Asynclitism: a well aligned baby or a tilted head?

This post is a quickie. I am compiling a list of suggestions for future posts via Facebook and Twitter which I will start working through. In the meantime this little topic has been cropping up a lot so here goes…

Asynclitism is when the baby’s head is moving through the pelvis ‘tipped’ to one side. This is usually diagnosed by a vaginal examination in labour. However, asynclitism is rarely caused by the baby having his/her head tilted to one side and rarely a real problem. Instead, like the anterior lip, it is a normal part of the physiological process of birth.

Disclaimer: Routine vaginal examination has NO place during a physiological birth. Unfortunately vaginal examinations continue to be commonly used to determine progress despite the lack of evidence supporting this invasive intervention. In addition, most women do not experience a physiological birth and instead have their labour induced or augmented. Once an intervention is implemented it’s effects need to be monitored ie. assessment of cervical dilation. Therefore, the following explains what is felt during an examination in relation to what is happening as the baby descends and rotates through the pelvis.

Asynclitism: normal birth physiology

The baby enters the pelvis through the brim/inlet. The easiest way to do this is with the head in the transverse position (facing sideways to mother). However, the baby is not lying in a perfecting vertical position. The woman’s pelvis is tilted and her uterus/baby are also sticking out at an angle – check out a pregnant woman for confirmation. If at this point in the birth process you put your fingers into her vagina, you will feel the side of the baby’s head near the symphysis pubis. If you dig further you will feel the saggital suture towards the back of the pelvis. The baby’s head is not tilted… it is perfectly aligned with the baby and the pelvis.

Once the baby has descended into the cavity/mid-pelvis he will use the space and the counter pressure of the pelvic floor (unless the muscle tone is reduced by an epidural) to rotate an anterior position (facing towards mother’s back) to fit the shape of the pelvic outlet. It is not until the baby has made this rotation that you will feel the centre of the head in the middle of the pelvis. If the baby’s head is well flexed, you will also be able to feel the occiput, the posterior fontanelle and the lambdoidal suture (I love that word – lambdoidal).

As usual the text book depictions of a perfectly central saggital suture reflect our cultural need to keep birth neat and orderly. It fits in with the clean and clinical depictions of birth in which the woman is replaced by diagrams and graphs. The reality of a vaginal examination is very different and involves bodily fluids, squishy bits, hair, caput (swelling on baby’s head), moulding, the amniotic sac, difficult to distinguish parts of the head… and is usually an unpleasant experience for the woman (yes, she is involved). When birth becomes complicated there may be an indication for a vaginal examination (eg. to determine position), but in the absence of a complication there is no point. Telling a woman that her baby is asynclitic is at best pointless and at worst stress inducing… OK I’ll shut up about VE’s and save it for dedicated post later on. Moving on…

Asynclitism: a variation or complication

Occasionally the baby enters the pelvis with his/her head tilted down towards their shoulder (a variation). If the baby continues to descend in this position it can alter the progress of the birth process. The woman may experience irregular contractions without change over many hours. Most of the time the baby will sort themselves out, particularly with an actively mobile mother. Techniques to create more space in the pelvis may help to provide additional room for head wriggling and repositioning. I have found that techniques which help the baby move back out of the pelvis are very effective (eg. mother on all fours, bottom in the air + rebozzo work). Once baby is up and out  a little, he can reposition and come down again with his head better aligned. Unfortunately a common response to this situation is to put up syntocinon (pitocin) and create stronger contractions. It doesn’t take a genius to work out what happens if you have stronger contractions pushing the baby through the pelvis even harder and faster. The baby needs space to realign his head rather than more pressure and compaction (and the additional risk of syntocinon). Very occasionally the baby is unable to adjust his position and the birth becomes complicated – the baby becomes increasing compacted in the pelvis and begins to show signs of distress. In this situation the woman may require assistance to birth (instrumental birth or c-section).

Summary

Asynclitism is a normal part of the birth process. When it is caused by a tipped head it can alter the pattern of labour and may require additional work and support. It can be difficult to work out which type of asynclitism is happening via a vaginal examination (normal or a tilted head). Therefore it is best to keep fingers out of the vagina and focus on the woman and what she does or does not need from you.

Further resources

Spinning babies

I would love to hear your experiences of asynclitism.

About midwifethinking

independent midwife, lecturer and student of all things birthy
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76 Responses to Asynclitism: a well aligned baby or a tilted head?

  1. Thanks for the great post!
    My son was Asynclitic although as I didnt have a VE (and only so I could enter the tub to waterbirth) until right at the end of labour (9.5cm with anterior lip) so we didnt know until then. His labour was 30hrs and I am told a longer labour is not uncommon with asynclitic positioning. Can you comment on that?
    If I didnt have a doula to keep me home labouring for most of that time I would have been at hospital way too early, potentially had more VE’s and likely had some form of stress placed upon me due to the labour length (was at the Birth Centre).
    I am glad about my well researched decision to hire a doula – it made a huge difference to my birth outcome, a drug free waterbirth.
    Keep up the great work, I share alot of your stuff with my HypnoBirthing groups and other resource on Facebook.
    Cheers, Bree @ Pregnant Possibilities.

  2. kavita kali says:

    my first baby was asynclitic and it was a 3 hour pushing phase, and took *a lot* of work…my 2nd, i did not push consciously, my uterus did all the work, and the midwives didnt make it because it was an hour labor/birth.

  3. Kate Cornfoot says:

    Reading your terrific posts, I can’t help but shake my head in confusion at the way birth is augmented, interfered with and disrespected in traditional, medical birthing environments. You explain things so clearly, in such a common-sense way; I dream of a time when these concepts are common sense in even the hospital environment.

    • Laura says:

      I feel exactly the same. Reading this I think of all the times I’ve stood in delivery suite watching birth be medically managed when if women were supported to trust their bodies and not fed panic stories to guide them into inductions and augmentation instead they would birth their babies the way babies should be birthed. I’m a UK midwife just moved to Australia from a busy London hospital and I’ve just discovered this blog….it’s fantastic and very refreshing …well done and thank you!

  4. Holly Platt Wells says:

    This is really interesting.
    My first was diagnosed as asyclitic 2 and a half years after his birth when looking back at pictures and seeing a caput on the side of his head. He was also a compound presentation with a hand over his eye.
    The labour was relatively short, 6.5 hours, and I laboured in water at home. The pushing phase was incredibly hard work and I ended up standing and lifting a leg onto the side of the pool through pushes. I pushed for a little under 2 hours.
    I totally agree with your thoughts on VE and augmentation. I would also add that without full mobility and awareness I’m fairly certain I would have needed assistance to birth.

  5. Starzia says:

    My son was diagnosed as posterior and asynclitic after I transferred to hospital from a planned home birth. I had been in labour for 2 days, was fully dilated and had been pushing for 5 hours. My midwife had done a VE on me to determine his position during pushing but had not been able to tell what position he was in due to his head being too compacted for the fontanelles to be felt. The Ob tried to do a VE when we arrived and said the same thing, the position was finally diagnosed via ultrasound.
    He was born via caesarean after ventouse attempts failed. :-(

  6. Comadrona says:

    Yep, totally agree… and if the woman can get into a knee-chest position (bottom up in the air and knees on a pillow to make her bottom even higher) and do a few contractions like that, this will give the baby the space he needs to tip his head the other way. However, if we keep our fingers out and encourage he woman to move according to her body’s requests, Bob is usually our Uncle!

  7. Holly says:

    Having had a caesarean with my first baby I planned a home birth with an amazing, experienced independent midwife for my second. My first labour was very long due to malpositioning and I experienced the typical cascade of interventions one can expect from NHS “care”. The second time I had done everything to avoid a repeat of that; osteopathy to ensure good pelvic alignment, spinning babies techniques and yoga during pregnancy and hired a with-woman IM. But my labour followed the same pattern: long, irregular contractions (every 3-7 minutes from the first one, not a gradual build up) and an uncontrollable urge to push. After about 7 hours of pushing I begged my IM for a VE, she tried to disuade me, knowing how strongly against them I was, but I knew there was a problem. She examined me and did not tell me how dilated I was, at my request, all she said was to try a few things to encourage a better position for my baby. After a few hours of actively trying to open the pelvis and no change in the contractions, I asked for another VE, this time with all the information. I was 5-6cm and baby was asynclictic. We tried a few more things and my waters went spontaneously while I was sat pushing hard on the toilet! My baby’s heart rate plummeted and then spiked, my pulse was sky rocketing, so I decided to go into hospital for a c-section. I had decided before the birth that I would only go into hospital for that reason, I believe that if all avenues have been explored at home then there is nothing more that can be done except instrumental or surgical delivery. When my son was born his head was posterior, though his body wasn’t, exactly as my first son had been positioned, twisted. My second baby’s face and shoulder were very scrunched up, indicating that the pressure on his head and neck was intense. Even now, at 12 weeks old, his right eye doesn’t open as wide as his left. I guess I’m one of the tiny minority who can’t birth malpositioned babies quickly enough. My full birth story is on my website, http://spirited-mama.com/ entitled Opening Eyes.

  8. Carolyn Hastie says:

    Great post as usual Rachel! I agree asynclitism is a normal part of the birthing process – and apart from the vagaries of pelvic curves, station of the head and the angle of the person’s examining fingers causing the perception of asynclitism, I explain to people that babies ‘rock’ their heads from side as they make their way down through the pelvis to negotiate best passageway for themselves. Their ability to ‘rock’ their heads from side to side is their way of negotiating pelvic types, muscular tension etc. As you and Holly (above) have indicated, movement to create more space in the pelvis helps the baby to wriggle and rock their way down and out. Thanks for having this conversation – asynclitism is one of the many aspects of birthing that I find fascinating. All I can say is those babies are enormously clever and creative.

  9. Kathryn K says:

    Very useful link to tips for creating space, thank you, that’s more ideas to convey to parents antenatally. I’ve put the book you mention on my wish list, but in the meantime, what is Chunging?

  10. Stefanie says:

    I also had a asynclitic posterior birth 2 months ago. I was in normal easy labor for 6 hours, went to the hosp. Had to have an admitting VE and was a 5 at 2 am. Labor got very tough and My 2 doulas and my DH and I tried every position possible. We sifted for hours, I tried pelvic floor releases, EVERYTHING to get him to turn out of posterior. My Dh even held me up suspended in the air during my Contx, a hung from bedsheets tied to him. The baby ended up ascending and I agreed to one more VE 8cm dialated and she couldn’t feel his head ( waters in tact) at 12:30 pm. Being a VBAC they laid out all my options and my DH and I decided on the c/s. ( no water breaking, bc of the risk of cord prolapse, I didn’t want the epidural and wait option bc i didn’t want the toxins in my baby, and I was spent and was lacking confidence about continuing on). They told me that he was posterior asynclitic which is the exact same position that his older brother was in 2.5 years earlier and 8 lbs 15 oz with a giant head. I have serious doubts that he would have come out on his own. I will still try to VBAC again though!

  11. K says:

    My 3rd was asynclitic, with his head tipped to the side almost as if he were listening to a radio in another room. ;) My labor became long and irregular towards the end (ended up being 18 hours as opposed to my 5 & 8-hour labors.) By the 12-hour mark I started feeling frustrated that I wasn’t making the progress I wanted to and felt like I had in my previous two labors. After a nap and a meal, I started feeling frantic and decided to do a self-VE. I knew he was down fairly low in my pelvis and so when I felt for his position, I realized he was tipped. I did hands-knees for two ctx (all I could stand – that hurt!) and then squatted and my doula sifted me with a wrap. Got things going nicely and he was born a few minutes later, in my birth pool, just as I’d planned. :) One reason why I think it worked out was that I was at home, could move as I liked, and didn’t have the constant pressure of VEs making me feel incompetent and scared. I was in total control of every choice there was to be made, and my support team respected me and did whatever I needed done.

    Thanks for this post – great job as usual!

  12. Suzanne says:

    Perfect timing I have an exam coming up on this and the text books were not helping me “see” this concept. Your post really helped me understand….now if I can make words into pictures.

  13. Jennifer says:

    My oldest was born via c/s after an induction led to a severely asynclitic baby that even forceps couldn’t help. They broke my water when I was -3 station and he fell into a horrible position and wasn’t going anywhere.

  14. Sally P says:

    I had the pleasure of birthing my second at home in water asynclitically in a three hour labour, 1 hour dilating and 2 hours pushing. I was 43 weeks, and went in and out of labour from 36 weeks. Two days before I gave birth I had a session of acupuncture to get things moving along. It was a very “easy” labour with contractions coming one after the other, for an hour. In the gap between two contractions I could feel my son turning his head and wiggling it around, which made me laugh as I had not felt anything like this with my first. Interestingly I could feel my cervix opening like a spring being released when he was doing this! Once the pushing urge came it was uncontrollable, I couldn’t fight it, so different to my first birth, which there was no urge to push at all, my body just did it for that one. When I was pushing I would get a pain centrally above my pelvic brim at the front, which felt not so good, so avoided pushing past that pain, and never mentioned to my Midwife for an hour, so made only a little progress in that time. I had a feel and found an anterior lip of cervix was stretch so tight which I kept my finger on when I pushed with the next contraction and it moved back. Then a few more pushes and not much movement. So another 45 minutes of pushing with everything I had to get him down resulted in the asynclitic crowning, which was a sensation out of this world, the perineum stretching to beyond maximum on my LHS was a mind boggling sensation, I was sure there would have been some sort of damage, but not even a graze. Then the shoulders were quite stuck so Midwife assisted his birth by helping him along. He had lots of burst blood vessels in his eyes for 2 weeks after that! And was a big babe at almost 10lbs. He was what I thought the biggest I could fit out, but to my surprise, was beaten by his newly arrived sister, whom was 10lbs 8oz, my 5th birth also at home in water. Unfortunately I ended up transferring to hospital after the birth as I was unlucky to have placenta accreta… however for my first hospital experience in 5 births all at home I would have to say I was very grateful for the appropriate medical care I received, and it was all in due time, apart from the ambulance taking over an hour to get to home, but that is another story.

  15. My son (born at home) was posterior and asynclitic, but the midwife didn’t tell me about the asynclitic part until after he was born. :) I remained at 8cm dilation with lots of pressure and feeling a little pushy (not overwhelmingly) for 8 hours. He did not descend into the pelvis (remained at -3) at all until my water broke, at which point second stage began. I began pushing on a birth stool for a couple of contractions, but I could tell that wasn’t an effective position. My midwife asked me to squat, and I didn’t feel like it after a night and a day in labor, but I did. He immediately rotated, descended, and crowned, all in one contraction. What an intense sensation! He was born anterior. He had some unusual head molding, and he was all wrapped up in his cord – around his neck, under his arms. I do not know whether that affected his position or not. Placenta followed quickly. Mama and baby were not just fine, but wonderful. Note – the vaginal exams were at my own request. Oddly, because I did not feel I would get undue pressure based on the exams, and because it was not a straightforward labor like my other two, I had more exams at my home birth than with either of my hospital births (first was no exams, second was two exams).

  16. He was 8 lbs 14 oz., for the record, and I mistyped – 7 hours at 8 cm., not 8. :)

  17. I LOVE your posts!

    I too believe that no one should be ‘poking around in there’ when a mama is giving birth. I appreciated your explanation of dilation occurring in ellipses rather than concentric circles (and I’d like you to know that because of your post, we will be changing our diagram of dilation in the next edit of our student materials).

    And now your take on asynclitism being a normal variation! I believe we need to be careful about what we ‘name’ things for women during their birthings…our words possibly causing a defeated attitude.

    We are holding an instructor training this week, and I’d also like you to know that we have shared links to several of your posts with our Hypnobabies Childbirth Hypnosis instructor trainees during their prerequisite process, since many of them come to us as Hypno-moms without a background in childbirth. You have helped us tremendously to educate both our instructors and their students by shedding some light on and dispelling some myths about the physiology of normal birth, and also about the ‘choices’ our expectant families are faced with during their baby’s birthings.

    Thank YOU so very much!

    Yours in 550 gentle birthings,

    Carole

    Carole Thorpe, CHt, HCHI, HCHD, CLEC, CiHOM
    Hypnobabies® Childbirth Hypnosis, VP

    “Thoughts (words) become things…choose good ones!”

  18. Michelle says:

    This was a very interesting read for me. My first was an asynclitic baby, but not realised until she was extracted via an emergency section. Labour was hard, irregular, looooong (I laboured for 3 days at home – the midwives thought I was ‘just gearing up’ but it totally felt like full blown labour to me!) and eventually too exhausting to carry on without intervention.
    Sadly I had an epi (that only worked down one side), ARM and pitocin. Guided pushing for 3 hours. Then off to theatre for ventouse but by then she was totally wedged and wouldn’t budge. So it ended up in a c-sec.
    It bugs me that I’ll never know if I could’ve birthed her naturally if I had known what I was dealing with. I had numerous VE’s and no one picked up on her positioning.
    Anyhow, 7 months ago I managed a completely natural hospital VBAC and labour was very different (much shorter – 12 hours) as my baby this time was in perfect position (and born in the sac too!)

  19. Barbara Cumby says:

    Unfortunately both our babies were “nosy babies” and wanted to come out facing upward to see the world:), This was almost twenty seven and twenty five years ago. However, because of the doctors involved and the importance they placed on a vaginal birth versus a section I did deliver both without sections. They were somewhat complicated births but if I had been anywhere else in our province I was informed a section would have occurred. How wonderful the miracle of life and how beautiful if you are able to use the services of a midwife and birth at home! But I must add also when things become complicated and the medical profession does everything possible to ensure as much of a natural birth as possible it is a blessing.

  20. Joy says:

    I am a McTimoney Chiropractor, so am replying to this from the woman’s point of view and not the baby’s. My view is that the mother’s pelvis is not in alignment, and therefore, as the baby’s head “fits” into the pelvis during birth, it is forced to adapt and perform this asynclitism. If more women had chiropractic treatment as a preventative measure during pregnancy, my guess is that we would see less of it.

  21. Thank you everyone for commenting and sharing your experiences. It is your contribution that makes this site a valuable resource for mothers, fathers, midwives, doulas, etc. :)

  22. Rose says:

    My son was born at home after a 21 hour labour, 9 hour pushing stage. About 7 hours into pushing I allowed a VE, done by a midwife, she discovered he was asynclitic. I did have very regular chiropractic and massage treatments throughout my pregnancy and chiropractic every other day for 39-41 weeks. I am confused, will a baby be born asynclitic? Does it just take longer? I was “threatened” with a hospital transfer but I have an excellent chiropractor that was able to be at my birth, she worked my psoas muscles, gave me an adjustment,and then took me to the toilet where she worked my hips & then finally to the stairs where I was doing standing lunges – the midwife did another VE and his head was tipped the the “right” position. He came out (with a hand up beside his face) two hours later. No perineal damage. I have wondered a lot about this since his birth, he is now almost 13 months, but haven’t really read much on the subject.

    • Occasionally a baby can actually be born with his/her head tipped to the side (see Sally P’s birth story in the comments above). However, more often the baby will adjust like your’s did, and come out with their head aligned. Unfortunately waiting for the baby to adjust can take some time and in hospital they often do not wait and instead create further problems by interfering.

  23. Cora says:

    I planned a homebirth with a midwife who rushed me through my start-and-stop labor with my asynclitic baby by giving me shot after shot of herbs and having me push before I was ready. I found out later she had told her assistant to keep giving me the herbs even when I couldn’t catch my breath between contractions because she wanted to be home before dinner. I pushed for hours and ended up with an emergency cesarean.
    I didn’t realize how grossly she had mismanaged my care until reading this post, however this is a very healing realization. My body did not fail me, my midwife did.

    • I am sorry you were failed by those around you during birth :(
      This makes me mad. Homebirth becomes unsafe when the midwife applies hospital thinking to the process i.e. interferes to meet an agenda that is not the woman’s.

  24. margaret says:

    My son was born after grueling 30 hour labor with 6 HOURS of transition symptoms in which I only went from 6cm to 7 1/2cm. (I requested cervical exams because my body started pushing on its own and I thought, maybe just MAYBE…. nope).

    Essentially what ended up happening was, I, extremely sleep deprived (over 48 hours without) requested an epidural, slept for 3 hours, woke up and he was crowning! His head was cocked to the side even THEN!!!! I had a vaginal birth but not a natural one, which I’m JUST NOW becoming OK with- I’m very happy I didn’t have to have surgery on top of what I went through- as I ended up with the spinal headache from the epidural.

    This time, I’ve hired a doula, am being adjusted by my chiro every week and am a LOT more active (running after a 2 year old and indulging my gardening obsession). I’m hoping for quick easy birth this time…. but I’m not holding my breath. We almost didn’t have any more kids after what happened last time. I don’t tell my labor story to pregnant women. My midwife (the same who delivered my son) is VERY optimistic that i’ll be successful and it’ll be a heck of a lot easier this time. :)

  25. Ash says:

    Hi.
    Great blog. I’m a 1st year student midwife.
    My first baby was undiagnosed footling breech, my second was a vbac. It was a good labour but stalled at 5cm when we got to the hospital, and again at 8cm. About 15 hours of dilatation followed by 3 hours of pushing in all different positions, including on the birth stool.
    Pushing began involuntarily, such an amazing phenomenon. I love my body! No interventions apart from an unwanted ARM, to attach an unwanted electrode monitor. In the end I was so tired I was on my side on the dreaded bed. I forgot to get in the shower for pain relief and to cool off. When she finally popped out, she was posterior and judging by the position of the caput and electrode mark, her head was slightly deflexed and slightly asynclitic. The caput disappeared within the first hour, so maybe it wasn’t true caput just a bit of swelling? Anyway, I loved my vaginal birth, asynclitism and all. She’s 1 now and as perfect as the day she was born. Perhaps if we have a third, we’ll have a perfectly positioned baby.

  26. Comadrona says:

    Yes, posterior is definitely an important factor but also it is very common to “stall” at 5 and 8 centimetres, especially when you leave your nest to come in to hospital. I have found that VBACs often have a lot of emotional work to do (no matter what the reason was for their C/S and how they felt about it). It is a shame that people kept doing VEs on you – if you are dilating “slowly” (according to the ridiculous partogram) you can become scared and frustrated. 15 hours for a labour is fine, so is eight and so is 46 – if mum and baby are coping OK. Next pregnancy, make sure you sit with knees lower than hips at all times. This is the single most useful thing you can do to help baby into a nice OA position. (Also, forbid ARM – babies position themselves more easily when membranes are intact.) But no matter what, because you have laboured and birthed previously, the next one is usually much smoother. What a champ you are and what a great body you have – you birthed that lovely big girl under your own steam!

    • Ash says:

      Thanks for your comments Comadrona :-) I did do a lot of emotional work in preparation and labour (my man is amazing so that helped) and I also worked very hard to keep my knees below my pelvis. I’m a very tall lady so that required a lot of effort. I sat on a big ball, got on all fours, and practiced yoga. I did a lot of walking and even went up a few little mountains quite late in pregnancy (safely!).
      I tried to decline the ARM for the same reason that you expressed, but it would have meant war as I was birthing in hospital and there was a doctor hassling me because I had requested that they delay inserting a canula. I asked if I could go home and was told no. I cried when they did the ARM. But I laboured on, and at least the toco freed me from the horrendous belts. Apart from the ARM and the doctor and the stupid toco, it was all good. I loved my birth. I wrote a letter of feedback to the hospital too.

  27. Sarah says:

    My 9 lb 6 oz asynclitic baby was only diagnosed during the c-section, when she had to be vacuumed out of my hip. She was an induction, including pitocin and ARM, so I’ll never know if she was stuck there before we went into the hospital (possible, since I’d been having contractions but hadn’t gone into labor yet on my own and dilated easily), or if she fell there and got stuck during the induction. I walked and walked and walked during the first part of that induction, and then after my epidural my ob had me on hands and knees for about 2 hours, and she still didn’t progress past about -2 station (hence the c-section). She’s now 4, and her 9 lb 2 oz brother was born naturally via VBAC 7 months ago.

  28. Victoria says:

    I am still not sure what happened at my birth three months ago. My water was broken for about 12 hours before really heavy labor started. Ten hours later, I was fully dilated except for the infamous “lip of cervix” which I pushed past. My midwife, doula, and husband supported me as I pushed in various positions for a few hours. At some point, it seems that my baby’s head actually went backwards. After another hour or so of pushing, my labor stalled out, and contractions diminished. We all decided to head for the hospital so I could get an epidural and rest. When I woke up, I pushed him out in under two hours. His head was perfectly round. There was no molding or swelling. The OB at the hospital called it a “short cord.” I don’t buy that. Could he have been asynclitic for a period of time before straitening out? Is it possible that the lack of molding caused the pushing phase to last about six hours?

    • Hmm an interesting birth story. Sounds like your baby just needed some time and space to get aligned well. Were you spontaneously pushing or being coached? I doubt the cord had anything to do with it! Those cords are such a grate scape goat :)

  29. heather j says:

    I had no idea my 9.5lb baby boy was posterior and asynclitic until he was born because it was an unassisted birth… probably a good thing too… I didn’t have the opportunity to worry or pathologize it.

  30. Hopefully more midwifes, doulas and women will read this post and learn from it. This sounds exactly like my labor which, after 3 days at home ended up in a transfer to hospital, for epidural then Pitocin, then baby and I went into distress, I went into shock and an emergency c-section. Surgeon told us that baby’s head was stuck in right side of my pelvis, he had to pull hard TWICE to get him out. I WISH MY MIDWIFE KNEW ANY OF THOSE POSITIONS TO HELP ME, instead she would just call me on the phone and listen to my contractions. I could have tried them, and birthed sooner, and vaginally, and maybe I would not have chronic pelvic pain now. I was very active during my birth, but I didn’t do several of those positions on your list. Thank you for posting this!

  31. Lillian says:

    I see blame being put on midwifes often when things don´t work out as one wishes. I read that she did VEs and that created pathology, I read she didn´t do any or enough VEs and wish she had to diagnose and correct the situations. Sometimes these things happen and it´s not clear what caused it, but it´s very easy to blame someone instead of accepting that sometimes, yes, this happens. We as midwifes walk a fine line. I read my mama´s mind and ask or discuss options as we all should, but even then, when it just didn´t go their way somehow it was my fault.

    • You are right midwives do often ‘cop it’ when things don’t go as expected… and sometimes you can’t win. All you can do is try to practice from the heart and accept that sometimes you will make mistakes, and sometimes you will not – yet will still become a scape goat for blame and disappointment. The key is to find support with other midwives. I have taken my share of blame (warranted and not) in my time. It is an unfortunate part of the job. I hope you have love and support from your fellow midwives.

  32. Emma says:

    I love this post especially the description of what you’d feel if you did a VE. My story is here: http://myhousesmellslikevanilla.blogspot.com.au/2010/07/my-birth-story-homebirth-for-first.html and other photos show clearly the bruise on my daughter’s head from being crooked, and there are a few shots of her immediately post birth with a round head from moulding on the TOP of her head. She was deflexed as well as asynclitic.

  33. sara r. says:

    I heard the birth story recently of a mom who was due the same day as I was, with the same midwife. Her birth was very long and involved a malpositioned baby. After hours and hours of laboring in every position imaginable, and contractions that were up to 3 minutes long, my midwife decided that the baby was just stuck on the pelvis and needed a “do-over”. They managed to tip the mom up and help the baby to back out of the pelvis and then back down, at which his head was in a better position. Labor progressed, but they didn’t realize that the little guy had stuck BOTH of his hands up by his face. When she started pushing finally, his head started crowning but then stopped. His heartrate started dropping and 3 minutes of craziness and putting her in different positions later they managed to get him out and he was okay. The midwife thinks that his elbows got stuck on the pelvis; who would have imagined that?
    If she had been in the hospital the outcome probably would have been much worse- either a c-section for FTP or a c-section at the end when he got stuck and that would have been really dangerous for both of them.
    She said it was her scariest birth and then I understood why, 4 days later, she thanked me for my “low-drama” birth and asked me to have 12 more babies. lol.

    Oh and I just have to say that I have so much respect for moms that have these kinds of long labors and long pushing phases. I seriously can’t imagine how taxing that much be. My first labor was 5 hours and second was 2.5, and although wonderful, they were long enough for me!

  34. Rachel says:

    I had a beautiful home birth 20 months ago. It was an amazing experience, but some questions have since arisen in my mind. Firstly, everything went smoothly and I was dilating fine. My midwife then informed me that I had a cervical lip. Which I have since found to be normal and not a big deal. So, we did the ” rotisserie chicken” and the lip evened out. Labor continued to go smoothly but once I started feeling the urge to push, the pushing stage lasted almost 2 hours. Im still not sure why it took so long. I was in the water, in “good” position. Apparently my little one’s head was asynclitic. When she came out she was very bruised and even had some abrasions on her face- like actual trauma to her skin. It has bothered me ever since then because I dont know what caused it, what I could have done differently etc. Did it have to do with her being asynclitic or my positioning or what? I know you weren’t there and may not have any answers, but I would love thoughts or insight.

  35. I love your posts so much. You are so very articulate and have a great perspective on normal birth that is very refreshing to read. Thank you for sharing your thoughts with us! They are so valuable.

  36. Pingback: Asynclitic: Optimal Fetal Positioning

  37. Emma says:

    My second had his head “tipped to the side”. This was discovered during a VE when I was 10cm (but not yet feeling the urge to push). I was immediately hooked up to an epidural and had an instrumental delivery (failed suction followed by forceps) as it would be “impossible” for me to push baby out myself. I feel quite annoyed now having read this as I was active before they gave me the epidural and so they could have let me try to push him out myself! I am currently pregnant with my fourth and am having a vbac this time due to having an emergency c-section with my third – the cascade of interventions strikes again! I am in the UK can’t afford a private midwife and am having to have my baby in the consultant lead unit at hospital. I am only 16 weeks and they have already told me I must have continuous monitoring, a cannula, no food or drink etc all because of the relatively small risk of uterine rupture. I now have to either give in to this or have an enormous fight on my hands. Sometimes it doesn’t feel like I am a person anymore just another risk factor :-(

    • Can you find a doula to support you. It is difficult to labour whilst ‘fighting’. Remember you have to give consent for any procedure ie. monitoring, cannula etc. You have the right to decline. It seems they are already setting you up for failure :(

  38. Sandra Smith says:

    Thank you so much for the excellent posts! I am learning so much! My third birth was asynclitic, I planned a home VBAC birth after having a very routine home birth with my first, and a c-sec for breech premature twins second. I labored at home for about 20 hours, active, upright, duck walking on the stairs, standing lunges, flipping over during contractions. I had excruciating pain in my right hip all the time, worse with contractions. My waters were intact and baby was coping well, but I was exhausted and suffering and elected to transport to the hospital thinking I would request an epidural. I was fortunate enough to have a young OB attend me who was taught internal version. She broke the bag, and then during a contraction pushed my baby’s head up and turned it. I felt a forceful “thunk” as he descended deep into the outlet, and within 30 minutes he was born with two contractions – I distinctly remember the OB telling me not to push, but it was futile. It was like asking someone to stop throwing up midstream. I then became “that mother who came in and delivered within an hour without an epidural” and felt like several different nurses came in just to see what that looked like! I am expecting my fifth child in March, a planned homebirth, and this baby likes to hang out posterior. I have been doing yoga for 15 years, the Spinning Babies exercises and optimal positioning, see a chiropractor who does myofascial release, do homeopathy and acupuncture, and I’m getting cranial sacral work done. All in the hopes of preventing another long, painful labor. I’m not sure whether to accept that it’s ok if this baby is posterior or if I should keep doing everything I can to help him/her rotate.

    • Try not to worry too much (easy for me to say). Even if your baby does get into an OP or asynclitic position is does not necessarily mean your labour will be the same. I have known women who have had the exact same baby position but their labour was totally different ie. easier. Good luck and remember you have space within you for baby to turn and adjust. If needed you can maximise this space during labour… and position that helps baby move back out of pelvis and pelvis open eg. ‘bum in the air’ on all fours.

  39. Hi! Just found your blog and loving it! I’m a doula at the moment, and looking at training as a nurse-midwife next year. Lots of great info here, thanks for writing.

  40. Tracey says:

    I am a midwife myself, and I do not do many VE’s… for many women, none at all, and most others only at mother’s request. I do find them very useful at tomes though…. for myself, with my 11th baby (after the first being “normally” longish but not terribly difficult, and the last 9 being fairly short and easy, the last boy at 10.4 lbs coming in less than an hour) baby # 11 had her sweet head turned funny. Labor was agonizing, wouldn’t progress… asking my midwife to assess position (I could not tell myself) gave me the info needed, and her sweet guidance on position helped me get baby moved. Many hours later, pushing was still hard (and I usually LOVE that part) but she was finally born at home… bruised and lopsided, but here… Sweet relief!

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  42. Shelley says:

    I love this blog and have recommended it to lots of my pregnant friends. Despite being a true believer in birth being a natural event, both my attempted home births have ended up in emercency ceasarians at full dilation. First time was a long 46 hour labour where I transfered in at 9 cm due to meconium and then stalled. Pitocin and then 12 hours later my son was born by section in a OP position with deflexed head (born with caput and serious molding). I never got to push. Second time I was really careful about positioning during my pregnancy and my VBAC labour progressed well at home. But at some point my girl moved to OP and despite pushing for over 2 hours in various positions (toilet, squatting, supported standing, lunges), I only felt baby shift a couple of times and my bump remained high. When I did a self VE I could only feel a very small, bulgy part of her head very high up. Midwives decided it was time to transfer and when we got to hospital the CTG showed distress and a repeat section was agreed as she was too high for an instrumental delivery. My notes say second stage of 5 hours and she was asyntiltic and LOP and that pathogenic CTG was the reason for the section.

    But my notes also say that in theatre I passed 1600mls of urine once catheterised!! I could not for the life of me pee during the later part of my labour and the midwives at home did a ‘in and out’ catheter but only managed to get 100mls urine out when I knew I had drank loads more that. I was wondering whether a full bladder could cause bad positioning – or did the bad positioning cause me to be unable to pee…?! I wonder if an with an earlier catheter, I might have have avoided another section? Any thoughts would be most welcome as I’m going round in circles on this! Thanks!

    • A full bladder can slow descent of the baby, but a position that ‘pinches’ the ureathra can lead to urinary retention. The fact that this happened twice despite you creating a supportive birth environment makes me suspect that your bladder did not create the problem… not sure you will get a definite answer – unless you want to see what happens a third time? ;)

      • Shelley says:

        Thanks for your reply! I always wanted 3 children but Im not sure I can face another c-section recovery. Both the midwives and the ob said that I should go for an elective if there is a next time… But there is a little part of me that feels I have unfinished business!! Time will tell I guess…! ;-)

  43. Victoria Gilmore says:

    I would like to have a second opp. about my birth . I was induced at 38 weeks due to pregnancy induced hypertension. It came on pretty quickly a little less than two weeks. I had a 24 hour protein urine test done on Friday. Went in Monday for my 38 week check and was sent straight to the hospital to get induced. Had pit and also magnesium sulfate ( which made me drowsy and tired ); and it took I think about 20 hours for the contractions to finally come on. And of corse when they came on the CAME ON! So unfortunatly even though i can really handle pain very well I had to have an epi. Well my baby got stuck in my pelvis and after a couple hours of pushing I was rolled into the OR for a c-sec. Apperantly baby was not only stuck but she was face up with the cord wrapped around her neck twice. Bascially just kinda looking for a little reasurance that a c-section was OK. And that I wasn’t cheated out of a natural birth.

    • I am guessing that you had pre-eclampisa rather than just ‘hypertension’ – this would have been diagnosed via your urine and blood tests. This is a really serious condition and induction is definitely warranted – if left to get worse both mother and baby are in danger. It probably took so long to get you into labour because your body was not ready and I’m not surprised you opted for an epidural – induced contractions can be much harder to deal with: http://midwifethinking.com/2011/07/17/induction-a-step-by-step-guide/ Induction increases the chance that you will end up with a c-section. Regarding your baby being ‘face up’ you might find this post helpful: http://midwifethinking.com/tag/occipito-posterior/
      And the cord is probably just incidental: http://midwifethinking.com/2010/07/29/nuchal-cords/ As for a ‘natural birth’ – you had a pathological and life-threatening condition that required medical intervention ie. an induction… and an induction is definitely not natural and increased your chance of having a c-section. I hope that gives you a little reassurance :)

      • Victoria says:

        It does make me feel better. Alot better in fact ! I guess I was just wondering if there was anything that the doctor could have done to get her “un-stuck” from my pelvis?

        • Not sure… without being there it is impossible to say. There are a lot of techniques you can use eg. rebozzo to help reposition a baby in the pelvis but I don’t think doctors generally know about or use these techniques. They tend to opt for what they know and are good at ie. surgery.

  44. Jen says:

    My daughter was said to be asynclitic. I had very few VEs during labor and wasn’t even aware of the problem until I was pushing. I had the irregular contractions which should have clued me in but I really didn’t know what they meant. I resisted all forms of augmentation to my labor and pushed in nearly every position possible. Even on my back–as a LAST resort. In the end, my daughter was still at zero station after three hours of pushing against the cervical lip and then I was sectioned. I was later told that it was really CPD and that my pelvis was too narrow and that all future deliveries will have to be c-sections.

    I think that no matter how I look at it, I’m left with the feeling that my body failed. That I failed. I also always wondered if I would have been better off with a midwife which, unfortunately, wasn’t a legal option where I lived.

    • Hi Jen
      It sounds like you did everything you could to shift your baby. You did not fail. It is impossible to know if it would have been different with different caregivers. Hopefully you were not being directed to push as this can create further problems. Some midwives will use techniques to help the baby move back out of the pelvis and re-enter in a ‘better’ position, eg. rebozzo. This is what I would have try with a case like your’s, and have found it to be very effective.

  45. Pingback: The Anterior Cervical Lip: how to ruin a perfectly good birth | MidwifeThinking

  46. Pingback: Anterior Cervical Lip – something to avoid? | misskalypso

  47. Emily says:

    Great article thanks. I have a friend who had an anterior lip for many hours and an asynclitic 2.3kg baby at term. She ended up with a caesarean after home birth transfer. Interestingly, the baby had her head tilted to one side until around 8 months of age. My theory was that there was oligo or anhydramnios causing positional tight neck muscles on one side and babe was unable to straighten her head in order to descend to be born vaginally. Would love other’s thoughts on this theory

  48. Pingback: Welcome to the World, Baby Bug! | Embracing Life

  49. Jenn says:

    I have been loving your site and share your stories on a facebook VBAC support group I am in often. My VBAC was to an asynclitic 8#14oz girl. The “real” labor was only 5 hours start to finish… I think I started with transition though…a contraction lasting 15+min with peaks inside of it, and throwing up… contrary to plan, we headed straight to the hospital judging by what my body was doing. I labored upright in the shower almost the entire time… except the last inch when they ushered me to the bed for a VE (I had started pushing on my own as I had read your post on pushing when you feel like it instead of as directed) and had me do some position menuvers(sp is wrong…) until the dr showed up and told the nurses to allow me to push even with the lip. I had thought labor was starting the day before as contractions were getting regular at 5-7 min and harder than usual… taking some concentration and too painful to lay down with, but they stalled once I arrived at the hospital and I went home, ate rabbit liver, drank laboraide, took a nap, enjoyed my toddler, weeded the garden on hands and knees, for about 20 hours… I remember feeling her punch me (it felt like in the cervix) between EVERY contraction… even until the very last one. After looking at your diagrams, I almost wonder if she was posterior’ish too?
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  50. sara fisher says:

    I have had all 5 of.my babies at home with midwives. I have had uncomplicated births, one was posterior and born that way, so I pushed a bit longer and with more effort. My 5th baby though, was acynclitic. It was my hardest birth, by far. It was longer than my other births, but the tricky part was the long pushing phase. I had been pushing for 2 hours and not feeling him move down. Baby had a heart rate drop at one point, so I asked midwife to check. I knew something was mot right. That is when she felt his head acynclitic, and it made sense. I pushed for a total of 3.5 hours, working very hard and moving, swirling, rocking hips….. I went deep within and got super serious. I ended up pushing with all my heart for a long time, and finally felt him start to move! He came out with a huge cone molding on the side of his head, but nice and healthy and 9.4 pounds. I have some awful pelvic floor damage. I felt a buldge after birth, and it did not go away. I still struggle with it off and on. I discovered on my own, through research, I have a prolapsed rectum, which can buldge at times into vaginal wall. :( cyetocele? I can’t remember technical name now. Anyone else have experience and solutions for this? I tried physical therapy, but that did not help. I am scared to have anymore babies, with pelvic floor damage now. :(

    • sara fisher says:

      Rectocele is what it is called. Also, I felt intense pubic pain and constant back pain through labor, not great breaks like my other births.

      • Getting the baby out of your pelvis (backwards/upwards) might have helped him realign and then descend in a better position… of course easy to say with hindsight! I’m hoping someone will come and share some information re. recovering from a rectocele. Have you had a medical review?

        • Sandra says:

          I had a separated pelvis with my 5th homebirth, and a rectal prolapse. Let me tell you, all PTs are not the same. One made me worse. A good osteopath, Webster technique chiropractor, pelvic floor PT, myofascial release, trigger point release, and alignment through Rolfing and Restorative Exercise is helping me slowly recover. Magnesium and psyllium husk at bedtime to keep bm easy, a Squatty Potty platform for good toilet body mechanics. Also check out MuTu; but make sure your pelvic floor trigger points are addressed.

  51. Emma says:

    Asynclitism…I’m so glad I’ve finally found a word for it! I gave birth to my son three weeks ago. I was induced on my due date as my liver was not functioning normally, it wasn’t dramatic or life threatening but as I was having small contractions anyway the doctor decided to go ahead and induce me. I went into active labour around 5am, when my waters broke I was 4cm dilated,within 20 mins I was 8cm’s. So I can forgive the midwife for thinking my son was coming fast and anything like an epidural was a waste of time. I pushed until 8.30am,using only gas and air, I knew and repeatedly told the midwife something was wrong,he just was not coming past a certain bit no matter how much I pushed. It felt like it was blocked. There was a shift change and a new midwife around 8/8.30. Another 20 mins or so (no real idea of time scales at this point) of pushing and this new midwife could see something wasn’t happening right. She did,to her credit move me into many positions but it felt pointless, I know midwives probably hear it all the time but I knew he was not for coming out. She felt inside to see if she could understand the position of the baby but couldn’t. A flurry of activity, now a doctor is in the room also examining me (which was extremely painful). The decision was made to move me to theatre. The fantastic team tried forceps,then suction and then finally I had to have a cesarean section. I lost over a litre of blood, my blood pressure went through the floor but my 8lb12 son was finally out at 10.45am. Only 6 hrs ish after my waters breaking. Recovery has been slow as I’ve had the c section and the vaginal stuff to get over,I feel like a bit of a mess from the boobs down. I can’t fault the NHS/midwives/theatre team or the aftercare I received. All was fantastic and very responsive. I can’t help but think though the first midwife could have caught the situation earlier and perhaps moved me around etc to try and get his head to shift but even she thought he would pop out in no time.

  52. quartzknee says:

    4 weeks ago I had my first baby via c section due to asynclitism. I feel very good about how everything went and was well supported. Baby was in a good position that day however he must have flipped over when my waters broke. I was fully dilated less than 2 hrs after my water broke (no contractions prior to that) and given the speed of my labour, I had no drugs. We waited and moved me into a million positions because baby had not descended. Once he was down, pushing was incredibly painful in my hips and back as he must have flipped. After almost Getting an epidural, he flipped again and I started pushing normally. We moved many positions, had a great team, used warm compresses etc but he would move down and then up, not progressing. Eventually the pushing and contractions, which I could not take a break from, were excruciating. After almost 7 hours of pushing, I was given options of extractions or c section and I went with the c section and have zero regrets. He was found to be very asynclitic. Middle of the night and I had two GPs (my main birth doctors) and two OBs come to assist. They showed caring and understanding and I feel good about my birth regardless of it not being vaginal.

    • quartzknee says:

      I did not attempt vacuum or forceps because he had not moved far down and it seemed the chances were high of having a c section regardless, and creating further complications.

    • A positive birth experience is not about how the baby emerges… it about how the woman feels during her labour and how people treat her. Congratulations :)

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