Natalie Portman

Hi, friend, and welcome back to the podcast. I am thrilled to have Dr. Marrow with us today. She's a board certified O-B-G-Y-N, vbac, mom of two and practices at Full Circle Women's Care. My favorite O-B-G-Y-N practice here in Jacksonville, Florida. We're talking about a topic that can feel stressful for many moms. Fetal malposition, we'll cover ways to help baby get into an optimal position for a vaginal birth. What happens if baby is breach or transverse and procedures like ECV to turn baby head down? Marrow, thank you so much for joining me today.

Naicie Marrow, MD

Thank you so much for having me, Natalie. You know, you're definitely one of my favorites as well.

Natalie Portman

Oh, I know you guys literally are the best. I think it's Dr. Adams will say like boutique birth experience. And that's what I feel you guys really do. Try everything you can to just make it a unique experience that you're not just a number, you're not just somebody showing up and you're just gonna be run of the mill patients. So you guys really care and I love that.

Naicie Marrow, MD

You make the job easy. And we appreciate that more than anything, just the support that you provide. And you know, we're all out working to increase the experience and, and safety with birth and, you know, always, always grateful to see you in the room.

Natalie Portman

Oh, thank you. I appreciate that. Well, today we're kind of touching on a subject that is not talked about a lot, honestly. And that's, whenever a mom should, start paying attention to her baby's position. you know, If a mom hears at her 20 week anatomy scan, oh your baby's breech, and mom hears that and she might be freaking out, but when is a time that's appropriate to start C Clueing into, okay, what position is my baby in? And when should that start getting on her radar?

Naicie Marrow, MD

Great question. So in the first and second trimester. It's a swimming pool. Baby has, you know, full lay of the land and is free to move around as it desires. We really start to take interest in fetal position at about 32 weeks with just kind of feeling around and seeing where things are. Maybe recommending some different positioning to help 36 weeks, we really need to know the position of baby, whether that be through ultrasound or with fetal mapping. So that we can make plans for ECV by 37 weeks. So certainly we should be, you know, placing hands on mamas by 35, 36 weeks so that we know what we're dealing with moving into the late third trimester.

Natalie Portman

Yeah, that's awesome. And there's a tool called Belly Mapping that Spinning Babies teaches, and I put that on my client's radar. just a fun activity to start doing at like 32 weeks and on. And I mean really before then, if you're trying to feel that baby. Yeah, they're moving so much, they have so much room to move around. So yeah, that's really, really helpful. So when it comes to, mom is realizing, okay, my baby is in a, breach presentation, a transverse presentation where they're laying completely sideways in the uterus which, you know, transverse is impossible to deliver vaginally, a baby cannot. Go through the pelvis that way. Or even something like a posterior presentation or sunny side up. what are some things that a mom can do when she's realized, okay, my baby is in one of these mal positions.

Naicie Marrow, MD

So first we like to take kind of a holistic approach if we can, working with chiropractors to help realign the pelvis. Acupuncture and moxibustion have been shown to have some benefits. We try those things first once we, you know, realize that those things aren't being successful. There are a few other techniques that we do recommend for your breach baby. We typically recommend. Spinning babies which is a, a really neat program. But basically there are different positions that we ask for you to get in including like forward-leaning inversion, which is basically you standing on your head sideline laying. Which is when we kind of lay you on your side with your left leg crossed over. And then rebozo can really be helpful. Rebozo is when you take a sheet or a long cloth and you put mom in knee, chest and sift baby to help disengage from the pelvis and then hopefully realign back in the right direction. So those are some techniques we can use for breach babies, for babies that are op so head down but not really facing the right way or sunny side up. There's something called the miles circuit and again, there's open knee, chest where you are on your hands and knees with your bottom higher than your head. Hopefully getting able to disengage, followed by left lateral lying. And then some asymmetrical stepping or be upstairs or curb walking just to help baby reposition back into the pelvis in the right direction. So those things we recommend particularly for a breach baby, you know, we try them up until the day of the ECV if you decide to move forward with that. An ECV is an external cephalic version where we manually will rotate your baby. And for your baby that's head down, but perhaps Asynclitic or op, we ask that you do the mild circuit until you go into labor.

Natalie Portman

those are all things that I recommend to my clients as well. And there's a, a good handout that the miles circuit is available on the internet, but I'll just link a, a handout for that 'cause that is super helpful. I personally find it very uncomfortable, especially that first position to do the miles circuit, but if you're doing it correctly, it's kind of uncomfortable. I have had some clients that are like, it's comfortable and I'm like, okay, we might need to talk about that, because you're probably not doing it right. It is very uncomfortable because you're, you're putting so much of your weight forward really if you have somebody helping you, like they have a sheet or a rebozo kind of helping you keep that position, that's like the only way I personally could ever do that that first position for the miles circuit.

Naicie Marrow, MD

side lying is the other one. Like people are like, oh, you know, I'm so comfortable. I'm like, no, then you're not turned enough you should be almost laying on your belly and just flip that leg over. This is not for comfort.

Natalie Portman

I completely agree. Yeah. And so let's talk more about the ECV. I have personally witnessed you do a couple e cvs. And they're so, like, honestly, they're kind of exciting to watch. I know for mom, it's very intense. I personally have not had an ECV, but I've witnessed a handful. And the success rate is what, about 50%.

Naicie Marrow, MD

Correct. Somewhere between 50 and 60%.

Natalie Portman

Yeah. And, and I have personally seen, and this might also be what you've seen, it's usually more successful with mamas that this is not their first pregnancy. Usually the uterus has stretched before and it just has a little bit more room. Is that what you've seen as well?

Naicie Marrow, MD

Exactly. The studies do indeed show that we're gonna be more successful in women who've had more babies and with the use of tocolytic agents or agents that relax the uterus and also with the use of epidural smaller babies are easier to turn. Posterior placenta can make it a little bit easier just 'cause we don't have that cushion, you know, of the anterior placenta. It can still be done with the anterior placenta, which is something that I think may be a miss. You know, people don't really think that we can, but we can still do it. It does make it harder though. And then maternal weight makes a difference. So it's gonna be a lot easier on women with lower bmi just 'cause we are able to get in and manipulate baby a little bit easier. If your baby's transverse, half the work is already done. So if the baby can give us a little bit of tilt beforehand, it, it makes the, the turn a little bit easier. Those direct breach babies, you know, it's a, it's full turn.

Natalie Portman

and also to mention, like you had mentioned at the top as an option is the spinning babies.

Naicie Marrow, MD

Mm-hmm.

Natalie Portman

if baby does not turn with the spinning babies the techniques used in that increased the chance that the ECB would be successful because the spinning babies kind of catchphrase that she uses is like we're creating room for the baby to be able. To find that spot. Like baby can only go where it has the room, right? And if baby doesn't wanna flip, there's always a reason for that. So, you know, even trying those techniques ahead of time are going to increase the likelihood that the ECV will be successful. And I've witnessed I think one ECB with an epidural and yeah, it is really helpful otherwise. It's like going into labor. The, the intensity of that sensation. And that's really why a lot of my clients will still ask me to come to an ECV is because I'm gonna be there to kind of just help them relax breathe. We're gonna do some of those releases just before the ECV is attempted, just to give the body and the mind the best chance to just allow it to, to happen.

Naicie Marrow, MD

Exactly. The epidural isn't necessarily magical but what it does is create comfort for the patient. It really is an intense experience to have an ECV. It's an intense experience. We do have probably about 50% of our patients do them with epidurals and 50% that don't. Those who have had some sort of birth prep do so much better because they're able to keep those ab muscles relaxed, and that's what's really important. You respond appropriately when there's a. Large human pressing on your belly. The ability to be able to relax during this procedure is so important 'cause we don't have a lot of time to work. And we don't always have the opportunity to go back and put that epidural in later. And so I always, always give a little tester push as I'm doing my initial assessment and I'm like, okay, if this is not comfortable for you, then you should consider getting an epidural. So I do try and just kind of give them, I give them about 50% and 50% is a lot, and if 50% is, you know, is not working out, then epidural is, is an option. That doesn't mean that you can't then go on to have an unmedicated birth, but this procedure is different. This is, this is different.

Natalie Portman

it's not a contraction. It is, it is a manual manipulation your, your

Naicie Marrow, MD

This is not a, you know, a 32nd, contraction that you can then have a five minute break. This is constant activity for several minutes on your abdomen. So it is, it is not, I always tell people there's no reward for suffering. And ultimately our goal is to get you your unmedicated birth later. So let's, let's do it.

Natalie Portman

Yeah, definitely. The other benefit too, if you do decide to get the epidural, is if there is some emergency where baby is

Naicie Marrow, MD

Exactly

Natalie Portman

well to the ECV and you need to rush back for a C-section. You already have an epidural in place. a much better chance that you will be awake during that C-section than if it's a true emergency, you're gonna go under general anesthesia. If it's, if it's, you know, a truly a medical emergency.

Naicie Marrow, MD

Right. And as we'll probably get into, while that is a risk, it's exceptionally rare. And so while, you know, that shouldn't be the primary reason, it is something to consider, but by and large, these procedures are very, very safe. And. I've been doing this for, I think I counted 15 years the other day, which is crazy. And I've never had one result in an emergency that required a cesarean delivery as its outcome. So still a very safe option. We do see drops in the baby's heart rate during the ECV, which almost always will resolve once we discontinue the procedure. That doesn't mean that anything bad is happening, just, you know, babies. Telling us I don't like that position. Let's go back to where we were. And it doesn't always mean that we need to stop. We just may need to adjust what we're doing.

Natalie Portman

Yeah. That's awesome. What other risks are important for a mom to consider if she's in this position of possibly needing to entertain this as an an intervention for her? You know, baby.

Naicie Marrow, MD

So we talked about the heart rate changes. That is the most common risk. Almost always they resolve once the procedure is discontinued. There is a very low risk of placental abruption breaking your water and umbilical cord prolapse. Less than 1% for all of those, And then we talked about the risk of the heart rate not coming back up and ending up in an emergency C-section again, exceptionally, exceptionally, rare by and large it's a very, very safe procedure.

Natalie Portman

Thank you for sharing that. Yeah, I, I think there's a lot of moms that, you know, hear about the intensity of the procedure and they're like, I don't wanna go through that. And that is absolutely every woman's right to, to make that. Choice. But for the moms that are willing to kind of just wrap their head around that experience might be like, what the known risks are, and then just evaluate is attempting this worth attempting a vaginal delivery? Potentially. Hopefully. But what about if the procedure is. Unsuccessful and, most providers at this point are going to schedule a c-section. I wanted to just hear your thoughts on this, but why is it that most providers, OBGYNs, specifically, are recommending a C-section for babies who are not head down? And are there ever any situations where a vaginal delivery might still be an option, even if baby is breach

Naicie Marrow, MD

so that's a great question. Up until about 2002 vaginal breach deliveries were a lot more common. In 2002, there was a very large study that took place or it was actually like a retrospective a multicenter study where they looked at a bunch of breach deliveries that were vaginal. And then breach deliveries that were cesarean. And by and large the risk of perinatal mortality. Neonatal mortality and significant morbidity or injury to the baby was significantly lower in the vaginal delivery. Group. Those numbers were about. Fourfold different. So there was about a four fold increase of poor outcome with vaginal breach deliveries rather than vaginal cesarean deliveries. And because of that, the American College of Obstetricians and Gynecologists then recommended that the breach vaginal delivery was no longer an appropriate way to to manage the breach baby. So since the early two thousands, there's really been a significant shift to delivering babies that are breached via cesarean delivery. And unfortunately not a significant shift to trying to turn those babies. So we are seeing more cesarean as a result of that. There are scenarios where a vaginal delivery. Of a breach baby may be appropriate. Certainly in a mom who is a multiple or who have had multiple babies. A baby that is on the smaller side and having your baby with a provider who is comfortable with breach vaginal deliveries. And this should be a planned scenario. This is not something that should just happen on, on the fly. I always tell. Our mamas. If a provider tells you that they're not comfortable doing something, they mean that. And sometimes we'll see situations where. People are like, I'm just gonna show up in labor. And I don't recommend that because if someone tells you they're not comfortable with something, they mean that. And there can be significant poor outcomes with vaginal breach deliveries if you aren't well skilled in doing so. And so there are certainly case by case basis where a breach baby can be born vaginally, but it's something that you should talk about very early on with your provider and make sure that they're comfortable and well skilled in that technique.

Natalie Portman

I've also heard that, if you're having twins or multiple babies where maybe that's also an appropriate situation if one of the first is head down and then you, the subsequent maybe is, is breach.

Naicie Marrow, MD

That is a little bit different because those babies are typically much smaller. And so the risks are so much less with the smaller twin baby that many providers will feel comfortable delivering the twin B breach but not a singleton, you know, eight pound breach baby.

Natalie Portman

Yeah, my best friend was actually born a vaginally breach back in like the early nineties, and I was talking with her mom about the birth because it, you know, back then was kind of starting to fade out. her provider told her, yeah, you were probably one of my last vaginal breach deliveries. But I just thought that was so fascinating that, you know, I knew somebody personally, my best friend that her mom had that experience.

Naicie Marrow, MD

I trained in 2009 to 2013. So that was kind of where breach vaginal term deliveries were really falling out of favor. And certainly now because the recommendation is to not even attempt it anymore. We aren't training people to do them. And and so yes, while it is unfortunate that it is not necessarily an option in a lot of places these days, people aren't trained to do it, and so they shouldn't even be attempting to do it.

Natalie Portman

Yeah. And you know, you're somebody who has also been through your own birth challenges. I don't know if you wanna go into a little bit of that. But, but now you're helping other women, you know, navigate theirs. The, the way full circles practices is that midwives are handling those low risk moms low. Births pregnancies, and then the obs are there to step in if and when needed. You know, when things just are getting a little bit more complicated or complex throughout the pregnancy or the birth experience, but what advice would you give to a mama? Just to help her process the emotions that come up with a birth plan that is not really going according to plan. And I think just even your, personal experience in that I'm sure informs how you support those mamas when they're in that situation.

Naicie Marrow, MD

Exactly. So a little bit about my backstory. As I mentioned, I started ob GYN training in 2009. I had my first baby just out of residency, a new attending in 2014. As someone who had delivered hundreds upon hundreds of babies, I thought I had it all figured out. I'm an OB GYNI know, I know everything. I'm young, I'm spunky. I'm, you know I ended up developing gestational diabetes in pregnancy and needed an induction at 39 weeks. What I actually had was a lot of birth fear because of my, my training to, to be honest, I. You know, birth is beautiful, but I don't always get to be a part of the beautiful things. And so I carried a lot of birth fear into my experience. I went in for my induction. I had my epidural before I was two centimeters. I was bed bound. I did not move. I arrested and ended up with a cesarean section for my first baby. Second time around, I, met my good friend and now partner Dr. Adams, who was very clear that I was not doing that again and put me in touch with some wonderful doulas here in town who worked with me with hypnobirthing and with birth support. Second time around, same medical problems, same induction situation, completely different preparation. I was able to have a successful trial of labor, a successful vbac with my second baby who was bigger than my first baby. And I know that was because I. Was prepared rather than really succumbing to the fear of birth like I did the first time in terms of my piece of advice definitely. Create the experience that you desire, but be flexible within that. I think one of the first lessons of parenting comes through pregnancy and labor. Nothing is predictable. Set yourself up with a team that you know has your best interests in mind with your doula and your delivery team, and, ensure that they're gonna work to make things as beautiful as possible, but also be flexible as things change. Particularly as it relates to kind of baby positioning. When you do everything that you can and your baby is still breach or op or whatever, that is not failure. That is a change of plans and that's okay. Birth is beautiful regardless of the route. And I think when we become more accepting of that everybody ends up in a healthier space afterwards.

Natalie Portman

that's beautiful advice and the phrasing that I use a lot is we get to steward the things that we can, we get to, to just. Do the best we can with our, our head knowledge, our heart posture, the physical preparation, but that none of those things guarantee any sort of outcomes because it doesn't, there is so much more that's out of your control and when you tie your worth to the outcome of your birth, as if. That's a reflection of like your strength or your preparation or whatever. No, like it, it's a complete utter lie. And I think that when you can make that disconnect in your heart and mind of, I, I cannot control the outcome, but I can control these little things, the foods I'm eating.

Naicie Marrow, MD

Exactly.

Natalie Portman

Am I taking care of myself? Am I making sure I'm not stressed out of my mind? My whole pregnancy? Just doing whatever you can in the capacities that you know you can control, and the rest of it you give to God and you, you give it to your providers who, again, have to be in your corner. And I think that's one of the first things that I go over with my doula clients is I ask them, who's your provider? How did you choose them? Do you feel like they're gonna support you with the type of birth experience you're hoping to have? a lot of the time my clients are going with, with you guys because you are aligned with what they're hoping to accomplish, especially if they're involving a doula in the team. Because there is, like you're saying, that collaboration there. So it's like we're all working towards the same goal. So yeah. Who you're choosing as your birth team, especially your provider. Is huge. So thank you for, for just sharing that. 'cause it, it is so true. What would you want every pregnant mama to know about fetal positioning? What encouragement or practical advice would you share?

Naicie Marrow, MD

Firstly, make sure position is being evaluated. Your provider should be putting hands on you somewhere into the third trimester. To see which way baby is lying. If your baby is breach early on, ask your OB if they're comfortable with ecds if not, and that's something you think you'll be interested in, it may be worth putting some feelers out and seeing if you can find the provider that is comfortable. If. Your baby is uh, or a breach. Believe in the science. Those exercises that we give you do work, but you have to do them. So help us, help you. If your ECV fails or you decide against an ECV. Delivery is at 39 weeks. We don't want to be sneaky or just come into labor or push back the cesarean because coming into the hospital with a breach baby in labor is chaotic. You will not get the birth you desired, and the outcome may be traumatic or even worse. There may be a poor outcome. So if you've done all the things and we've decided that the cesarean is the next move, it's 39 weeks, please meet us there on that day. And like I said if your provider tells you they're not comfortable with something, they mean that. So honor that and develop a plan that works best for, for everyone involved.

Natalie Portman

Great advice. Yeah. And again, going back to not seeing a cesarean as a failure of a birth, that just because that was probably not your plan, a means that you did not have your baby, does not mean that you didn't do all the things correctly to have the outcome you wanted or anything like that. Those things are not tied to you because those are things out of your control. So. I just, I love the, the practical advice that you shared, but also bringing up those reminders that you can do all the things and still not, have that vaginal delivery, but that does not mean your birth is not going to be beautiful and you're gonna meet that precious baby that you have been working so hard for and, have a beautiful experience and outcome.

Naicie Marrow, MD

And I love that there's a trend now with Start moving towards the gentle cesarean. And so that's another good question to ask about early on. What is your approach to the cesarean delivery? What things do you offer in the operating room? Because, you know, in the unlikely but possible event you do end up there. You you do want to understand what, your experience will be in the operating room as well.

Natalie Portman

Yes. I'm so glad you're bringing that up because at this point, I think you guys are the only provider here in Jacksonville that is offering a gentle cesarean. Can you tell the mama who's listening about what that involves? And if that's not something that her provider is aware of, what are some reasonable things that she can maybe ask for to accommodate a more gentle cesarean approach?

Naicie Marrow, MD

it's all about creating a calming experience in the operating room. The operating room can be very scary, very cold, and so whenever possible, we try and increase the comfort. We turn the lights down low in the operating room so that we're just operating with the spotlight. It just creates a nice mood. We allow our mamas to bring music in. So whatever playlist you created for your vaginal birth, bring it. We love a good time. We love a calm time. We love a good, like it's a birthday party. Let's enjoy it. have clear drapes that allow for first looks whenever baby is delivered. We're able to do delayed cord clamping with cesarean. And once a baby is assessed and evaluated then baby is brought back to mama for skin, to skin for the duration of the procedure. We can also do breastfeeding in the operating room as well. Just really increasing the bonding from the very start, just like a vaginal delivery so that we don't lose that golden hour.

Natalie Portman

Yeah, and you also allow not only the partner back, the husband, the dad, you also. Also allow the doula to come along, which is very unique. So it is, it's such a joy to be able to support my clients when they choose to go with you guys, because I'm like, I know that there's no boundaries that are reasonable where I'm not going to be allowed to support you. And that's that goes back to that experience that you, you don't feel alone. You don't feel like because you're going a different route with your birth, that that means that you're not worthy of the support and the encouragement during that birth experience. So I, I always love that you guys allow that. Something that I actually, I just recorded an interview and we were talking about vaginal seeding. Is this something that you guys have ever done with your clients where you're just helping the baby get the introduction of the vaginal microbiome in a cesarean delivery where obviously they're not going the vaginal route?

Naicie Marrow, MD

Currently it is not something that we offer. There is no standard protocol with ACOG or the hospital, and so we cannot facilitate that experience. However, it is your baby, so whatever you decide to do with your baby, it's between you and your baby.

Natalie Portman

Gotcha. Well, thank you so much again for coming on and just sharing your advice and your encouragement. This was such an amazing conversation, and I know it's gonna be so helpful to so many mamas.

Naicie Marrow, MD

Thank you so much, Natalie.