I just got back from my 40 week appointment and my OB seems very concerned that the baby was not engaged. She says there is no change between last week and this (basically no effacement and 1-2 cm dilated). The baby is low, but not engaged or pushing on my cervix. During the internal she said that it seems the baby is hung up on my pubic bone.
I first want to say that I am 100% relaxed and willing to wait, but was wondering if there could be any truth to a baby being "hung up" on my pubic bone. I know last time I had a true pubic symphysis separation and this time I have very little pain there. This baby also seems to be smaller (Tommy was 10 lbs and at this point I was measuring large; I'm measuring normal with this one, but mostly this baby feels smaller to me). I have a gut feeling this one will be around 9 lbs and I also had a gut feeling that I would not go into labor before my due date. The latter was right. I guess that since last time I believe I didn't dilate because my posterior baby wasn't actually putting pressure on my cervix that there is some worry there with this one not on my cervix yet, even though I know that all this might not happen until labor starts.
So I have been wondering if there is anything that you can do to get a baby to lower. I asked on the ICAN mailing list and also am planning on talking to my doula about it. My OB also stripped my membranes again and not as gently as last week. I am now heading to the mall to "be walked" by my mom. I feel like a dog!
I'm writing this entry in parts again. I have gotten a lot of different opinions on getting a baby to drop in the last day. Mostly squats have been suggested, but in the book "Optimal Feotal Positioning" (which I highly recommend) it warns against deep squats for fear of engaging the baby in a poor position. It doesn't say what the chance of doing this is; it just says that it is now a popular practice that is overdone because of this problem. I think I'll stick to doing squats during contractions, as that feels right! I'm a little nervous to at other times as this baby does flip around from anterior to posterior (LOA to LOP). Mostly baby is LOT I think. I think Tommy engaged direct OP so early because I was coaching softball and squatting all the time (at least thirty minutes a day or more) to catch my pitchers. He engaged early and was wedged in pretty well from what it seems. My former OB was no help on that because not once did he mention he was posterior, but I know he was! I could tell from his shape in me (of course I didn't know this was a bad thing) and even after birth you could see how his legs bent up outside of me just like they were inside. He'd curl into the same little ball with feet together in front and those curves and knees off to the side that used to poke out of my belly right by my ribs. I had the classic back labor and his head had a big ridge from thirteen hours of pounding against my pelvis and not getting anywhere.
I had a little more bloody mucous last night and this morning, still not much, but I guess something is happening. The long walk we took last night felt great! My mom was very sore after, but I feel better than ever so I guess I'll drag her out with me again. She's in better shape than me so I have to laugh at that. I have a cold too and it is getting worse. I have more thick chest congestion and my throat is killing me. I think it's mainly from breathing through my mouth at night although it was getting worse right before bed as well. I am perfectly happy to wait for labor until I feel better!
Another day another entry…
I've been "walked" quite a bit these last few days by mom. She's the one who is tiring out first, not me. I have a lot of energy once I get walking! Today's walk brought on quite a few contractions and lots of pelvic pressure. I've been having snotty discharge for quite a while now, but more since this last appointment. It is now blood tinged as well. There was more blood in it today than yesterday. This morning I put in EPO in addition to just doing nights and between this morning and just now something has sure changed with my cervix and not for the better. It is still not dilated, but it rose again! It went more posterior as well and I can't feel into it because it is too high. Baby's head seems to be in the same place, but the pelvic pressure is greater. I'm heading to bed to nurse Tommy for a long time because he hasn't nursed much these past few days and I'm a little engorged! I rolled onto my breast during a nap earlier and the pain woke me! He was napping too or I would have nursed him then. He's been too busy the rest of the night to nurse and I'm just praying he'll want to now. So unless this long nursing brings on labor (which I doubt) I'd say nothing is going to happen tonight. My sore throat is now worse too, but Tommy who was also sick is feeling much better today so hopefully it will be just another day and I'll be feeling better too!
And update number three for the week…
I am now five days past-due. I had an appointment for a non-stress test and amniotic fluid level check today to asses the baby's well being. I didn't get a true NST. I wasn't having any contractions so the OB just gave up on the monitors. She checked my fluid levels and they are extremely low (only an AFI, amniotic fluid index, of 3). I got to see the entire thing and she looked and looked and all she saw was a teeny tiny pocket near the baby's head. There should be at least two pockets of fluid to have normal levels. My placenta she called a grade 3 with lots of calcifications. She said it looked pretty typical of a 40.5 week pregnancy or a little later.
The good news is the baby is in perfect LOA position and the baby looks fine! Practice breaths were being taken and the heart rate was completely normal. She saw one stretch of the baby (a full body movement) and it looked fine. Baby was sleeping though despite the OJ I drank right before the test.
She then checked my cervix. I'm still about 1cm, not effaced at all and very high. Baby is not engaged at all and basically still in the same low position s/he was last week and the week before.
After we had a long talk where she was very kind and understanding and not pressuring at all. She said that she would really like to see the baby born in the next few days before the low fluid/old placenta problem gets worse. She said that it is unlikely as low as the fluid is for me to see much of an increase. She did say the heat (mid 80s), my mild cold which is getting better, and perhaps lack of hydration could make some difference, but she doubts it would be significant enough to put me into normal fluid levels. (I doubt this too as I have drank a TON and taken baths, etc to keep my hydration up). She said that an aging placenta is actually what triggers labor so that it isn't uncommon (basically calcifications alone aren't making her nervous which is nice).
What she would like me to do is go into the hospital tonight to get some prostaglandin gel applied. She said they would monitor a little while to make sure baby was ok then send me home and then I would go back again the next day and the next and have a true NST on Friday and another fluid level check. She said that rarely does prostaglandin alone put you into labor, but she thinks it would be good to help things a little as nothing seems to be happening on its own. My mother was there as well and neither of us felt that she was pressuring me. She did say that if I didn't go into labor soon this route would be better than a more serious attempt with gel then pitocin in a week or so. She didn't mention a planned repeat c-section and didn't seem as anti-induction as a few weeks ago. She doesn't feel that the gels have a greater risk even in light of the NEJM article. Her words were "you can't base decisions at this point on one article". She knows I want a vbac desperately and is supportive. She didn't mention baby size, but I brought it up and she basically said without doing an ultrasound that she guesses 8.5-9 lbs. She feels I can deliver vaginally and that it would be odd if I had a baby much smaller than that (I feel this is a 9 lber. Tommy was 10 and this one feels tinier). I gained 2 lbs each of these last two weeks after having lost every week until then. I am at a net loss of 31 lbs this pregnancy now.
We talked a lot about the risks of more c-sections (she quoted after 3 c-sections there is a 50% chance of placenta previa and with previa there is about a 50% chance of accreta! I had never heard something that high). It is obvious she really takes the risks to future pregnancies with a c-section seriously! I'm having as many babies as God wills and I'm only 28 (well almost 28) so that might be a lot of babies. A vaginal birth is very important to me. She also talked about the rupture risks even with induction, which she doesn't think are significantly higher unless you use cytotec. I told her that even 2% or more still seems low to me and she agreed. She said if the gel put me into labor I would not have to stay in the hospital. I could leave (provided things looked ok on the little monitoring they do) and return when I felt like it. I had asked that question - I fear starting labor and being stuck there!
I'm not sure what to do. The placenta calcifications don't worry me, but there was extremely low fluid, which did worry me a little. She said that an older placenta and less fluid can cause less effective labor and the baby would also tolerate labor less. I had never heard that an "old" placenta had influence over the effectiveness of a labor.
I have pretty much decided I'm not going in tonight, but I'm thinking about tomorrow. For one thing I want a day or two for this cold to get better before I go into labor! Plus my mom is worried about bringing a newborn into a house infested with colds. Tommy and I got sick mid week last week then Tom and my dad started in and my mom just got it now too! I have a lot of thinking to do in the next few days.
I have gotten some feedback from people on the ICAN list about the inaccuracy of fluid levels by ultrasound. I have read up on low fluid levels and I really don't think this doctor missed pockets. I watched the entire ultrasound and she checked long and hard looking for pockets. She didn't rush and she covered my entire belly several times over everywhere. I had gel from hairline all the way down each side and up to my ribs and she combed every area slowly several times! There were no dark spots (dark means fluid) on that ultrasound! She checked the abdomen of the baby for fluid to count as a pocket and found none. She checked the kidneys to make sure they looked ok as well (they look fine). I also am well hydrated as I have been taking in tons of fluids these last several days. I really and truly believe my fluid levels were extremely low. She said if they were double they would still be very low. If I do decide to go with the gel I will request another fluid check at the hospital before I get the gel. Maybe things will look different, but I doubt it!
I do trust this doctor. She never once pulled the "dead baby card" out (a common saying where the doctor says you better do this or you might end up with a dead baby. My last OB did this kind of thing a lot). She left every decision up to me. I think this makes it even harder! She easily could have scared me, but she logically and intelligently discussed things with me and didn't push her opinion at all. She even helped explain the risks of another cesarean to my mother in detail. This doctor really wants me to have a vbac! I am feeling really great about my choice of OB now.
I have done some reading on fluid levels (using Obstetric Myths vs. Research Realities in particular as a reference to find studies) and nothing in there makes me feel better. The studies say that they don't know if inducing helps outcome in low fluid, but that there is more of a risk of cord problems and fetal distress. There is no study that I can find that says low fluid doesn't mean more risk or that it is better to just wait it out. There is also no study that says it is better to induce. There is a lot of information on how safe postdates are when the tests look good, but in this case the tests aren't looking good! What if I don't go into labor in a week or so? Wouldn't it be better to induce now when the baby is strong and more able to tolerate labor than to wait and have the baby be less strong? I'm not talking about a dead baby, but I'm talking about the difference between a labor where I can move around and stay upright and one where they see things they don't like and want me stuck in bed on my left side to monitor! Plus this doctor isn't talking a full on induction. She says that with the gel I will go into labor if my body was ready, but it won't put me into labor if I'm not ready. She understands I don't want to follow up with pitocin to get labor going and she thinks that is fine. She isn't talking no turning back induction (although I know of people who were similarly unfavorable like I am and who have gone into labor with gel alone! One is a good friend who had a mere 5 hour long vbac labor on an unfavorable cervix after a single gel application). She was very supportive of me still being able to head home to labor until I was ready for the hospital if the gel does put me into labor.
Ultimately while I want a spontaneous labor and a perfect birth what is most important to me (aside from a healthy baby which is the most important thing of course!) is a vaginal birth. Induced, not induced, long, short, whatever I don't care. I just want a vbac! I won't consider it a failure if I get some gel to help things along. I just wish I could be told somehow with certainty that if we wait everything will be fine. I was prepared today to fight a borderline fluid level. I was not prepared to be told and to see for myself that there was only one pocket less than one centimeter! Statistically the longer I take to go into labor from now, the higher the chance of problems, especially problems related to low fluid. I feel like I'm damned if I do and damned if I don't! If I do the gel and go into labor and the baby goes into true distress I'll blame myself for agreeing to it. If I don't and the baby goes into distress in a week or so than I'll blame myself for not going with the gel!
Obviously I didn't go in tonight for gel, but I think I'll call the OB again in the morning and talk to her some more. My cold is feeling much better this evening, perhaps the long cry I had while on the phone with a friend drained all the mucus out. My sinus headache is gone and my ear isn't feeling any pressure. Hopefully I'll go into labor during the night tonight and all of this will be irrelevant!
