One of my long-time patients is due to have her fourth baby in a few weeks (she gave me permission to tell this story). She was measuring kind of big, so we got an ultrasound to see whether everything was okay.
The obstetrician who did the ultrasound told her that this baby was pretty big (seven and a half pounds at 36 weeks) and in the breech position. The baby was head-first a few weeks ago. He suggested that she talk to me about having a cesarean for the birth, although she has had three vaginal births in the past.
At the next office visit, we talked about the options:
- Wait for labor, and if the baby is still breech, she would have a cesarean. (No one in my practice offers breech vaginal deliveries routinely. Plus this baby is much bigger than her others, so it wouldn't be advisable).
- Schedule a cesarean for 39 weeks, and proceed as long as the baby is still breech at that time.
- Try to get the baby to turn back to a headfirst orientation.
After discussing the pros and cons, she chose to turn the baby.
How do we help a baby to turn?
- Exercises can be done at home to try to elevate the baby out of the mother's pelvis, so he can turn himself. These involve having her hips higher than her shoulders, either by going on all fours with her shoulders on the floor, or lying head down, face up on a slant board (with a strong person to stabilize and spot for her).
- Moxibustion, the burning of a Chinese herb, has been shown to be successful at helping babies turn. I don't know any Chinese medicine doctors in Cleveland, so I didn't offer this.
- External cephalic version, in which the doctor moves the baby by pushing on the mother's abdomen. This is typically done on the labor and delivery unit, in case of complications.
Currently our plan is to try the exercises at home for a few days, and then to come in to the hospital for external cephalic version. We will ultrasound first to check the baby's position, and if it is still breech, I will try to move the baby around.
External versions are sometimes very easy. Other times, especially with first babies, the buttocks are wedged into the pelvis, and it just doesn't go. When the mom has had several children before, the butt is usually not deeply in the pelvis, and the mother's abdominal wall is not usually overly muscular.
My patient isn't overweight, and there is lots of fluid around the baby. She has never had surgery on her uterus, which might make it riskier to manipulate her uterus like this. All in all, this is probably the best sort of situation for an external version.
Addendum: The version was really easy -- she got an injection of terbutaline, a medicine similar to caffeine that has the side effect of temporarily calming the uterus, then I cupped the baby's head and butt in my hands and pushed the baby into a forward somersault.
In less than a minute, the ultrasound showed the baby to be in perfect position, head first. No heart rate problems, no pain. And now two weeks later the baby is still head down. Just waiting for signs of labor...