Just had a seriously awful day at work. No major disasters – mother and baby well (which is, of course, the main thing) – but left feeling rather miserable.
Baby in good position – LOA (left occiput anterior) – head well down – good contractions. Then, after 6 hours of lovely normal labour (I thought!), the woman ended up with very thick anterior lip of cervix, epidural, syntocinon, CTG (continuous electronic foetal monitoring) -everything she didn’t want. I’m still trying to work out where I went wrong. I think the basic difficulty was the woman really hated VEs (vaginal examinations), so held out (too long?) before doing one – when all the outward signs were of late first stage.
Please – advise needed! Tell me about your experiences of anterior lips of cervix. Why do they happen? Could it be positional? – woman sat upright on the bed -cross-legged – most of the first stage, then knelt forwards. I tried all the usual tricks to stop the (small) involuntary pushing efforts she was making – lying down, breathing Entonox. What else could I have done, without earlier recourse to epidural? (She had agreed to have Pethidine, but then things were taken out of my hands at that point by more senior staff.)
In my mind this cervix was just getting bigger and bigger and I felt I had to seen to be doing the Right Thing (I’ve been 10 years “out”, remember!) – and the woman got tenser as I got tenser and the relatives got tenser and the pushy feeling got stronger and everyone got even more tense – -I felt I was being censored for having her upright when she was – and that this contributed to the premature urge to push.
Any ideas gratefully received!
Could it have been at all possible that letting her go with the urge to push early may have shifted the cervix earlier? This is a pet topic of mine at the moment, and I just wonder if the urge to push prior to full dilation is largely physiological, and that attempting to prevent it (in the absence of clear evidence of malpresentation/position) could lead to more, rather than less problems . I have seen very thick anterior lips shifted by maternal efforts.
There is NO good evidence on this topic (if you want the results of a systematic review I have recently undertaken, I will send them to you). We are actively researching this area, and would be very interested in any opinions/views/experiences of others out there.
A recent incidence survey we have undertaken accross four consultant units indicates that at least 1:5 women experience an early pushing urge; this rate does not differ between primigravid and multigravid women; and all groups of women experiencing an early pushing urge appear to have a better chance of normal births than those who don’t. These results may be heavily confounded (by the use of epidurals, for instance) but they are interesting, don’t you think??
My only tricky one was a primip wanting to push from 5 cms. I got her in the bath and just had to talk her through every contraction. She had an SVD at home but I wonder what would have happened if I hadn’t gotten her to stop pushing? I know the original question was about an anterior lip but then you went on to suggest that the urge to push then was physiological. So could there have been a positive purpose to this physiological response?
From personal experience stopping pushing when you want to is very difficult- especially when you are standing up with a massive head sitting in your pelvis! From professional experience I would suggest the best way to get rid of an anterior lip is to get the woman to be active and change position and go with what she is feeling. Having a good yell at everyone might help, too………
Maybe it’s better for the woman not to stick in one position for too long. Often it seems to be the movement and the changes of position which bring progress, often quite suddenly. I’m a great believer in hip rocking….
This had occurred to me. She got so stuck in a comfortable cross-legged position, absolutely refusing to budge, until I persuaded her to kneel up. Then the problem seemed to start.
Perhaps I should have encouraged more activity earlier.
Maybe. But sometimes all women need is a change. Not activity, just change.
Experience over the last five years of independent practice has led me now to discourage women from pushing on an anterior lip. In every case where they have pushed too soon, they have pushed for an hour or more without any progress, and ended up dispirited and tired. I learned to strongly advocate knee chest position (with or without gas and air) to enable the lip to clear easily – usually within half an hour.
On the other hand, when I was working in hospital soon after qualifying I had a fascinating (and scary) time with a woman from the Philippines, having her third baby, but the first one in this country. She was admitted in early first stage – can’t remember the dilatation, but about 4 cm I think. When I performed that first v/e on admission (hospital protocol) she started pushing, and said that she wanted me to keep my fingers on the cervix and let her push. I didn’t, because I believed that she was in early labour at the time. Anyhow, to cut a long story short, she carried on for several more hours, in a state of anger (with me) and distress (at the delay, I guess) until the next v/e (still not fully dilated, but there had been progress). Then she repeated, even more insistently, her intention of pushing against my fingers. So she did, (pushing for all she was worth, blue in the face, the lot) and the baby was born within five minutes (I managed to get her to slow down for crowning, so not too much perineal damage…). She said afterwards that that is what the midwife taught her in the Philippines, and she was astonished that we do not usually do this! I wonder how the second stage of her first labour was managed???
That is in fact the only time I have been successful in reducing an anterior lip with my fingers. I have seen other midwives do it, but I have not ever managed it. It is also usually very uncomfortable for the woman, and even if she has given permission she often changes her mind when she realises how painful it is.
I’ve used the procedure you are describing but only with the woman on her hands and knees. The VE is from behind (tricky, but not impossible) and fingers push the cervix up between the contraction and then she pushes with the contractions to bring the head down past it. I always explain the whole thing before starting and let them know they can change their minds at any time. The advantage for the midwife with a woman in this position is that you can get better leverage on the cervix (yea, I know this sounds terrible but there are times when you just have to do what you can for a woman with a prolonged ant lip). I know I am being successful when the pressure of the head pressing down and squashing my fingers against her pelvis is such that my fingers have gone past pain to numb. And the woman in this position will have gravity to assist. But it always has to be done with the mother in control of the situation.
I just can’t believe that something that seems to happen to so many women must be pathological. In fact, I’ve always instinctively felt that letting women go with the urge to push *does* help – but do not have the evidence to back me up. The only support for my instinct I have is the fact that I do not recall *one single incidence* of an obstructive swollen anterior lip of cervix, in any of the 100s of births I supported whilst working in West Africa. That either means it didn’t happen – or, if it did, was simply not a problem. I was usually only called late in the first stage of labour.
Back in the UK, the whole notion of an anterior lip problem seems to really worry midwives – allowing one to develop is Not Good At All. The problem is that I now feel so awful over what happened to this woman, that I doubt I will ever have the guts to do anything differently in the future. But that cervix was so soft and pliable, even when swollen, that I can’t help wondering…
I found out today that the woman I wrote about in my original post gave birth 3 hours after I left (at which point she was 6 cms dilated with very swollen cervix, syntocinon had just been started and an epidural sited). Oh, the power of epidural…
What about just observing mum and baby while she pushes spontaneously? Our recent incidence survey of four consultant units found an incidence of an average of 40% of all women in spontaneous labour who wanted to push prior to full dilation. Corrected for low response rate, this still equals a minimum of 18% early pushing urge. These women did BETTER on average than those with no early pushing urge, although this is not corrected for confounders. these findings were not affected by parity, as far as we could tell. We are pursuing this line of enquiry…
Have been with a woman tonight who had normal birth and it was brilliant. But I want to ask for opinions.
To set the scene: I arrive on the late shift to be told by the co-ordinator that this woman needs epidural and synto. First baby, came to clinic Friday and was having irregular contractions. Possible SRM(spontaneous rupture of membranes), so they asked her to stay in (why I don’t know). Anyway she did SRM at midnight on Friday and then contracted mildly 1 in 10 overnight and was using gas and air on the ward. By 4am this morning she was wanting more painkillers and was 1cm dilated and stayed on the ward. By 6am she was 2cms dilated and definitely wanted more painkillers but went in the bath. At 9.30 she went to the labour ward on her insistence, was 3cms, and had pethidine and by 13.30 was still 3cms. So at hand-over I was told she needed an epidural and syntocinon.
Started looking after her at 14.00 and she was terrified; she was only seventeen. So took her out of the main labour suite and did a bit of the darkened room and massage and suggested the pool. She was up for it and her Mum was so supportive of her. By 17.15 she decided to get out of the pool and wanted more pethidine. Went to speak to the co-ordinator who is brilliant and she discussed if there was no change etc. think about the contractions , now 1 in 5. So another VE and she was 5 cms. The brilliant thing here was that she said, right I’ll get back in the pool then.
By 19.00 had uncontrollable urge to push. No head to be seen. And really this is where my dilemma started . Do I say “brilliant, go with the flow”, or do I say, “I can’t see the head. chill if you can” ?
So I examined her after about 20 minutes pushing and no head visible and she was 9cms. Time is now 19.20. Now she is now going mad with pushing and the whole transition thing (but I MEAN BLOODCURDLINGLY SCREAMINGLY MAD). Her Mum again was ace, but I felt I needed another midwife for support, as I was unsure if I could see the head and our little mirror which we use for the pool had gone missing. The co-ordinator was brilliant, and as the contractions had dwindled we asked the woman to leave the pool and she resumed on all fours on the floor with her partner. Baby born 30 minutes later.
My question :
With a second or subsequent baby I would encourage someone to push if they felt the urge whatever, but with a first time mum , I wonder if they will get too tired? And will they end up with a swollen cervix? I know from experience this doesn’t happen with second time mums. Advice please….
You are wonderful. So was the mum. Go with the flow. She just could not stop pushing, could she? Her labour was progressing. This was not the premature ‘sort-of’ pushing one gets with an OP (occiput posterior – baby in posterior position) in first stage.
Midwifery Today E-news special on Anterior Lips
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I learned as a student nurse-midwife 18 years ago how to, in most cases, reduce an anterior lip. First of all, though, it may not be a problem at all and simply needs more time. But if the mom is tired or has been stuck for a while then I may try to intervene. I tell her that it is going to hurt but I ask her to work with me during one contraction. I will ask her to push as hard as she can and get three good pushes in, holding her breath and really bearing down. I ask her to lie in a semi-reclining position. I push up on the lip with 2 fingers while she bears down–usually, I can push the lip back. I then keep my fingers in-a lip tends to slip back down. In between contractions I may then try to ease the lip back. I try this for only 2 contractions. If it doesn’t go, we need “tincture of time.” Sometimes using a squat position can be a successful alternative to the semi-recline. If it doesn’t stay back, I then may try several position changes–hands and knees, side-lying–to get the pressure off the lip from the baby’s head. I may then re-try the above after 30 minutes or so have passed. Eventually, through time or descent of the head, success is achieved. It certainly is very rare to end up with a c-section for a persistent anterior lip that cannot be reduced. -Patty,CNM Indianapolis
Assuming that time hasn’t taken care of an anterior lip, I usually use arnica oil rubbed straight on the cervix. Sit back and wait a few contractions and if it isn’t gone, you can usually reduce it much more easily. Primrose oil sometimes works and I used that before I got sick of stubborn anterior lips, especially in primips, and got some arnica oil, which is also lovely on a swollen perineum. -Samantha McCormick, CNM Brooklyn, NY
The best way I have found to reduce an anterior lip is to lie the women in a left lateral position for a few contractions. When it’s gone she can get into the position she wants to to deliver. _G.R., community midwife England
I have found anterior lips appear mostly with ROA or posterior babies. My best remedy that has worked 99% of the time for a lip or edematous cervix: Using a 10cc syringe w/18 0r 20 gauge needle, puncture five evening primrose capsules, then draw oil into syringe. After all five have been drawn up, add an equal amount of gelsimium, arnica and blue and black cohosh into the syringe (if the primrose caps equal 1cc, add 1cc of each tincture). Dispose of needle. Shake the syringe to mix remedy. It is best if mother is in knee chest position. Do a digital exam and locate the lip or swollen area. Slide the syringe along your fingers to the spot and slowly insert the remedy. There will be some stinging sensation, which directs the mind to attend to that swollen spot. Tell the mother to think about that spot and melt the cervix away. Massage the remedy on the lip or swollen area. After administering all the concoction, keep the mother in knee chest for at least 20 minutes. -Shine Herfindahl, CDM, CPM Let me know how your lip melting goes: firstname.lastname@example.org
I have found a few thing that help in this situation. 1. Have the mom WALK during contractions–she will need to take very large steps and will need to have someone on each side of her. This really hurts!!!! 2.If walking down the hall is not possible (care provider wants continuous fetal monitoring), have the mom lift each leg in an exaggerated stomp, then squat and repeat several times. 3. If mom is confined to a bed, roll her from side to side over and over. I realize the above solutions are NOT fun for mom at all but they work! -Mary, doula
If the mom is not having a really strong urge to push, just wait it out with her, doing relaxing breathing as much as she can. Try hands and knees, or side-lying to reduce pressure on the cervix. Put some ice chips into the finger of a glove, then put this glove over your gloved hand and hold the ice against the lip. Mom can be in any position that allows you to reach her cervix. If she is having a strong urge to push and the cervix isn’t moving out of the way, you can have her flex her hips more by having her hold her knees back (she is semi-sitting/reclining on her back) and put 2 fingers against the lip and hold it up during contractions and then put pressure against it in between contractions. I always keep talking to the mom if I’m doing this because it hurts her. I try to reserve this for the times I’ve seen that big purple cervix pushing out with the baby’s head, or the lip is increasing, or the mom’s pain is increasing as she pushes (they especially say it is hurting more right above the pubic bone when pushing against a lip that isn’t shrinking). Sometimes “blowing” breathing can help her avoid pushing against the lip. Keep an eye on the baby’s position in labor-often persistent anterior lips are seen with posteriors. -Pat C.
..With the birth of my first child I did not know better and was told to push since I was “at a 10.” My baby and I were definitely not ready. The results were a very oxygen deprived baby (the L&D nurse also coached me to hold my breath and push to a count of 10 and beyond). I also broke blood vessels all the way down past my waist, both eyes were black and swollen shut, and I also broke all the blood vessels in my eyes (I had no whites at all for over a month). It also did long term damage to my pelvic floor and gave me problems with incontinence for two years, even with faithful kegel exercises.
All this could have been avoided by waiting until I had the urge to push. I never did experience the urge to push even as my son came out! The second time around, I was a Bradley Natural Childbirth instructor and I knew better. My midwife never did do a vag exam and I pushed only after the urge hit and worked with my body–no long pushes or breath holding. There were no bruises on me or my baby this time and I had a rather easy pushing stage. This was so much better! -Anna Matsunaga Tacoma WA
Anterior Lip Question and Answers
Q: I recently attended a birth as a doula. After labouring for 8 hrs. my client was almost fully dilated except she had an anterior lip. When the doctor did a vag exam, she was able to pull back the lip while the mom pushed with a contraction and ultimately pushed the lip out of the way. However, two hours later with strong effective pushing, the lip was still there. The doc was frustrated and couldn’t figure out why the lip wasn’t cooperating. An epidural was done to hopefully relax the mom and take care of the lip. After half an hour, this goal was reached. The mom continued to push when coached to do so because of course now she couldn’t feel any sensations to bear down spontaneously.
My questions are: 1) What else could have been done other than an epidural to resolve the lip dilemma? 2) Once the lip had disappeared, could the epidural be turned off or at least the amount of the drug reduced so the mom could regain some feeling to be able to push more effectively?
A: An anterior cervical lip occurs when the presenting part is not positioned correctly upon the cervix, causing unequal pressure that results in unequal dilation. Think of a square peg trying to come through a round hole. If there is unequal pressure, and the fetal head is not given enough time to accommodate (mold), then the narrowest diameter of the fetal head cannot come through the widest diameter of the inlet. In my experience, if a cervical lip is developing, you are dealing with an abnormal presentation–either an asynclitism (where the head is tilted out of the midline) or an extension of the head which must be corrected in order to facilitate the descent. The temptation is to treat the symptom–the lip–by pushing it back out of the way, without considering why it is there in the first place (the malpresentation) and correcting that. If you allow the fetal head to back off the cervix, even just a bit, it will often allow the baby to tuck its chin and approach the pelvis at a better angle.
As a doula, coach, or midwife, you have two choices. You can change the head directly by applying pressure to it, which is not comfortable for either the mom or the baby, OR you can encourage the baby to back off the cervix by changing the mother’s position. I have had great success with encouraging the mom to try two contractions on her left side, two contractions on her right side, two contractions on her hands and knees, and two in a knee-chest position. Have her epty her bladder first (she can use all the room she can get!), have her blow through the contractions, and refrain from pushing. These positions will usually make it easier to do that anyway. I rarely have to go through more than two cycles of the eight contractions before the lip disappears and descent takes place.
If you detect an asynclitic presentation, have the mom pull up on her top leg as she is side lying, which will open that side of the pelvis a tad more (sort of a half McRoberts position). Remember, you are trying to allow the baby a little room to back off the cervix so it can reposition its head correctly. Even if the mom has an epidural, she can be rolled from side to side, the upper leg adducted to facilitate the flexion. In this particular situation, an upright sitting position is not as helpful, and in fact the 45 degree angle pushing position which is de rigeur in the hospital actually compounds the situation because the pushing urge becomes so strong, and the angle so acute, that the baby has no room to back up and cannot reposition itself. Remember that the uterus is extremely competent at working the head down into the pelvis at the appropriate speed and angle if given the opportunity to do so.
Vicki L. Taylor, L.M., C.P.M. Pensacola, FL
A: The most probable reason for the persistent anterior lip under the scenario you describe is a large head that needs to mold. If hands and knees or side-lying with the top leg all the way over onto the bed things doesn’t work, eventually I try an epidural as a last resort just in case the woman is unconsciously holding back. Of course the epidural could have been turned off for pushing and then re-dosed for a cesarean birth if it became necessary. But if it’s any consolation, it may have turned out the same if it truly was CPD (cephalo-pelvic disproportion). I hope the client knows what a good job she did! -Cynthia Flynn, CNM, PhD
A: As I read the account of the labor with the lip that would not be reduced, I wondered if the birth would end up being a c-section. I’m sure that many will recommend an all-fours position or knee chest or upright postures, birth balls etc. as postural ways to help reduce the lip. These sometimes work. I’ve heard of putting ice on thick swollen lips, but have not tried it myself. I imagine there are herbal preparations that are used too. However, my own experience is that those persistent lips are an ominous sign–they just hang on and slip back over the head, despite efforts that seem to result in their disappearance. Often, a persistent OP is involved (all the more reason to read Optimal Foetal Positioning by Sutton and Scott), sometimes CPD, as in this case, where baby just didn’t descend. I imagine that the epidural gave the mother a chance to rest and regain some strength for the push ahead. I don’t know of any physiologic reason why having an epidural would cause the lip to go away. Does mother’s lack of relaxation cause a lip? Letting epidurals wear off after pain relief is achieved is a problematic situation, I think, particularly if the mother does not want to reexperience the pain. It almost seems unethical to provide relief and then to say, “Now we’re going to withdraw it.” Most mothers who receive epidural here seem to push quite effectively if allowed to await the urge to push as the baby descends. -Karen Pettigrew CNM South Dakota
A: Perhaps my question is part of the answer; What POSITION was the mother assuming during most of the second stage–squatting (upright), Fowler’s or side lying? -J.B.
A: …rushing 2nd stage by attempting to “resolve” the lip may in turn cause the baby to be pushed down too soon in an unfavorable position for vaginal delivery. I don’t practice the “you’re complete, now push” management of 2nd stage. I think this sets up the problem described above. From what I’ve seen so far, if the mom is going to push the baby out, no lip of cervix is going to keep her from doing that. I feel a stubborn anterior lip is more a symptom of other problems than THE problem. Positional changes (hands and knees) and putting her in water may allow enough relaxation to enable the baby to BACK UP and get in a flexed position. -Kelley Hewitt, LM
When to Push: Listening to the Body’s Cues by Lois Wilson
Excerpted from a coming issue of Midwifery Today, due in your mailbox in September!
At Victoria Jubilee Hospital in Jamaica … no one pushed actively for more than half an hour … women come across the hall to the birthing room when they feel a strong and absolutely irresistible urge to push. Prior to that, they are not “checked” for effacement or dilation, but rather are simply allowed to labor undisturbed. Their only cues to their progress in labor are their own physiologic sensations and their intuition. Once she is in the birthing room, the woman climbs onto the cot and a midwife checks her dilation. Very rarely does a mother come into the birthing room too soon-women are almost always completely dilated and ready to go, often with the baby’s head on or near the perineum….[They] subsequently finish the job in thirty minutes or less!
Thus the question begs to be asked: How many gloved hands have reached up inside of women followed by the declaration “You’re complete! You can push now!” followed by hours of exhausting effort, frustration, and intervention?…even when a woman is feeling a little “pushy,” she may be fully dilated but not really ready to actively push. I honestly believe that in our well-meaning attempt to tell a woman when we think she is at the pushing stage of her labor, we encourage her to push way too soon. The consequence is that when a woman begins pushing before a strong and irresistible urge is present (because her midwife tells her “it’s time!”), she uses her energy to accomplish a task that her body would do more effectively on its own if she was listening to her body’s cues rather than her birth attendant. Maternal exhaustion, a swollen cervix, fetal distress, and sometimes a transport for vacuum extraction or a cesarean section often follow. This is too high a price to pay!
Links to other sources of information:
Fascinating anecdotal stuff about cervical lips, in the USA Midwife Archives at Gentlebirth:
AH updated 24 February 2001