A week ago today, B and I were repacking our bags. We had already been packed with the bags in the car since week 37, with plans to be at the birth center for a few days postpartum.
But, to continue the theme of the unexpected, on Wednesday night, we dragged those bags back in and made some adjustments.
I should back up.
Earlier that morning I had my 39 week prenatal. I went in alone, as B was meeting with our general contractor about ADU stuff. It was uneventful, as I didn’t have much to report. I’d been having Braxton Hicks for a while, but nothing to write home about. No discomfort, no cramping, no little leaks, not a drop of bloody show. Just lots of belly and swollen hands and aching feet and ready to be done with pregnancy-ness.
My midwife Katherine and I chatted a bit about my plan for school this fall quarter (class on Tuesday afternoons, no call shifts, starting gyn clinic at week 8 or 9 of the term), which had just started up again on the 28th. We talked about my Mega Naps, and then she did Leopold’s (external palpation of the uterus). “Hmm…I know we’ve been calling him head down for a while, but I’m having a hard time finding my landmarks. Mind if I do an internal exam?”
Normally, she and I both wouldn’t bother for a first-time pregnancy at 39 weeks…but to be honest, I was curious. To my complete and utter surprise, I was 2cm dilated, with a soft cervix at midline and about 50% effaced (thinned out). Seriously?! But I hadn’t felt ANYTHING!
However, she couldn’t confirm a head down presentation. Normally, if the head is engaged at this stage of pregnancy, you can actually feel the bone sutures through the lower uterine segment. She couldn’t feel them, so asked for my permission to have another experienced midwife, Laura, do Leopold’s. Sure, why not?
She came in and almost immediately after placing hands on my belly, her face softened, and she sighed. “Yeah…I’m pretty sure your little one is breech,” she said. I nodded. I had a feeling. She asked if she could do another internal exam to confirm, which was fine with me. The first exam wasn’t as bad as I was expecting. The first words out of her mouth were, “Well, you’re 4cm…”
Katherine and I looked at each other in disbelief. “Uh, she was 2 when I checked her three minutes ago!” she said. “Yeah,” Laura said. “She was 2. Now she’s definitely a 4.”
Holy sheeeeeeeet. I still felt nothing. This is freaking crazy! I thought to myself. My life is about to explode
We talked about my options and the information I needed to move forward. First order of business: an ultrasound to confirm the breech presentation and to check the level of amniotic fluid around the baby. If the fluid levels were good, I’d be a candidate for an external version, where the provider uses their hands on the belly to try and turn the baby from the outside. If it was low, the risk of a cord accident is higher, and it wouldn’t really be safe. I’d then be facing the decision of whether to schedule a cesarean or attempt a vaginal breech birth…which very few OB’s offer.
Everyone has their own opinions about vaginal breech birth. My own thoughts can be summed up as: I wish we could see more of it, but it’s hard when so few OB’s and midwives actually have adequate training on how to manage breech birth. So much of the increased risk is simply due to the fact that people don’t know how to safely attend these births. OHSU offers a vaginal breech birth program, but they have strict protocols about who qualifies and the requirements are pretty narrow. I wasn’t sure I would meet the parameters, and so in the instant I discovered Tahini was breech, I immediately started thinking about the potential that this baby would be birthed via a cesarean section.
The ultrasound appointment confirmed what we all suspected–a breech presentation, with an amniotic fluid level of 7.0, which is on the lower end, but not dangerously low. I was a candidate for a version. The question was where to do it. In the end, I opted to do it in the hospital, at OHSU, where I am a student and where I know many of the OB’s. It felt like I had the best chance to work with a provider who would be accommodating of my wishes…and with the expertise of an academic clinical setting, I’d have the best chance of a successful external version.**
So, Wednesday night, B and I went out to dinner at our favorite restaurant. We talked through what was likely to happen the next morning when we arrived on the L&D unit. They would do another ultrasound, on the off-chance that Tahini verted himself overnight (unlikely, but it’s been known to happen). I’d have my labs drawn and a urine sample tested. I’d get an IV put in and they’d give me a bolus of fluid before placing a combined spinal/epidural.
Some places do versions without medication, others with a drug called terbutaline, which relaxes the uterine muscles…and other providers point to evidence that a spinal offers the best chance at a relaxed uterus and successful version. Our plan was that if the version was unsuccessful, we’d just move directly to a cesarean birth rather than attempting another version a few days later.
After the spinal was placed (in the OR), they’d attempt the version with ultrasound guidance, stopping every two minutes to check heart rate and make sure Tahini was tolerating the procedure. As we ate dinner we talked through potential scenarios…and commented on how unreal this whole thing felt. It’s entirely possible, we told ourselves, that in 24 hours, we could have a baby. On the outside. WHAT?!?
We came home and repacked our bags, preparing now for a potential hospital stay of 3-4 days. And then we tried to sleep. I was asked to not eat or drink anything after midnight, and plan to arrive on the unit the next morning between 6 and 6:30am. We didn’t really fall asleep till close to 1am, I think. And even then, sleep was hard to come by. How do you sleep the night before your life could possibly be changed forever?
Part IIb to follow…
**I should clarify: most of the time, I feel that the out of hospital is a safe place for most aspects of perinatal care. However, I do think in the scenario of breech and versions, there is a lot to consider. Sometimes versions can cause cord issues, which can lead to hypoxia for the baby…and the best way to avoid that is to be able to do a version with ultrasound guidance and immediate access to an operating room. While I fully respect the choice to attempt a version out of the hospital if someone is fully informed of the potential risks, I personally didn’t feel comfortable taking that risk and opted for an in-hospital version with a spinal/epidural in place so that in the event of an emergency, my team could move directly to a cesarean birth and minimize the length of time my baby might experience hypoxia.
I also think there’s something to be said for the academic clinical setting and the ability of providers there to gain LOTS of experience because they see a higher volume of breech babies than in a birth center. For me, when considering my options, I definitely wanted to know how experienced my provider was in versions, her success rate, and what her threshold of comfort was in continuing the version vs. transitioning to cesarean. These are all factors that anyone considering a version should be able to freely discuss with their care team.
In sum: I adore my midwifery team and would not have had my prenatal care done any other way. I still believe and practice under the premise that midwives can and do provide evidence-based, safe, compassionate care and are the ideal care provider for a low-risk pregnancy. I just don’t happen to believe that breech presentation is an entirely low-risk condition.