38 weeks! position, pelvic rocking, sacrococcygeal teratoma

Okay, I'll take the hint and make this a new thread.

Anne, I make a distinction between the positions of the baby's body and
the baby's head. Let's say I look down. My belly button is at 12
o'clock, my spine at 6 o'clock. For the past 2 months at least, the
baby's spine has been somewhere between 1 and 3 o'clock. So far, so
good.

When the head engages, it should turn so that the back of the head
(occiput) is toward 12 o'clock (occiput anterior) or 6 o'clock (occiput
posterior). I am concerned that the baby is tending to go OP rather
than OA. That is how it sometimes feels (ie, it feels very different
than when Monkey Boy's head engaged). And, as seen in ultrasounds 1-2x
per week plus an MIR a few weeks ago, the baby's occiput persistently
has been at 3-4 o'clock. Also tending toward OP.

(Re pelvic rocking to encourage OA over OP, this paper says pelvic
rocking apparently does not work: Randomised controlled trial of
effect of hands and knees posturing on incidence of occiput posterior
position at birth. Azar Kariminia, Marie E Chamberlain, John Keogh,
Agnes Shea. British Medical Journal 2004. Free PDF:
http://bmj.bmjjournals.com/cgi/repri...42.594456.44v1 )

I am still on course for a spontaneous vaginal delivery. I have opted
out of planning to induce, at least for now. The emphasis at this
point is on reducing the risk of the baby aspirating meconium. The
baby will need to be in tip-top shape to cope well with the pending
surgery to remove the sacrococcygeal teratoma. This is particularly
important because the baby is measuring so small (just 7th percentile).

I really, really don't want a C-section. I hope to have an
uncomplicated labor and delivery, but if it does get complicated I
think I had better consent to a C-section sooner rather than later.

Anne, I make a distinction between the positions of the baby's body and
the baby's head. Let's say I look down. My belly button is at 12
o'clock, my spine at 6 o'clock. For the past 2 months at least, the
baby's spine has been somewhere between 1 and 3 o'clock. So far, so
good.

which is varying between ROA (1 o'clock) and ROT (3 o'clock).

When the head engages, it should turn so that the back of the head
(occiput) is toward 12 o'clock (occiput anterior) or 6 o'clock (occiput
posterior).

No, that is wrong, the baby should go through the pelvis LOA or ROA, after
the head is through, thena slight turn is made, so that it looks like the
baby went through the pelvis just OA, but in fact it went through either
side turned to give the best route for the shoulders. It's typical that
yesterday I had a good picture of this, but now can't find it. You really
don't want the baby to enter the pelvis OP, which leads to back labour, and
if the baby doesn't turn, which rarely happens once they have entered the
pelvis, the outcome for vaginal birth is pretty poor, particularly in first
timers, but noticeably so in multips too, many tecnhniques for turning OP
babies involve preventing the baby entering the pelvis, or encouraging it to
come out to allow turning, then once it has turned, exercises to encourage
engagement in the correct postion.

http://www.who.int/reproductive-heal...s_S69_S81.html
here's the piccies, figure S-11, shows all the anterior positions, other web
pages will emphasise that LOA is best and you can see reasonably well in
that diagram that the size of what is coming though is bigger in straight OA
and so less favourable than LOA and ROA. It doesn't give a picture of
posterior postions, but the text indicates it causes plenty of problems,
though I strongly disagree with some of the suggested management.

I am concerned that the baby is tending to go OP rather
than OA. That is how it sometimes feels (ie, it feels very different
than when Monkey Boy's head engaged). And, as seen in ultrasounds 1-2x
per week plus an MIR a few weeks ago, the baby's occiput persistently
has been at 3-4 o'clock. Also tending toward OP.

not quite the same as what you said above about it should enter OP, I wonder
if what you mean is that if baby enters the pelvis (x)OA, or OP it can go
through (but with much lower chance/more interventions with the latter), but
if it goes in OT, it doesn't. Remember though, that engagement before labour
is a phenomenon of 1st time mums, though it does happen for others, but as
long as the baby is not engaged, there is plenty of time for it to turn,
including early labour, unpleasant though that can be.

(Re pelvic rocking to encourage OA over OP, this paper says pelvic
rocking apparently does not work: Randomised controlled trial of
effect of hands and knees posturing on incidence of occiput posterior
position at birth. Azar Kariminia, Marie E Chamberlain, John Keogh,
Agnes Shea. British Medical Journal 2004. Free PDF:
http://bmj.bmjjournals.com/cgi/repri...42.594456.44v1 )

I only had a very quick look, but a few things spring to mind, they were
only doing 10 mins twice a day and they may have then been sat in a recliner
the rest of the day and undone all the good work. The anecdotal evidence is
generally very good. I'm glad that some research has been done, but I hope
it's inconclusive outcome doesn't prevent others from doing more.

I am still on course for a spontaneous vaginal delivery. I have opted
out of planning to induce, at least for now. The emphasis at this
point is on reducing the risk of the baby aspirating meconium. The
baby will need to be in tip-top shape to cope well with the pending
surgery to remove the sacrococcygeal teratoma. This is particularly
important because the baby is measuring so small (just 7th percentile).

you had Monkey Boy before 40 weeks, IIRC, which means there is probably a
good chance your going naturally before that point, or not long after
anyway. I presume you/they are thinking about passing meconium being
something that postmature babies do? I'm fairly sure that the incidence of
meconium aspiration is lower in babies that pass meconium, it seems that
babies that pass meconium for other reasons (usually foetal distress) are
then more likely to go on an aspirate it, even so, meconium asipration is
still pretty rare and if it does happen, a good proportion of cases are
relatively mild and just require a bit longer of monitoring. It would be
interesting to find some research on meconium passing and asipration an
induction, that being an unnatural situation, it makes me wonder if more
babies pass meconium? It may be that inducing at 40 weeks for the reason of
minimising risk of meconium aspiration actually doesn't land on that side in
terms of statistics.

I really, really don't want a C-section. I hope to have an
uncomplicated labor and delivery, but if it does get complicated I
think I had better consent to a C-section sooner rather than later.

I very much get not wanting a c-section, I was absolutely petrified of them,
and got really anxious at one point in my first pregnancy when I realised
how high the c-section rate was and that was a big factor for planning a
homebirth (though it ended up as induction, on a very favourable cervix,
with a perfectly postioned baby!). In my 2nd pregnancy I had this awful
realisation at about 36 weeks that the best thing for me and that baby was
c-section, it took me 2 weeks to even verbalise that, when I eventually did,
the doctors did not take my concerns seriously, I had the birth from hell,
and now have severely restricted mobility and a lot of pain. Had I had a
more rational view of c-section, that it was good in it's place, but
something I wanted to avoid if it wasn't necessary, then I'd have fought
harder to go that route and might have got the message through and things
could have been very different.

Have you thought about what in labour would make you go that route, I mean
there are complications that can happen in labour which are easily managed,
others that might make labour difficult, but in no way less safe for either
of you. Suppose baby is posterior when you go into labour, chances are it's
going to progress more slowly (didn't you have precipitate labour last
time?), but what do you do about that, what are your techniques for managing
a back labour etc. then suppose baby is still posterior by the time you get
to pushing, how long are you going to give it? Does your baby's condition
change any of these from one where there was no concern about the baby? In
the end, as this baby can be born vaginally that is better for it as well as
you, I'm sure you know about the contractions preparing the lungs for
breathing and that c-section as a higher incidence of respiratory distress.
It seems to be that position is a big concern for you, but don't stop
believing in yourself, plenty of women go into labour with OP babies and
they turn and are born normally, some are born in that position and yes,
some do have problems and are forceps or c-section, but there is plenty of
stuff you can do to minimise the risk of that being you and your baby.

Boy, this has turned out to be long! In the end, if you do end up deciding
induction is the best route, the best things you can do for postion are
don't break the waters (if poss discuss in advance as it's often part of the
protocol for induction), stay mobile, avoid epidural.

Good Luck

Anne

"Pologirl" wrote in message
oups.com...

I am still on course for a spontaneous vaginal delivery. I have opted
out of planning to induce, at least for now. The emphasis at this
point is on reducing the risk of the baby aspirating meconium. The
baby will need to be in tip-top shape to cope well with the pending
surgery to remove the sacrococcygeal teratoma. This is particularly
important because the baby is measuring so small (just 7th percentile).

Pologirl,
I'm just so pleased and happy for you each week you post. 38 weeks is
wonderful!

I went into spontaneous labor at 40 weeks with Grant. We saw a group of
perinatologists during the last part of the pregnancy, and they had a policy
of seeing a different one each time (yippee). I had many mentions of
c-sections and inductions (you will be induced, etc due to low amniotic
fluid, blood pressure borderline, and GD). Two doctors were on my side, and
I saw one at 39 weeks who told me not to bother monitoring twice a week
(once was just fine he said, twice didn't change outcome), and he didn't
breathe the word induction. Whew. The next week, the day before my
appointment I was sure I'd be told I'd have to be induced, I woke up with
contractions, eventually realized I was in labor, had an hour and 45 minute
drive, and birthed him within 20 minutes of arrival. I don't think this was
at the doctors' convenience, but I believe it was the best thing we could
have done for Grant. He was so healthy for being so "unhealthy" if that
makes any sense. He underwent surgery within four hours after birth, was
breastfeeding at two days after birth, and was released at 6 days after
birth (it was an expected stay of at least 10-14 days). I think his birth
had a huge impact on his ability to nurse and heal.

Has your baby been measuring small all along? Or is this a recent
development? G measured two weeks behind in all his u/s. This was within
"normal", though they expressed concern. If they had known I fudged the
LMP, putting him actually at three weeks behind, I think they would have
been in a snit. He was born at 7 lbs 14 ozs and shy of 21 inches long.

I really, really don't want a C-section. I hope to have an
uncomplicated labor and delivery, but if it does get complicated I
think I had better consent to a C-section sooner rather than later.

I hope you don't have to have a c-section. I remember stressing a bit
about whether I wanted to be induced and possibly ending up with a c-section
or going straight for it. My preference was spontaneous labor, and
fortunately that is the way it worked out. You are doing a tremendous job.
Thinking of you!

Joy

Joybelle wrote:
I'm just so pleased and happy for you each week you post. 38 weeks is
wonderful!

Thanks! I can hardly believe it myself.


He was so healthy for being so "unhealthy" if that makes any sense.

That makes perfect sense. You cooked him just right, so he was as
healthy as he could be, apart from the NTD and its consequences. And
you managed those issues really well too.


Has your baby been measuring small all along?

Yes. And 7th percentile is 2(+) weeks behind. But this baby probably
will weigh more than Monkey Boy, who was 5lb 12oz and 18 inches at
birth. This baby now is estimated to be 5lb 11oz, based on femur
length, abdominal circumference, etc. But with all the US and MRI
scans I can see this baby is clearly plumper than Monkey Boy was.

Anne, you and I are saying the same thing; we're just not
communicating well. :-)

The baby is teasing me now, engaging head in pelvis (it feels like I am
walking around with a softball jammed in there---or so I imagine that
would feel. Hrm.) then popping back out. But lately baby's spine has
been more anterior than transverse, which is good.



Anne Rogers wrote"
you had Monkey Boy before 40 weeks, IIRC, which means there is probably a
good chance your going naturally before that point, or not long after
anyway. I presume you/they are thinking about passing meconium being
something that postmature babies do? I'm fairly sure that the incidence of
meconium aspiration is lower in babies that pass meconium, it seems that
babies that pass meconium for other reasons (usually foetal distress) are
then more likely to go on an aspirate it, even so, meconium asipration is
still pretty rare and if it does happen, a good proportion of cases are
relatively mild and just require a bit longer of monitoring. It would be
interesting to find some research on meconium passing and asipration an
induction, that being an unnatural situation, it makes me wonder if more
babies pass meconium? It may be that inducing at 40 weeks for the reason of
minimising risk of meconium aspiration actually doesn't land on that side in
terms of statistics.

On PubMed there are abstracts of many medical research papers that
discuss rates (and risks for) both meconium stained amniotic fluid
(MSAF) and meconium aspiration syndrome (MAS). MAS is life
threatening, in fact it is a major cause of neonatal death, and it only
occurs if the baby passes meconium in utero. But it does not always
occur. Even if the baby aspirates, there are additional risk factors.
For example, MAS is likely only if meconium is aspirated into the
trachea (windpipe). Meconium in the nose, mouth, or throat, but not
the trachea, is unlikely to cause MAS. For that reason, some
researchers advise caution in suctioning, so that the procedure itself
does not introduce meconium into the trachea. Going post-dates, and
inductions, both contribute to MSAF and hence to MAS.

I am more likely to agree to a C-section than to a chemical induction.
That is because my labor with Monkey Boy was precipitous (under 3 hours
from start of contractions to birth), and induction can make an already
precipitous labor even faster. Although I coped well with Monkey Boy,
I would not want this labor to go any faster. Too fast increases risks
of tearing the cervix and other internal organs (never mind the
perineum) and of abruption.

I have been reading a lot on PubMed, and I gather that good fetal
position is an important (very important!) precursor to a safe and
efficient labor and delivery. Hence my current focus. I also gather
that access to C-sections seems to encourage many obstetricians to
ignore fetal position.