I’m just too damn uncomfortable now—I need this baby OUT.)

I “splurged” on some bra extenders today.  Post-kiddo and prime fitness shape I was a svelte 34A.  After I got pregnant, I went out and invested in a few new bras in larger sizes (having JUST purged the ones from last time around.  Grrr.).  Those 36B/Cs have been pretty good, but lately I feel like someone is trying to smash me whenever I put one on.  Enter bra extenders, which claim they’re great for “temporary” weight gain/pregnancy.  Ahh, sweet relief.

Have I mentioned I’m over being pregnant?  

I’ve also started eating 6 dried dates a day.  Apparently there is small study showing that women who ate 6 dates per day starting at 4 weeks prior to their estimated due date had improved cervical dilation, less damage to their membranes, more spontaneous labor, less use of drugs to get labor started/continued, and shorter labor.  To be clear, the women who ate dates were in labor for 501 min versus 906 for the non-date eaters.  Ummm, being in labor for less time sounds good to me!

Wednesday, April 11, 2018

Head down, booty up

Okay, I’m willing to admit that maybe, just maybe, I went a little crazy when I heard baby was breech.  On one hand, there are a lot of decisions to make with a breech baby and I really believe that being educated as early as possible is important, especially if you’re going to try some DIY tricks as soon as possible to encourage baby to move.  On the other hand, breech babies can still move, so there’s no reason to completely flip out and spend hours, and hours, and hours reading about all of the issues surrounding breech babies/labor/etc.  (My next post was going to be all about diagnosing and treating hip dysplasia in newborns, a common issue with frank breech babies.)  And, in our case, this above-average sized (his head was measuring around 36w3d even though he was dated at 35w5d), super active, hopefully developmentally normal boy in his mother’s normally-shaped (as far as we know) uterus that has already been massively stretched from her prior pregnancy DID manage to get himself back in head down position.  YAY!!!!!!  When the ultrasound tech told me at the appointment yesterday, I screamed so loud I’m sure people around the office heard it.

It was definitely the moxi sticks.  Ha!

AND that’s not the only good news from the appointment!  My bloodwork came back showing that while my platelet count is still lower than normal, it’s not dropping (and in fact went up a bit).  YAY!  AND my cervix is soft and dilated ½ cm.  Yay!  Of course that really tells us nothing more than if, for some reason, we have to induce, it won’t be against a cervix that is tight as a drum.  Apparently there is no formula that says, if your cervix is x dilated you will go into labor in y days.  But a more dilated cervix demonstrates that your body is getting ready to have a baby.

For the first time in a week, I can completely exhale.  Here’s to an enjoyable break until the next challenge pops up!

Monday, April 9, 2018

Everything you ever wanted to know about breech babies (but didn’t really want to know)

Breech.  It never even crossed my mind.  He’s been head down for weeks.  Months!  To have him flip sometime between 34 and 35 weeks, well, it’s so unusual! 

I think part of the reason I’m so disappointed/mad about this is that I really thought, no matter what happens, at least I’ll have a repeat of my last nice, natural pregnancy.  Like, I can’t control anything in this whole process, but I can control that.  

Or not.

Instead, back down the rabbit hole I go.  There is no limit to what you can read about breech babies and ideas (some crazier than others) to turn them.  I’m going to do my best to summarize the insane amount of information I’ve taken in over the past few days.  

Breech generally

2-4% of full-term babies will be breech.  At full-term, around 65% of breech babies are in the “frank breech” position (butt down, legs and head up next to each other).  (Although another study I saw suggested that “frank breech” was more common is first time moms (at 82%) than it is in women that have already given birth (with complete breech being more common at 55%).)  At my appointment baby was frank breech.  5-10% are in complete breech (head up, butt down, knees bent, feet down).  10-40% are in incomplete breech position (one or both hips are extended.)  Incomplete breech babies are at an increased risk for cord prolapse, birth injuries, and asphyxia. 

25% of babies are in breech at 28 weeks, so prematurity is the most common reason for breech delivery.  At 32 weeks, 70% of breech babies will still turn to the “vertex” (head down) position, but the chance of a spontaneous rotation decreases each week.

If a baby is breech at term, it’s likely because there’s something preventing it from moving—either because there is an impediment to fetal movements (like the uterus shape is odd or umbilical cord is wrapped around baby) or because baby has abnormal fetal movements.  

Breech presentation is more common when:

·       mom had a previous pregnancy (a mom with previous pregnancies might have a loose uterine wall, making baby more comfortable in breech)
·       there is history of a previous breech presentation
·       it is a multiple pregnancy (one baby can crowd the other one)
·       amniotic fluid is either too much (polyhydramnios) or too little (oligohydramnios)
·       uterus anomalies such as abnormal shape or abnormal growths in the uterine wall (fibroids)
·       placenta praevia
·       prematurity 
·       birth abnormalities – around 9% of breech babies have some kind of fetal malformation (breech presentation is more “often associated with congenital fetal anomalies than in cephalic presentation. fetuses with congenital anomalies most likely suffer from underlying problems in fetal morphogenesis (they might fit better into the uterine cavity in breech presentation) and/or neuromuscular functional problems”)
·       maternal age above 30
·       cornal-fundal location of the placenta
·       abnormal maternal pelvis
·       maternal diabetes
·       maternal smoking

As far as the types of babies who might not turn, those who move less (such as female fetuses, abnormal fetuses, or growth restricted fetuses) are more likely not get into vertex (head down) position.  (And, apparently, my large and very active boy.)

That being said, one study reports that “The reason for breech presentation at term can only be identified in about 15 % of the cases.” (For what it’s worth, I have two good friends who had breech babies.  One had a cord issue, and another had too little amniotic fluid.)  

Breech pregnancies are higher risk, with greater chances for birth injuries and asphyxia.  Breech babies have double the risk of being stillborn (likely in large part because of the significantly increased risk of abnormalities).  “A breech presentation irrespective of mode of delivery is associated with an increased risk of subsequent infant physical or mental disability.”  L  






Breech delivery is generally via c-section

A vast majority (~90 in U.S.) of breech pregnancies are now delivered via c-section.  Around 12% of all c-sections in the US are performed because of breech presentation of baby. 

There was a study done almost 20 years ago (the Term Breech Trial) assigning breech women into planned c-section or planned vaginal delivery.  90% of the planned c-section women had c-sections, compared to 57% of the other group.  Infant mortality/serious morbidity was much higher in the vaginal delivery group (5% v. 1.6%).  Because of that, the study recommended c-sections for all breech babies.  The results of that study, published in 2000, “transformed obstetric practice worldwide.”  Almost overnight the number of breech vaginal deliveries plummeted and planned c-sections became the norm.

Now, there has been criticism of the study, including “Most cases of perinatal mortality were not related to mode of delivery.”  In other words, if a baby is breech because there’s something wrong with it, it’s not the vaginal delivery that causes the bad outcome.  Indeed, other studies have shown that there are more adverse outcomes in vaginal breech delivery when babies have something wrong with them, when mom has gestational diabetes, when there was a previous c-section, when it’s a first-time delivery, when epidural is used, and when the second stage of labor lasts longer than 40 minutes.  Some have suggested that careful selection of women who are good candidates for breech delivery should be considered.  (Discussed more below.)

Nevertheless, it remains true that the vast majority of breech deliveries are via c-section.



I have heard that in the city I live in, most hospitals will not even agree to let a woman try to deliver a breech baby naturally.  We’ll see what my doctor says.

Methods for helping a breech baby turn

Spinningbabies.com is definitely THE source of information for a variety of DIY methods moms can use to try to encourage a motivated breech baby to turn.  Some of them are more… out there… than others.  Although it’s safe to say that desperate mamas like my will try most or all of them, especially because they generally appear to be safe.



Anecdotally, I have a number of friends who had breech babies turn well into the 34-36 week period, and the internet is abound with stories of the same.



Inversions/positions to get a breech baby to turn

People swear by certain positions that can help keep your hips open/baby unengaged from the pelvis to allow a motivated baby time and space to turn.

              Forward-leaning inversion

Knees on bed or chair, forearms on the ground, butt up in the air.  Hold for 30 seconds several times a day.  One risk to this is that if baby is head-down, you could accidentally disengage baby from pelvis making it more likely baby would then turn to breech.  So only do this if you know baby is head up.

I’ve been doing this about 4x/day.  I definitely feel like baby lifts out of my pelvis, at least immediately afterward.

              Breech Tilt

Put an ironing board on a (stable) chair or bed.  Put some pillows on the ground at the bottom of the ironing board.  Lay on said ironing board with your legs up 1-3 times per day.


I’ve been doing this twice a day, for around 15 minutes at time.  It definitely works in the short term at keeping baby lifted, as my tummy feels much higher after I do it.

Misc. DIY

              Temperature

Put a heating pad on the bottom of your belly, and put an ice pack on the top.  The theory is that this will motivate baby to move away from the cold and the warm, getting him into a head first position.

              Sound

Play music at the bottom of your belly, or have someone talk to the bottom of your belly.  Hope baby is curious and moves head towards light.  I haven’t tried this yet.

              Light

Shine a flashlight on the bottom of your belly.  Hope baby is curious and moves head towards light.  I haven’t tried this yet.

Headstands in swimming pool

Do a headstand in a pool, using the same theory as inversions above.  I tried this.  It was hard.  And it didn’t feel like it was working, although I could only hold my breath for like 15 seconds becausesomething is crowding my lungs!!

Prenatal yoga

Prenatal yoga has been suggested to help keep joints limber and allow baby to move around and get into hips.  I’ve been doing this since BEFORE baby turned, and have a little bit of a worry that this is what got baby turned around in the first place.  Oh well.  For now they tell me DO NOT do any squatting until baby is head down again, because we do not want to encourage baby’s butt to get engaged in my hips.

Massage and other “breech balancing” body work

Massage has been suggested to help keep joints limber, particularly hips.  I had one the other day.  She used peppermint oil on the top of my belly, suggesting the “cold” could encourage baby to move head down.  Who knows.


There are also people who specialize in “body work.”  (I get the sense it’s like massage meets chiropractor.)  A number of women I have spoken to SWEAR by this when practiced by a small number of professionals in this area, who are IMPOSSIBLE to book appointments with.  (The most highly recommended woman is booked out a month after my due date and will not squeeze me in!)  I have appointments with two other different women coming up in the next few weeks.  (Both were also booked weeks out, but managed to squeeze me in for appointments weeks after I called.  One I have to drive THIRTY miles to see!)

Acupuncture/moxibustion

Moxibustion is a traditional Chinese medical practice.  It is the burning of moxa, made from dried mugwort leaves.  The leaves are compacted and rolled like a cigar and then lit and burned like incense at a specific acupuncture point (Bladder 67) located at the outer corner of the little toe of each foot.  Once a day for 10 days, preferably between 34 and 35 weeks.

There have been a number of (imperfect) studies suggesting that this practice has a higher success rate than not doing it:





I believe that acupuncture has some health benefits, but I am skeptical that burning a moxa cigar near your baby toes is likely to do anything.  THAT SAID, I am nothing if not a glutton for punishment.  So, after our breech diagnosis last week, I hauled my butt over to a traditional Chinese medicine shop and bought two fat moxa sticks.  (For something like $3.50 total.)  I’d read that they smell really strong and, ideally, would have burned them outside.  But it’s FREEZING where I live, so hubby and I thought if I burned them in a bathroom with the fan running that should be okay.  Well, I tried it.  And my house now STINKS like cigar smoke.  I mean it really, really smells.  (My nanny texted us when she came over the next day, saying “Why does the house smell like a Grateful Dead concert?”)  And, almost a week later, the smell has barely, barely gone down.  YUCK!  (Once it gets warmer and we can open the windows, I’m hopeful it will dissipate.)  In the meantime, I have continued to do the treatment once a day, but hauling my sad pregnant ass outside in the FREEZING cold, wrapped in a blanket with my little bare tootsies next to these fat cigars of incense.  And then coming inside with frozen feet smelling like a cigar bar.  Friends and family think I’m nuts.

I also have an appointment with an acupuncturist later this week to do a moxa treatment.  It’s fine to stink up her office!

Chiropractor / Webster technique

The “Webster technique” is a specific chiropractic technique directed at balancing the hips, and I’ve seen claims that it can get 80% of babies in the head-down position.  I’m generally pretty skeptical/squeamish about chiropractors, but I did use one with my last pregnancy (my back hurt so badly!) and I’m less nervous about them trying to balance my hips than I am about working on my spine/neck.  I have an appointment with a highly recommended, chiropractor trained in this technique this week, but I will be hesitant to let her do anything I am not 100% comfortable with.

Here’s a link to find chiropractors trained in the Webster technique:


Spinning babies offers a number of other options (rebozo sifting, hypnosis, craniosacral therapy and myofascial release), but I can’t research/try everything.

External cephalic version

External (from the outside) cephalic (head first) version (turning) is the final option for getting a breach baby head down.  At or near term, a doctor or doctors will try to manually turn the breech baby from the outside and get its head down.  The success rate varies considerably depending on the doctor’s skill and certain factors, and is generally estimated to be 37-66%.  The success rate is higher for women who have had children before than it is for first-time moms.

Factors associated with a higher ECV success rate include:
·       increased Amniotic Fluid Index (although I’ve also read too much amniotic fluid is bad)
·       at least one prior vaginal delivery 
·       a high estimated fetal weight  
·       baby is not engaged in the pelvis 
·       if the doctor can easily feel the baby’s head

Other factors that increase the likelihood of an ECV’s success (to a lesser extent):

·       if the placenta is posterior (on the back side of the uterus)
·       if the mother’s BMI is less than 32.7 
·       if there are normal levels of amniotic fluid (an amniotic fluid index >10)
·       if the mother’s waters are intact 
·       if the mother’s uterus is normally shaped 
·       if the mother’s abdominal wall muscles are relaxed
·       non-frank breech presentation 

ECVs also appear to be more successful if tocolytic drugs (drugs to prevent contractions) are used.  There is also a small study suggesting using vibroacoustic stimulation (applying sound to the mother’s abdomen) resulted in more successful versions than when it was not used.  But it sounds like one of the most important factors in an ECV success rate is whether the doctor is highly experienced or not.
Factors associated with a lower ECV success rate include:
·       nulliparity (first-time mom) (2-3.7x more likely to succeed if mom has had a baby already)
·       anterior placenta (posterior placenta increased the success rate by 2.85 times compared with an anterior placenta)
·       oligohydramnios (low amniotic fluid)
·       low birth weight
·       maternal obesity
·       descended buttocks into the maternal pelvis
·       firm maternal abdominal muscles 
·       tense uterus 
·       frank breech presentation (footling breech presentation had a 2.77-times higher success rate compared with a frank breech presentation)
·       the placenta is on the front, side, or top of the uterus
·       baby’s spine is located towards the back

While the procedure might be more successful the earlier it is done (as baby is smaller and easier to move), earlier in the pregnancy there is still a chance that baby will move on its own, and the procedure carries a risk to baby that could require an immediate c-section.  For that reason, most doctors prefer to do it between 35 and 37 weeks.

Generally, ECV should not be attempted if any of the following factors exist:

·       history of placental abruption
·       severe pre-eclampsia
·       signs of fetal distress
·       multiple pregnancy
·       evidence of uteroplacental insufficiency
·       significant third-trimester bleeding
·       suspected intrauterine growth restriction
·       amniotic fluid abnormalities
·       uterine malformation
·       placenta previa
·       maternal cardiac disease
·       pregnancy-induced hypertension
·       uncontrolled hypertension
·       a nonreassuring fetal monitoring pattern
·       major fetal anomaly

Success has been described as “all or nothing,” and it appears that if the procedure is going to work, it tends to be relatively quick and painless.  ECVs are reported, by some women, to be very painful.  And it appears that unsuccessful ECVs are actually or perceived to be more painful than successful ones.

Assuming the procedure does not work, but there is no evidence of fetal compromise, it can be re-attempted a week or two later.

Even women who have had a successful ECV are still at an increased risk for c-section, and particularly an emergency c-section.  (But this might not be because of the procedure, and instead whatever caused baby to be breech in the first place.)  If the ECV is successful, the baby can still turn and there is still a risk of c-section.  About 7% of babies will revert back to breech even after a successful ECV.  About ¾ of women who have a successful ECV go on to have a vaginal delivery.

In the case of an unsuccessful ECV, most women choose a c-section.

There are small but significant risks from an ECV, which include:
·       transient fetal heart rate changes (4.7%)
·       feto-maternal transfusion (0.9%)
·       emergency cesarean delivery (0.4%)
·       vaginal bleeding (0.3%)
·       rupture of membranes (0.2%)
·       fetal death (0.2%)
·       placental abruption (0.2%)
·       cord prolapse (0.2%)
·       preterm labor

While the risks are small, it would be VERY foolish to have anyone but an experienced doctor, using fetal monitoring techniques, to attempt an ECV.









Some doctors may hesitate to do an ECV if mom previously had a c-section, but this blog relies on a number of studies and argues that there is no evidence that this is a substantial risk:


Again, anecdotally, I know several women who had successful ECVs.  One ended up going into labor the same day as the procedure.  And I have heard of women who did not have successful procedures.

Vaginal breech delivery

Vaginal breech delivery is still an option, theoretically, although some hospitals/doctors will not do them.  (With good reason, it sounds like you want an experienced doctor if you’re going to attempt it.)  Some guidelines have been suggested before allowing an attempt at a vaginal breech delivery: 

·       the mother is willing to have a trial of vaginal breech labor
·       the fetus has no anomalies 
·       the maternal pelvis is confirmed to be sufficient in size
·       the estimated fetal weight is less than 4000 g (8.8lbs) evaluated by ultrasound and above 2500g (5.5lbs)
·       the fetus is in frank, or complete breech position with the head in flexed position
·       the mother has not had previous cesarean deliveries
·       the fetus does not suffer from an intrauterine growth restriction
·       the doctor should be experienced with breech delivery
·       the delivery should take place at a facility that can do an emergency c-section, if needed

The article below goes through the different strategies for vaginal breech delivery, and discusses long-term outcomes for children delivered vaginally:


C-section risks

C-sections are associated with adverse maternal outcomes, both short (hemorrhages, infections and thromboembolic complications) and long-term (generally relating to future pregnancies).  They are also associated with adverse child outcomes, including immunological development, atopic diseases, diabetes, and neuropsychological disorders.  They also carry a higher risk of postpartum depression and women have a lower ability to bond with their children.


The issue, of course, is that while c-sections carry a significant risk to moms, particularly in the short-term (relating to major issues, ie. death, and there are also the more minor but still significant issue of birth trauma to mama) and to babies, breech vaginal deliveries also carry significant risk to babies (and to moms if we want to focus on vaginal trauma).  The question is how do you balance those two things?


I read all the natural mama books when I was pregnant with my first, and I was hell-bent on having a natural vaginal delivery.  That’s still very much a goal, but from what I have seen breech vaginal deliveries can be really hard on mom’s poor vagina.  Also, I have a number of friends who had c-sections (several emergency—not fun—and planned—much better) and all of them are happy with the outcome and their recovery.  So I’m trying to get into the mindset that a c-section wouldn’t be the worst thing.  (I also have more than a few friends who had very traumatic and damaging vaginal deliveries and now wish they would have had c-sections, so I recognize vaginal deliveries are not always perfect and do have some adverse outcomes sometimes.)  I have to think about this more.

Determining baby’s position

Right after my appointment where I found out baby was breech, I was able to identify that baby’s position has absolutely changed from how it had previously been, and I was able to identify a head on my upper right side, and legs kicking on my left side.  (Frank breech!!)  Since then, and particularly this weekend, baby has moved a ton, and is no longer in that exact position.  (I have definitely felt kicks on my left side, although today they are back on my right side.)  I started to convince myself that baby had managed to right his ship, although now I’m not so sure.  I mean, belly mapping is hard!!

Here are some methods mamas can use to try to determine baby’s position:

Kicks—when kicks are low in the pelvis, you can be sure the baby has not turned.  If baby’s kicks are higher, baby might be turned down (unless baby is in frank breech position).  This technique is not as helpful to me because I’m dealing with a frank breech baby.

Heartbeat—If heartbeat is low in the belly, baby is probably head down.  (When using a Doppler to listen to baby’s heartbeat, a head-down baby should have the transducer on the lower part of mom’s belly.   When baby is breech, it would be on the upper part of mom’s belly.)  In all of my appointments when Dr. was listening for heartbeat when baby was head down, she would put the Doppler right near my vagina.  I have a stethoscope at home I’m going to try tonight.  (I also have a Doppler a friend loaned me, but I am hesitant to use it for fear that there is some harm that can be done to baby.)

Hiccups—if hiccups are lower in your belly, baby is more likely to be head down.  I know from experience when this baby was head down, his hiccups were basically in my vagina.  This weekend I started paying more attention, and they have been around my belly button (one day on the right side, and one day on the left side).  I was hoping that meant he was moving down.  I’m going to keep monitoring these.





Okay, I have another ultrasound appointment, and an appointment with my doctor, tomorrow, and I will be 35w5d (or maybe a few days less).  Let’s hope for good news at the ultrasound.  Otherwise, I’m going to have a serious conversation with my doctor, including trying to figure out whether to schedule an ECV and when, determining whether ECV is likely to be successful (Has baby descended into pelvis? Is baby still frank breech?  How’s my amniotic fluid volume?), determining which doctor in the practice has the most experience/success with the procedure and what those rates are, and determining whether and when to schedule a c-section or whether I would be a good candidate for a breech vaginal delivery (although I’m not sure I want to based on what I have read).  Wish me luck!!