Malpresentation

UK Midwifery Archives


These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.


Malpresentation – when the baby is in a difficult position

Posterior Babies

(OP = occiput posterior)

The place was at a home a young fit woman labouring beautifully with supportive partner. No great indication of an o.p. position. Actively pushing on all fours with her urges in second stage- no signs of descent after an hour. She felt like lying flat on her back and though as a upright type of a midwife I was not completely at ease with the idea I did not raise any doubts openly. The woman did it and proceeded to push out a face to pubes babe in the next two pushes- voila! A spiral labial tear needed repairing.

So then I talk to one of my independent midwife mates of many years’ experience about this who says well -“no suprise to her as she has had that experience on several occassions with direct op face to pubes births”. She seemed to think that the counterpressure/fulcrum effect helps to ease the head out. I’m glad it only took me 5 years of practice to discover that you never say never about anything a woman needs to do get her baby born physiologically but it’s sad that I was a bit of a slow learner.

Also in Real, The Philippines, it was the “norm” to lie flat on your back to give birth though this practice may have been introduced by a western doctor 30 yrs ago (though evidence not forthcoming). Lately the midwives have been encouraging other positions. However, by my observation the lying flat position did not appear to impede the women giving birth to good size babies in great condition with second stages shorter than an hour. However, I only observed a small number so I’m not going to extrapolate.

Only to say that I think….

The labouring woman needs to feel free and know that all positions may need to be experiemented with and she’ll find the one that works for her and her baby but none of them are pain-free. And just sometimes the woman may need some midwife direction -for example- the baby that comes unexpectantly hand/arm first- but that’s another story

Kerrianne


I have also had 2 experiences of women wishing to be flat on their backs for the second stage – and one of them was a direct face to pubes birth!

I’m also uncomfortable about women assuming this position, but I am fast learning that when women are not in an ‘obstetric environment’, they will naturally assume whatever position is needed at the time.

Lynn


I have birthed in a different position for all 4 of my babies–1st, semi-reclined with DH behind me holding my legs. 2nd, squatting next to the bed-had gone to a squat to help bring the baby down and when the midwife told me to get back on the bed that the baby was coming and I went to stand up-her head came out!! So, I went back to the squat and delivered there! She was “sticky” coming out–not a complete shoulder dystocia so I think that my body knew what position I needed to be in!

My 3rd, was on my right side, trying to get a posterior-asynclitism baby to turn-boy, when she did, she FLEW out!!

My 4th, she stayed anterior til I got to 9cm and then turned, it took 2 hours at 9 to get her to turn, I was flat on my back, rocking from side to side thru each ctx. I didn’t know why at the time, it just felt like it was what I needed to do. My body tool over. I did that for probably the last 20 min or so and the dr checked me I was complete. She was also a little “sticky” and I think they knew that and kept me on my back. I had always said that I would never birth that way, but that was obviously the way that I needed to be!

It still amazes me how different all of my births have been and how my body/me knew just where I needed to be! My midwife was at the hospital with me with the last along with a very supportive Dr and they both said that the rocking that I was going basically “screwed” the baby thru my pelvis to get her out, that it was just the thing that I needed to do! But that they wouldn’t have been able to say that til they saw it!!! That gets back to allowing women to trust their bodies and listen to their bodies!!

Just thought that I’d share my experience, that no matter where you are, you can and should follow your body!! I know that not all women are “allowed” to in hospital settings, but everything should be done to get them to!!

Dawn


My first baby was OP, and eventually born with the aid of forceps, but I spent most of transition bemoaning my lot, whimpering, asking for a c/s, (I think you can picture it), *on my back writhing around on the the floor*. I had always assumed it was because I was exhausted and doing the “pathetic” transitional thing, rather than the “stroppy” one. But maybe not. Makes me feel quite good really!

Tikki


I have heard that second babies are much less likely to be posterior as there is more room – is this true?

How about getting your hands on a copy of ‘Understanding and teaching optimum foetal positioning’ by Jean Sutton? You can get it from NCT Maternity Sales (www.nctms.co.uk) for about £6.

Here’s my recollection of what it says on this: if the tummy is tight in front (first baby, and/or very tight abdominals) then there is more room towards the back of the mother’s uterus than the front. The baby’s back is bulky, so in those circumstances there is an increased likelihood of a posterior baby, as the bulky back is pushed towards the rear of the uterus, where there is more space.

With a second baby, the uterus and abdominal muscles are nice and accommodating, so there’s more room for the baby’s back at the front of the tummy. On the other hand, the baby has lots of room to move around, so it might switch position a lot. But even if baby ends up posterior second time around, it is easier for him to move to anterior because there is more space.

You can read more about posterior babies, OFP, and turning them, at the following places:

AIMS article – posterior babies : what mothers can do – see www.aims.org.uk and go to ‘articles’.

‘Get your baby lined up’ from the Home Birth Reference Site – (www.homebirth.org.uk/ofp.htm)

Angela


Diaphragmatic Release to correct posterior presentation

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From MIDWIFERY TODAY E-NEWS
a publication of Midwifery Today, Inc.

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There is an excellent way to change persistent posterior babies that has worked every time I have used it. It may need to be done several times in late pregnancy, but it will turn the baby every time. It is a chiropractic technique called a diaphramatic release. It is non-manipulative and easy to learn. I learned it from Dr. Carol Phillips, who teaches chiropractic care for pregnant mothers and newborns. Every midwife should know this technique. I no longer have any posterior babies. Neither my mothers nor I miss those long hard back labors!!

It is easy to recognize a persistent posterior baby. You cannot feel the back on palpation, rather only little lumps and bumps of limbs. To do a diaphragmatic release, it is best to have the mother lie on her back. If she is in advanced pregnancy and this makes her very uncomfortable, you can have her lie in a recliner or semi-sitting position. If you use that position, place a small pillow or adequate support behind her lower back.

One hand will go horizontally across her lower back where the uterine ligaments attach. This is where you would put lower back pressure during labor. You do not need to press, as just the pressure of the mother lying on your hand will be sufficient. (Be sure you take off any rings you may be wearing, for your hand’s sake!)

The top hand will go on top of the abdomen, horizontally just above the pubic bone with the thumb upward. Just rest it lightly on the abdomen, no pressure. Then all you have to do is wait. Things may start right away or it may take several minutes before you feel anything. What you will feel is a motion beneath your hands. For the hand in back it will feel much like it does when there is a contraction taking place during labor as you feel the muscles tighten and contract beneath your hand and release. For the top hand it will be either a waving motion or a circular motion under your hand. At first you will think you are just imagining it, but you are not.

The best description I can give is that it feels as if the mother has a tennis ball in her abdomen that is being bounced back and forth between your hands. As it hits one hand it will roll across it or around underneath it and then bounce back to the other hand. Sometimes the motion is so great that it will actually make your hand wave on the abdomen. Sometimes the mother will feel things inside, sometimes not. What she feels may not be located where your hand is located.

The movement under your top hand may stay all in one place or move around. If it moves, try to gently follow it with your top hand to keep it centrally located under your hand. Do not move the back hand. Sometimes it will move around in a circle, sometimes off to one side, or even clear down to a hip. It all depends on the muscles that are involved and the type of injury that precipitated all the spasm of abdominal muscles.

Our muscles really only know how to contract and shorten, not how to relax and lengthen. They depend on another counter muscle to contract and pull the first one out of contraction. Abdominal muscles do not have as many counter muscles, so this technique allows the muscles to relax.

If you go back into the mother’s history, you will almost always find a history of a car accident (especially with a seat belt on, where there has been a twisting of the abdominal muscles because we use only one-shoulder restraints) or severe fall. However, I have had a mother cause it simply by doing too much hoeing in the garden.

You continue the diaphragmatic release as long as you feel motion under your hand. Usually it will just fade away and you will no longer feel it. Sometimes, if you end up over a bony prominence, it will end with a vibration. The process takes some time, often at least 20-45 minutes. But if you consider the time you save in labor, it is well worth it. You may need to repeat the process over several visits. I usually start at about the 6th month unless I have a mother with a history of car accident or several prior posterior babies.

This procedure has also been used this technique to turn breech babies. I use it for transverse but find it less effective for breech. I usually use a tilt board for breech and then do a diaphragmatic release after the baby turns. It works marvelously well for posteriors. I have never done one where the baby did not turn to anterior. However, on some occasions, after a few days the baby will turn back to posterior and you will need to repeat the process more than once. The more severe the history, the more likely you will need to do it several times before the baby will stay anterior.

Posterior babies use to be the worst problem I had in births. The long hard back labors wore us all out and occasionally ended in transfers for maternal exhaustion. I am thrilled not to have these any more. Now my biggest problem is cervical lips! But I am working on a solution for that also, using evening primrose oil!

I do believe every midwife should have this valuable tool, the diaphragmatic release, in her bag of tricks. It is so easy and non-interventive. It is much better than other suggestions I have seen of putting your fingers in the baby’s suture lines and trying to turn the head!

–Judy Jones

Reprinted from Midwifery Today E-News Volume 2 Issue 18 May 5, 2000
To subscribe to the E-News write: enews@midwiferytoday.com
For all other matters contact Midwifery Today:
PO Box 2672-940, Eugene OR 97402, Tel. 541-344-7438
inquiries@midwiferytoday.comwww.midwiferytoday.com

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Sally wrote:

I am 39 weeks pregnant and received details of diaphragmatic release to correct posterior presentation via a friend on the UK Midwifery Mailing List. She in turn had received details from her midwife who has successfully carried out the “trick of the trade” that you reported. Her posterior baby became an anterior baby after just three goes at the diaphragmatic release.

I showed the article to my midwife who said that she would be unwilling to try it out as she has not been trained to do it. I am left feeling desperate as I know exactly what a back to back labour is like as that was my first baby’s preferred position!

Unfortunately nobody had any suggestions for DIY Diaphragmatic Release, but things turned out very well for Sally anyway:

I was not able to turn my baby and my midwife was a little nervous to use a method of turning that she had not been trained for. On the basis that she was not particularly happy I stopped doing the ‘lying on your hand’ routine and just hoped all would be well.

I am pleased to say that on the ‘big day’ I had a very short labour, 3 hours, and my baby turned himself to the correct position in time for the second stage of labour. He was delivered in a birthing pool which was a truly magical experience. I was able to maintain an excellent position in the pool by leaning forwards and kept a squat pose throughout all contractions. I’m pretty sure this all helped him to turn.

Sally


Transverse Lie

A friend is 29 weeks preg with second baby. First is 2 years old and was a normal vertex birth at home. Second baby was head down at 20 week scan, but has now apparently turned transverse according to the community midwife seen last week. My friend is quite well informed and thinks the midwife’s diagnosis is probably correct as she feels that her fundus has dropped recently. She knows that, rationally, it’s far too early to worry and that the baby has plenty of time to turn head-down, but would appreciate suggestions to help it on its way. The placenta is a very high anterior by the way, which I think may well be relevant at this stage as we know from Jean Sutton that babies like to face their placentae.

I have suggested that she tries to gently massage the baby round, spends time on hands and knees doing hip-hitches and wiggling her bum to create movement in the waist and hopefully prod it round, and to do lots of swimming eg breaststroke – hopefully the stretching and contraction of abdominal muscles and leg/hip movements would help things along. Does anyone have any other ideas?


At 29 weeks I would really not be concerned at all that the baby is not presenting by the vertex! You would certainly be expecting plenty of movement and would be concerned if it wasn’t. Please reassure her that it is early days yet and the only thing she needs to do is relax and enjoy the rest of the pregnancy!

Jenny


I looked after a woman last year who had had a C/section for transverse lie for her previous baby, and came to me pregnant again. Sure enough, by 24 weeks the baby was transverse, and remained so for the next month or more. I suggested that she wear one of those velcro-fastened wraparond corset things physios give out to women with separated abdominal recti muscles (she had one already, because she suffered from the problem badly after her transverse lie pregnancy). Then I asked Jean Sutton’s advice, and she said in her inimitable way “Cycling shorts. That’s what she needs. Tell her to wear cycling shorts day and night until the baby gets the message!” So I did, and she did, and the baby did! She had a lovely straightforward poolbirth at home.

I’m sure the massage idea will also help, and also the all-fours. Swimming is also excellent – to be precise, floating belly down, completely relaxed (either using floats, or having hands on the bottom at the shallow end) and visualising and talking to the baby about which way round she would like it to be, and why. The woman has to be completely in earnest about achieving the desired end – a little bit of cycling shorts, or the occasional all fours will not do the trick. But if the woman really means it, then it will happen, I am sure.

Melanie (independent midwife)


If the problem persists past the time that the fetus should be turned into the vertex position, then it might be due to some peovic rotation, especially the pelvis. I know that Chiropractors deal specifically with the spine and getting chiropractic care has helped decrease pain during labor and as well as decrease labor time. Because chiropractors release the nervous interference caused by spinal problems, the internal environment for the fetus often times becomes favorable for it to turn.

Edna Giuntini (chiropractor)


The exercises will help – my baby was transverse at 37 weeks and cooperated after I did the exercises in “Active Birth” by Janet Balaskas – Sheila Kitzinger also illustrates them in “Your baby – Your Way”. I have heard that carrying a toddler will help to make the unborn baby turn to breech or transverse – does your friend carry her child a lot? Could she try ways of keeping her child close without so much carrying, until the baby settles head-first? Once baby turns, squatting will help to engage the head.

Monica O’Connor
Home Birth Assoc. of Ireland


Update on the second baby who was transverse at 29 weeks:

After a week of concerted efforts by mum to tighten her tummy muscles and lots of belly-down hip-wiggling on all fours, the baby shifted! He spent the next few weeks mainly breech with the occasional foray into oblique, but on a walking holiday at 34/35 weeks he flipped over and apparently engaged right away. The baby stayed head-down and was born at home at 38 weeks.


I’m looking for advice for a friend, first baby exactly 35wks today, baby lying transverse. Midwife suggesting ECV (external cephalic version), not sure when, baby was breech at 33wks. When is the optimum time for ECV to be carried out? Should she be worried, or does she have plenty of time left for baby to turn? Is there anything she can do?

Ann


Best time for an ECV is usually 37 weeks, but it can be done in labour.

Sara


In our Trust, External cephalic version is usually performed at 37-38wks and position confirmed with a scan. The baby is then monitored for about an hour and the woman sent home.

Antenatal checks are made weekly untill she delivers to ensure that the baby stays cephalic. There is a scan done initially to check the baby’s position, and to make sure there are no problems, eg low placental site, that might be causing the baby to adopt this position in the first place. The placental site is usually diagnosed from an earlier scan, though.

Ann (Team Midwife)


I have known four transverse lie babies. Each of the mothers had had spinal surgery. Could not have been a coincidence, surely. It seemed that they had to carry the babies that way.

They were all privileged to have care givers who were willing to correct the position during early labour and all gave birth vaginally. One baby turned several times, the mother finally wearing a belly support to hold her in position until pushing.

Angela C, midwife


She can try wearing a pair of cycling shorts or support tights. It narrows the abdomen encouraging the baby into a longitudinal position.

Andrya


Sounds as if your friend’s baby is already trying to turn head down. It just needs a little help perhaps.

Tell her to swim every day, if she can, just lying on her belly in the water, as relaxed as she can be, using floats to support her head, shoulders and hips if she can beg or borrow them. Gentle breaststroke, head in the water, or walking on her hands in shallow water with body floating, keeping relaxed belly in all these variations. All this can help.

Lots of crawling. Scrubbing the kitchen floor on hands and knees is good!

Tell her to chill, and not to worry – her baby is already on its way round!

She could also take to wearing cycling shorts, the lycra kind, which makes it so uncomfortable for the babe in transverse that it will do all it can to shift!

Melanie, midwife


Unusual for a first baby to be transverse–has there ever been any damage to the pelvis? Re. a transverse lie–Jean Sutton recommends wearing cycling shorts!! I guess the tightness can help the baby to move into a more comfortable position–such as a longitudinal lie.

Pam, midwife


Just watch out – my first baby turned OP when I wore leggings that were too tight! I think he must have been as uncomfortable as I was. (Though obviously OP is preferable to transverse!)

Jennifer


I just have to ask – does this mean maternity cycling shorts? I am/was a cyclist and I for one wouldn’t be able to get my cycling shorts anywhere near my bum and bump now :)))

Jenni


The idea comes from Jean Sutton– I don’t know about’maternity cycling shorts’—but—who knows–perhaps there’s a whole new area to be developed there!!

Pam, midwife


Well, you buy a pair of cycling shorts you can fit over the bump. I don’t think they sell maternity cycling shorts, but I am sure they sell shorts for large men….

It does have to be reasonably tight, and yes, it will be uncomfortable, but even more so for the baby, which makes it turn around.

How can it damage the baby? It’s only being squeezed, which happens all the time naturally anyhow.

I’ve looked after a couple of women who have used this method, one was determined, and wore quite tight ones for part of every day (couldn’t stand them on all the time). Her previous birth had been C/S for transverse lie. Her baby turned from transverse to longitudinal lie within a week or so, and stayed that way. She had a satisfactory poolbirth at home, which was what she had wanted.

The other lady bought shorts which weren’t really tight enough, and didn’t have the same amount of determination. The technique didn’t work for her -though her baby did turn head down, it didn’t engage in the pelvis.

Both these women had widely separated abdominal recti muscles from the start of pregnancy, and the second had a pendulous abdomen as well.

The humble start of a bit of evidence-based practice? Who knows….

Melanie, independent midwife


From the US Midwife Archives at www.gentlebirth.org:

(RE: a Transverse lie) “Get her into a warm pool. She walks into the water until up to her shoulders. Then have her dive down to the bottom of the pool. As she is deweighted so is the baby and the heavy part of the baby (the head) will go into the pelvis. She may have to do this three times but I have never had it fail.”


Update on the baby who was transverse at 29 weeks: After a week of concerted efforts by mum to tighten her tummy muscles and lots of belly-down hip-wiggling on all fours, the baby shifted! He spent the next few weeks mainly breech with the occasional foray into oblique, but on a walking holiday at 34/35 weeks he flipped over and apparently engaged right away. The baby stayed head-down and was born at home at 38 weeks.


I cared for a muslim couple once where the woman was in established labour, baby was transverse lie, doctors frantically trying to persuade her to have a section. She and her husband steadfastly refused and prayed to Allah throughout – baby was cephalic by end of first stage…

Max


Have just got back from work. Have been looking after a woman, first baby, unstable lie, for a few days. Several external cephalic versions, but a baby who repeatedly ‘swung back’. Finally went for caesarian section today – bicornuate uterus, so of course the baby had just been getting into the most comfortable position possible.

I did ask a doctor why they were continuing to try the ECV when it seemed obvious that the baby had its own reason for turning back the way it was, and you would have thought I had 2 heads for even thinking that way–it was as if this was simply an ‘uncooperative baby’. Well, perhaps she’ll learn one day………..

Jill


Oblique Lie

I have a client, first baby, 32 weeks, oblique lie. Head down to left of mother’s pelvis and bottom under her ribs, anterior position. I have suggested hands and knees positions with hip wiggling but any further suggestions would be very welcome. Does anyone think that Jea Sutton’s cycle shorts idea would help? Any ideas gratefully received.

Jill


32 weeks is way to early to worry about this. Have a little patience and this baby will more than likely put itself into a better position without doing anything.


I am not a midwife and this is all just guesswork! But I would imagine that anything that might possibly help with a transverse lie, would be just as good for an oblique. After all, an oblique is a transverse that’s part of the way to becoming vertex, or vice versa! Presumably anything that tightens the abdominal muscles and encourages the heavy head to swing downwards would be good. So Jean Sutton’s cycling shorts idea, or the elasticated corset, would both have the effect of squeezing in at the waist and pushing the baby round to a vertical presentation. By ‘cycling shorts’ I assume she means something like control top shorts or pants, or something that will be firm and tight around the tummy.

If my baby was oblique then, just using common sense, I would want to look at which side the head was on. Assuming it is oblique/vertex and not oblique/breech, if the head was on the right then I would lie on my left side at night, to encourage it to swing towards the centre. I wonder if it would help to do exercises which involve contracting the abdominal muscles on that side, too? For example, how about lying on the left side and raising the right leg – that shortens the muscles on the right side, which presumably would squeeze the baby round a bit?

Not specifically on obliques, but it might be worth looking at the US Midwife Archives at www.gentlebirth.org – there’s lots of wonderful stuff there. On a very quick skim through I just found this note:

(RE: a Transverse lie) “Get her into a warm pool. She walks into the water until up to her shoulders. Then have her dive down to the bottom of the pool. As she is deweighted so is the baby and the heavy part of the baby (the head) will go into the pelvis. She may have to do this three times but I have never had it fail.”

Just a few thoughts anyway. Good luck to the lady you’re looking after -she’s lucky to have a midwife on the case who’s prepared to look into things for her.

Angela


Any snug binding will lift and move the baby. Have mom sleep on the oposite side of the body. Has she tried Pulsatilla? Can work wonderfully.

Sherri


Face and Brow Presentations

A brow presentation is caused by a deflexed head getting extended as it descends through the pelvis. Occasionally the brow may ‘fix’ at the ischial spines of the pelvis. If you have a small baby and large pelvis this will not be a problem. Perhaps (because we do not have x-ray eyes) some face presentations come out of a brow presentation, but there is enough space for the baby to descend. Perhaps the baby is too big for the pelvis, and with a deflexed head, gets thoroughly stuck as the head deflexes more.

To avoid a brow presentation, perhaps avoid an occipito-posterior (OP) position if possible -there may be fibroids in the uterus, or some other obstruction which means the baby can only settle into the OP position………….Suggestions only.

When I really think about the mechanisms of birth, we only understand some of it. The mechanics can be affected by many things. The mother of course is so psychologically wired during the labour also. To avoid an OP labour should help somewhat though.

Debs, independent midwife


A birth story on www.deborahs.zonehere.com is an excellent example of the benefits of listening to a mother’s instincts.

Deborah (provides home birth support and info in Northern Ireland) went 17 days overdue with her second baby and was fighting off induction threats. When she eventually went into spontaneous labour, she had a good, trouble-free birth,but the baby had very visible moulding on his forehead showing that he had been a brow presentation until very recently. There are some clear photos of this on the web page. If she had agreed to induction beforehand, she would have ended up with a caesarean presumably, after God knows how many hours of labour.


I took over the care of a women in labour with her first baby at the beginning of an early shift. She was in spontaneous labour, had spontaneously ruptured her membranes and her cervical dilatation had been fairly quick. She had been fully dilated for approx. 40 minutes when I took over, and her contractions were just becoming expulsive. She had had 2 doses of Pethidine over the previous 10 hours or so.

Anyway, the woman was distressed, but not wanting any Entonox. She was mobilising around the room, walking out to the loo and doing just about everything she should have been. On questioning she stated that she was pushing with her contractions, but nothing was visible and she did not appear to be pushing to me!

After a while, nothing obviously happening, I discussed doing a gentle VE (vaginal examination) to check the position of the baby. On abdominal palpation there was no head palpable (it was VERY well down in the pelvis). A good sign I thought!!

On VE she was indeed fully dilated, but I felt a suture in the transverse with the head below the Ischial Spines. “Strange”, I thought! I could come up with no reason why that should be! The FH (foetal heart) had been absolutely normal throughout (intermittent auscultation). I had word with a Registrar who for some strange reason sent in an SHO (Senior House Officer – doctor junior to Registrar)!! He insisted on repeating the VE and, surprise surprise, confirmed that I was right!

Being by now about 8.45am it was time for the ward round, so we were left alone for about another 30 minutes or so (!!!). She continued to change position a lot, I encouraged her to stand, and she continued to push, more obviously by now. Eventually the Reg came in, did a VE and diagnosed brow presentation, this was confirmed shortly afterwards by a Consultant (she’s a VERY good consultant!!). Oh no, I thought….to Theatre we go! Well yes, we did, but NOT for a CS (caesarean section). The woman had a spinal anaesthetic, and Keillands Forceps were put on with the idea of using them to flex the head – it worked and after a VERY easy rotation the baby was born OA (occiput anterior), 3.7kg (just over 8lbs).

Afterwards the consultant said to the woman that she shouldn’t have any problems having another baby vaginally. The woman and her husband were delighted…as was I!! The only sign of a problem on the baby was a bruise and a graze on its forehead where she’d been pushing for so long.

The SHO was a bit miffed that neither I nor he had made the diagnosis, but when I explained that it had been nearly an hour earlier that we had examined her and that she had been pushing for that time, probably extending the head more to make the diagnosis easier for the Reg he was ok <g>.

The woman had skin to skin contact for about 3 hours afterwards and the baby breastfed brilliantly 🙂

I commented later that if that Consultant couldn’t get our CS rate down nobody would! (It’s around 22% I believe).

Belinda.


My first was untimely cut for brow… I had a Caesarean..

The cause: 1) I allowed my baby to be induced, for dates. Like a lamb to the slaughter. I believe they used misoprostil on me. One little pill per vaginum anyway.

2)Then, like a fool, for 12 hours of pretty intense labour, I semi-sat so the ctg machine could get a good trace. Thus helping him neatly into the wrong position.

3)Finally, although I desperately wanted to move I kept my mouth shut and stayed in the same semi-sit and I tried to push him out for two and a half hours. I was a strong young woman and had him jammed in my pelvis very firmly.

I was given an epidural for high forceps but it was decided that he was to be sectioned out under general anaesthesia. The House Officer could not get him out and the consultant came racing in on his white charger and apparently used forceps to extract him through the incision.

I am able to honestly tell my clients that I have had almost every intervention, but all in one birth. It took me only a couple of pushes to get each of my other three babies born. There’s nothing inadequate about my pelvis, just the care I was given and accepted.

Angela C.


My nephew was born brow with ventouse, diagnosed when fully and pushing, my sister could feel his hair. She had a 4th degree tear, but he was 10 lb 12 oz. His head was born direct OP. Difficult birth of shoulders. He is a happy 19 month old. She was transported from home.

Freda


Face and Brow Presentations

I had a most unusual brow birth last year – OP brow! It took me the entire 2nd stage (over an hour, multipara) watching this strange sight at crowning, and lots of drawings afterwards to even work out what I had seen. At the peak of the crowning, the hairline was clearly halfway across and the head popped out OP.

I spent some time later with a doll and pelvis trying to work out how it all worked. Has anyone else ever seen or heard such a thing?

Lynn


I wonder if this is comparable to a face presentation? I understand that face presentation babies can only actually be born vaginally if they are OP. Of course, now somebody is going to say that they had an OA face presentation baby born vaginally!!


Oh yes, and it was waterbirth too – I can see how it could have been a face that as it was OP, deflexed into a brow at crowning – as I hadn’t done a VE since early labour, luckily, I had not established a definite position. It palpated in a lateral position though.

Lynn


One of our Mennonite midwives gave a case presentation of an OA (Occiput Anterior, Mentum Posterior) face birth. Amish Great Grand Multip Mum. On discovery of the presentation she transported mum to hospital for a section. She was not allowed to be in the room with the mother, but this is what she heard from the doorway. The mother was being catheterised as part of the section preparation, and immediately, spontaneously pushed. The baby swivelled and came out all in one push.

The midwife said she went to her old texts and found that OA(MP) face babies will often turn on pushing.

Angela C, midwife


In a face presentation the chin (the mentum) is the denominator, ie the bit of the baby that is actually coming first. In a head presentation the occiput (the back of the head) is the denominator, and a posterior position refers to where the occiput is in the pelvis.

Usually the baby’s back lies in the same plane as its occiput, ie LOA means left occipito anterior and the back of the baby lies to the front and on the left of the mum’s tum. Likewise ROP means occiput to the right and at the back. OL (occipito lateral)& OT(occipito transverse) mean the baby’s occiput is lying to one side or the other .

If a face presentation is mento anterior, the chin is to the front and the baby’s back is to the mothers back. If the midwife can keep the head extended until the chin is born, the head which is in the hollow of the sacrum will flex and be born.

If the chin is to the back, ie mento posterior, it may rotate to mento anterior, but this is unlikely. If it does not and is a persistant mento posterior it cannot be born vaginally and a CS is necessary.

Delay in labour is common as the face is badly fitting presenting part and may not stimulate good contractions. Before we had good CS I saw several face presentations born following absolutely rotten awful labours, though I have seen some easy labours with a face presenting. Now I would advice any woman with a face presentation, even a mento anterior to go for a CS if her labour does not progress easily and spontaneously.

Mary Cronk


From Breech to Brow, by Thomas Ind – correction of a brow presentation with ventouse, proceeding to vaginal birth.
(www.obgyn.net/pb/cotm/9810/cotm_9810.htm)

Great photo of face presentation OP (Mentum Anterior) baby (www.birthdiaries.com/diary/face.htm)


Shoulder/Hand Presentation

Please read this inspiring story (on a separate page) about a baby with (probably) shoulder presentation, and a prolapsed hand, resolved at home, from a midwife on the list.


From the US Midwife Archives at http://www.gentlebirth.org/archives/position.html#Nuchal:

“One of our midwives recently delivered a baby with both hands over the head. It went well, just a BIGGER stretch. If the little rascal is sucking its thumb, it’s unlikely to give it up – it is also hard to pinch enough to make them budge. Get the mom mentally ready to open really big! ”

OUCH!!!

Rectifying Malpresentations

In some cases of malpresentation, eg asynclitism, brow, face, shoulder etc, is it ever possible to shove the baby back up and try to realign it? I can see that you would not be able to reach past the presenting part to do an internal podalic version in these cases, but what about pushing the baby back and then hoping it realigns itself while mum does knee-chest or similar? Is this not possible because the pp is engaged in the pelvis?

On the US Midwife Archives page on malpresentation, I found this story from an ob who appears to do something like this. Anyone know what ‘Trendelenburg‘ is?

The wake-up call came at 4:00 am last night from a panicked house doctor. A full-term para 3 with no prenatal care came in fully dilated at direct MA/+2 station. A quick sono in the DR showed no neck masses and the fetal chest directly to the left of the maternal midline.

I called for general anesthesia and placed her in steep Trendelenburg, disengaged the face, slipped my fingers around the occiput and simultaneously flexed the head and pressed upon the fetal chest (I believe it’s called the Baudelocque maneuver). The vertex came down quite easily, I applied the vacuum and delivered the infant without difficulty.

3,400 gram female, 9&10 apgars… with a face only a mother could love. ”


You ask “what is Trendelenberg?”

I have always understood it to be the “all fours with bottom high” position. Mother leans on elbows with shoulders as low as pos and bottom as high as possible, but a colleague argues that it is a sort of exaggerated recovery position. Either way the pressure of the presenting part is relieved from whatever it is compressing, cord, vasoprevia, arm etc.

Judy


Trendelenburg is an angle of inclination of a delivery table – the woman flat on her back and the table tiltied as steeply backwards as it will go, so that her head is down and her bottom up. A sort of technological knee-chest effect, I suppose.

Lesley


Ear Presenting

Re ‘shoving the presenting part back up’. This case may be of interest.

1st baby average size tall mum at term labouring at home through day aiming for Domino. Pattern of labour changed to suggest to me (on the day at the time) ?OP though didn’t palpate as such. Strong painful contractions early part of the day in labour and progressing then near tea time irregular spaced out with some very sharp ones and starting to get back ache. Transfer to unit took place about 7pm when mum requested to start Entonox (she definitely didn’t want a home birth). Second examination in labour found cervix 7cm dilated well applied (I don’t know how) with head -1cm above spines but presenting by the left ear membranes intact.

Discussion took place with mum related to the fact that the phrase ‘can’t you grab it by the ears’! now took on a whole new meaning. I’d have to think about what could be done for a few minutes as this was some thing new. Doll and pelvis came out then discussion with colleague. By now contractions strong and regular. My concern was to keep membranes intact and not let head come down too far before head could flex and rotate (being upright just didn’t seem the right thing to encourage in this situation). After discussion with parents decided to apply as much encouragement/pressure as possible through some contractions aiding flexion but not to ‘let’ (if such a thing is possible) head come down (push it up).

Left lateral with bottom fairly high was comfy for mum and judged to probable be a good position in which to achieve this during VE which mum consented to. Contractions now strong and still regular. Registrar advised may be needed later in view of situation advised not required at this time – plan A in progress. Just after midnight mum birthed a lovely baby, about 3.4KG, membranes rupturing spontaneously with descent of head (OA).

Midwifery instinct told me that the plan had worked, but who knows?

Heather

Links to other sources of information:

On this site:

Prolapsed hand at a home birth – inspiring story about a potentially dangerous situation which occurred without warning, and was managed successfully at home.

Archives on Breech birth, with many further links.

On other sites:

Posterior Babies – what mothers can do – from the UK’s Association for Improvements in the Maternity Services (AIMS)
www.aims.org.uk/posterior.htm

US Midwife Archives page on suboptimal fetal positions

Get Your Baby Lined Up! – page on optimum foetal positioning, from the Home Birth Reference Site
www.homebirth.org.uk

From Breech to Brow, by Thomas Ind – correction of a brow presentation with ventouse, proceeding to vaginal birth.
(www.obgyn.net/pb/cotm/9810/cotm_9810.htm)

Great photo of face presentation OP (Mentum Anterior) baby (www.birthdiaries.com/diary/face.htm)


AH updated 17 June 2001


Return to the Archive Index

Radical Midwives’ Homepage – www.midwifery.org.uk

Skills

Posted on

April 12, 2013

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