The Anterior Cervical Lip: how to ruin a perfectly good birth

Posted on January 22, 2011 by

Here is a scenario I keep hearing over and over: A woman is labouring away and all is good. She begins to push with contractions, and her midwife encourages her to follow her body. After a little while the midwife checks to ‘see what is happening’ and finds an anterior cervical lip. The woman is told to stop pushing because she is not fully dilated and will damage herself. Her body is lying to her – she is not ready to push. The woman becomes confused and frightened. She is unable to stop pushing and fights her body creating more pain. Because she is unable to stop pushing she may be told to have an epidural. An epidural is inserted along with all the accompanying machines and monitoring. Later, another vaginal examination finds that the cervix has fully dilated and directed pushing begins. The end of the story is usually an instrumental birth (ventouse or forceps) for an epidural related problem – directed pushing = fetal distress; ‘failure to progress’; baby mal-positioned due to supine position and reduced pelvic tone. The message the woman takes from her birth is that her body failed her, when in fact it was the midwife/system that failed her. Before anyone gets defensive – I am not pointing fingers or blaming individuals, because I have been that midwife. Like most midwives I was taught that women must not push until the cervix has fully dilated. This post is an attempt to prompt some re-thinking about this issue, or rather this non-issue.

Anatomy and Physiology

Birth is an extremely complex physiological process but very simplistically 3 main things occur:

  1. Dilatation of the cervix
  2. Rotation of the baby through the pelvis
  3. Descent of the baby through the pelvis

But this is not a step-by-step process – it’s all happening at the same time, and at different rates. So whilst the cervix is dilating the baby is also rotating and descending.

1. Dilatation of the cervix

The cervix does not open as depicted in obstetric dilatation models ie. in a nice neat circle (Sutton 2001). It opens from the back to the front like an ellipse. The os (opening) is found tucked at the back of the vagina in early labour and opens forward. At some point in labour almost every woman will have an anterior lip because this is the last part of the cervix to be pulled up over the baby’s head. Whether this lip is detected depends on whether/when a vaginal examination is performed. A posterior lip is almost unheard of because this part of the cervix disappears first. Or rather it becomes difficult to reach with fingers first.

The cervix dilates because the muscle fibres in the fundus (top of the uterus) retract and shorten with contractions = pull it open (Coad 2005). This does not require the pressure of a presenting part ie. baby’s head or bottom (lets stick to heads for now). However, the head can influence the shape of the cervix as it dilates up around it. For example, a well flexed OA baby (see pic A) will create a neater, more circular cervix. An OP and/or deflexed baby (see pic B) will create a less even shape. For more about OA and OP positions see this post. Most baby’s will be somewhere between these two extremes whilst the cervix is opening and will be changing their position as they rotate.

2. Rotation

Babies enter the pelvis through the brim. As you can see from the pictures above this is easier with their head in a transverse position. As the baby descends into the cavity their head will be asynclitic – with the parietal bone/side of the head leading. This is because the angle of the pelvis requires the baby to enter at an angle – see picture on the right. Once in the cavity the baby has room to rotate into a good position for the outlet which is usually OA. Rotation is aided by the pelvic floor and often by pushing.

3. Descent - the urge to push

The urge to push… and I’m talking spontaneous, gutteral, unstoppable pushing… is triggered when the presenting part descends into the vagina and applies pressure to the rectum and pelvic floor. This is called the ‘Ferguson reflex’ – probably after some man. This reflex is not dependent on what the cervix is doing, but where and what the baby’s head is doing. So, if the baby’s head hits the right spot before the cervix has finished dilating the woman will spontaneously start pushing. An alternative but common scenario is when the cervix is fully open but the baby has not descended far enough to trigger pushing. Unfortunately some practitioners will tell the woman to push and create problems instead of waiting for descent and spontaneous pushing.

Pushing before full dilatation

Because we are not telling women when to push (are we?!) they will push when their body needs to. If we are directing pushing we risk working against the physiology of birth and creating problems (see previous post). Spontaneous pushing before full dilatation is a normal and physiologically helpful when:

  1. Baby’s head descends into the vagina before the cervix has dilated. In this case the additional downward pushing pressure assists the baby to move beyond the cervix whilst pulling the cervix out of the way.
  2. Baby is in an OP position and the hard prominent occiput (back of head) presses on the rectum. In an OA position this part of the head is against the symphysis pubis and the baby has to descend deeper before pressure on the rectum occurs from the front of the head. In the case of an OP position, pushing can assist rotation into an OA position.

I am yet to find any evidence that pushing on an unopened cervix will cause damage. I have been told many times that it will but have never actually seen it happen. I have encountered swollen oedematous cervixes – mostly in women with epidurals who are unable to move about. But, this occurs without any pushing. I can understand how directed, strong pushing could bruise a cervix. But I don’t see how a woman could damage herself by following her urges. In many ways the argument regarding pushing, or not is pointless because once the Ferguson reflex takes over it is beyond anyones control. You either let it happen or start commanding the women to do something she is unable to do ie. stop pushing.

Telling women to push or not to push is cultural not based on physiology or research. For example, in some parts of the world eg. Central Africa, women are told to push throughout their entire labour (on an unopened cervix!). This is often accompanied by their midwife manually stretching the cervix too – ouch. Alternatively in other parts of the world eg. the US women are told not to push until a prescribed point in labour. It seems midwives are bossy worldwide.

When left to get on with their birth, occasionally women will complain of pain associated with a cervical lip being ‘nipped’ between the baby’s head and their symphysis pubis during a pushing contraction. In this case the woman can be assisted to get into a position that will take the pressure off the cervical lip (eg. backward leaning). When undisturbed women will usually do this instinctively. At a recent waterbirth a mother (first baby) who had been spontaneously pushing for a while on all fours floated onto her back. A little while later she asked me to feel where the baby was (for her not me) – baby was not far away with a fat squishy anterior lip in front of the head. The mother also had a feel, then carried on pushing as before. Her daughter was born around 30 mins later.

Suggestions

Avoid vaginal examinations (VEs) in labour. What you don’t know (that there is a cervical lip) can’t hurt you or anyone else. VE’s are an unreliable method of assessing progress, and the timelines prescribed for labour are not evidence based (see this post).

Ignore pushing and don’t say the words ‘push’ or ‘pushing’ during a birth. Asking questions or giving directions interferes with the woman’s instincts. For example, asking ‘are you pushing’ can result in the women thinking… am I? Should I be? Shouldn’t I be? Thinking and worrying is counterproductive to oxytocin release and therefore birth. If she is pushing let her get on with it and shush. For more about pushing in general and a link to a great audio by Gloria Lemay see this post.

Do not tell the woman to stop pushing. If she is spontaneously pushing (and you have not coached her) she will be unable to stop. Pushing will help not hinder the birth. Telling her not to push is disempowering and implies her body is ‘wrong’. In addition, after fighting against her urge to push she may then find it difficult to follow her body and push when permitted to do so (Bergstrom 1997).

If a woman has been spontaneously pushing for a while with excessive pain (usually above the pubic bone) she may have a cervical lip which is being nipped against the symphysis pubis. There is no need to do a vaginal examination to confirm this unless she wants you to. If you suspect or know there may be a cervical lip:

  • Reassure her that she has made fantastic progress and only has little way to go.
  • Ask her to allow her body to do what it needs to, but not to force her pushing.
  • Help her to get into a position that takes the pressure off the lip and feels most comfortable – usually a reclining position.
  • If the situation continues and is causing distress – during a contraction apply upward pressure (sustained and firm) just above the pubic bone in an attempt to ‘lift’ the cervix up.
  • If the woman is requesting further assistance the cervical lip can be manually pushed over the baby’s head internally. This is extremely uncomfortable!

Note: This nipping situation is rare and usually a cervical lip will simply move out of the way without causing any problems.

Summary

An anterior cervical lip is a normal part of the birth process. It does not require management and is best left undetected. The complications associated with an cervical lip are caused by identifying it, and managing the situation as though it is a problem.

This post is also available in French


Posted in birth, midwifery practice | Tagged , , , , , | 201 Comments

Stages of Labour and Collusion

Posted on December 22, 2010 by

My New Years resolution is to stop colluding in the myth of stages of labour. Will you join me? This may be a little difficult as a midwife and an educator but I’ll give it a go – will you?

The stages of labour

In current midwifery texts labour is divided into three distinct stages, and further divided into phases within those stages. The first stage of labour involves regular and coordinated uterine contractions accompanied by cervical dilatation. This stage includes three phases: latent, active and transitional. The second stage of labour begins when the cervix is fully dilated and ends when the ‘fetus is fully expelled from the birth canal’ (Stables and Rankin 2010, p.533). Again, the second stage is further broken down into three phases: latent, active and perineal. ‘The third stage of labour is the period from the birth of the baby through to delivery of the placenta and membranes and ends with the control of bleeding’ (Stables & Rankin 2010, p.547).

This concept of birth reflects the scientific, mechanistic model of how the body works (see ‘a quick history lesson’ ). It does not reflect women’s experience of birth or the physiology of birth.

Problems with assessment and categorisation

The idea of stages of labour contradicts what we know about the physiology of birth. Physical changes in the cervix and uterus occur during pregnancy and the onset of labour is a gradual happening without a distinct start time. The definition of ‘established labour’ includes regular rhythmic contractions (3:10 or more, lasting 45 secs or more) and progressive dilatation of the cervix (1cm per hour). However, women’s natural contraction patterns vary, and the idea that a cervix will follow a graph is outdated – see ‘the effective contraction’. What about a woman who only ever has contractions 2:10 but births her baby? Did she skip the first stage of labour? Women with OP babies often have different labour patterns that will not fit this definition.

The definition of the first and second stages of labour also assumes that a vaginal examination will be carried out because everything hinges on what the cervix is doing. However, this doesn’t quite work. If I examine a woman at 3pm and find out her cervix is fully dilated does that mean her second stage started at 3pm? What if her cervix had been fully dilated at 2pm but I didn’t know? The only time measurement we can know for sure is the end of the second stage of labour – because the baby emerges (assuming we remember to look at the clock). We could get a time for the birth of the placenta, but the end of the third stage ends with ‘control of bleeding’ which is open to interpretation.

The impact of collusion

Care providers have accepted this categorisation despite the lack of evidence or sense to support it. The stages of labour are like the emperors new clothes. We educate women on the stages of labour; we assess their progression through these stages; and we fill in documentation about their progression through the stages (eg. time of 2nd stage). Perinatal data forms require the precise hours and minutes that a women spends in each stage of labour.

How this translates into practice is that midwives basically make it up. There is a box to fill, so we fill it. This results in some comical paperwork conversations between midwives/midwifery students eg.: ‘What time would you say second stage started?’ ‘Umm not sure – she was making grunty noises around 5.30pm…’ ‘OK, I’ll put 6pm.’ Midwives also massage the paperwork to fit policies eg. ignoring that the woman was actually ‘pushing’ for 3 hours and only documenting a 1 hour second stage to avoid trouble.

These made up times are carefully recorded and then sent to organisations that collect and analyse the stats to provide information about labour and birth. By making our records fit the myth, we are colluding in maintaining the myth that labour can be compartmentalised into distinct stages and measured accurately.

Perhaps more importantly by colluding we are re-defining women’s birth experiences – often in contrast to their own experience. Have you tried explaining to a woman why we only record ‘established labour’ and disregard the hours or days that she experienced contractions before being assessed as in established (real) labour?

The future

I guess I have it easier than those working in hospitals with hospital documentation. I’m in control of my own paperwork and have already excluded the stages of labour from the birth notes I write at homebirths. However, I still have to complete perinatal data forms. So, the question is do I put a ‘?’ in the box or draw a line through it?

Merry Xmas readers and thanks for following my blog in 2010

*Update: This post has been expanded into an article for AIMS. You can read it here.

This post is also available in French

Posted in birth, midwifery practice | Tagged , , , | 40 Comments

Shoulder Dystocia: the real story

Posted on December 3, 2010 by

kytriallaw.comRecently the media have been demonstrating ignorance and lazy journalism with a scattering of items about shoulder dystocia. Apparently doctors are having to attend special classes to learn how to break babies bones because mothers are fat and make their babies too big. At least that is the story – women are creating a problem and doctors have to solve it. The reality is that almost half of shoulder dystocia occurs with babies who are not ‘big’. This post will discuss how to avoid a shoulder dystocia and deal with the situation if it occurs. There is plenty of great information available on the internet about shoulder dystocia. So, I will indulge in some lazy blogging and link where I can.

Resources: You can download an information leaflet from midirs, and CETL learning have a slide presentation available online. Both of these resources give a comprehensive overview of the incidence, risk factors and the standard approach to shoulder dystocia. In addition references are provided for those who want/need them.

What happens during a shoulder dystocia?

Basically the baby’s shoulder/s get caught on the pelvic brim (more info about the pelvic brim, cavity and outlet in this previous post)

Avoiding shoulder dystocia

A lot of midwifery and obstetric learning resources focus on how to manage particular complications or problems. I prefer to avoid the situation in the first place, if at all possible. Although in some cases shoulder dystocia is unavoidable, there are a number of ways to reduce the chance of it occuring:

Undisturbed birth

When women are able to birth instinctively without direction or intervention they are capable of magic. I have seen some bizarre birth positions and movements that made perfect sense once the baby emerged. And in the case of a stuck shoulder, instinctive pelvic movements can release the baby without drama.

Patience

The baby needs time to get into the best position to move through his/her mother’s pelvis. When we try to hurry birth, the baby may be unable to make these adjustments. Induction augmentation of labour and instrumental delivery increase the chance of a shoulder dystocia happening (Gherman 2002). Directed pushing can force the baby into the pelvis without allowing time for subtle adjustments to happen.

I am also convinced (but have no research to back me up) that pulling babies out can wedge their shoulders against the pelvic brim. Waiting for a contraction when the head is out can feel like forever (could be 5+ minutes) and it’s tempting to tell the mother to push or give a gentle pull on the head. But, the baby may be using this time to make the adjustments necessary for the shoulders to birth. As long as there is some change with each contraction and the baby is well (pink/bluish), you can wait – bite your tongue and sit on your hands if you have to. Usually the shoulders will be born with the next contraction following the head but not always. The next contraction may rotate the baby, then the next contraction birth the shoulders. Watch and see.

Being proactive with epidurals

An epidural will completely alter the physiology of birth and the instinctive behaviour of the mother. Once an epidural is inserted ‘active birth’ often goes out the window. In my opinion ‘active birth’ is not necessary when a woman is undisturbed – she will instinctively get into positions that work for her without prompting. However, active birth becomes essential for a woman who has an epidural. Looking after a woman with an epidural should be hard work. As a care provider you now have to help the baby through the pelvis by prompting and assisting maternal movement and position. This is where the ‘creating space’ tricks become important.

Birthing in a semi-recumbant position increases the chance of shoulder dystocia because the pelvis is unable to open ie. sacrum move back and coccyx uncurl. This is often the default position for women with epidurals. However, most women are able to get into an alternative position with assistance, and most hospital beds are adjustable. It is possible to get into a squat using a bar attachment to hold, and women can kneel up and lean over the back of the bed despite a lack of feeling in their legs. A lying lateral position is always available if movement is really difficult. Lots of position changes during pushing may be difficult but can make a huge difference to the outcome.

Management of a shoulder dystocia

Despite anything and everything mothers and care providers do – some babies will still get stuck. Even though shoulder dystocia is relatively rare (1:200), knowing what to do is useful. Firstly it is important not to make a bad situation worse, therefore:

  • Do not pull the baby as this will impact the shoulder further. This is the most common mistake people make because they panic. Traction can result in brachial plexus injury to the baby (see movie above). Unfortunately the care provider can then find themselves facing litigation. An article by Johnson outlines the medico-legal perspective ‘…for many years it has been accepted that OBPP [obstetric brachial plexus palsy] is an injury caused by excessive traction on the head when the anterior shoulder is impacted above the symphysis pubis.’
  • Do not cut the umbilical cord if it is around the baby’s neck. While the cord is intact there is still a chance that the baby is receiving oxygen which gives you more time and assists with resuscitation afterwards.
  • Communicate with the mother. You always have time to explain what is happening and why you are doing what you are doing, or asking her to do something.

Here is a video illustrating why pulling babies out is bad practice:

We all learn and retain information differently. As a lecturer I teach two different approaches for different reasons:

HELPERR – A STANDARD APPROACH

I’m sorry, but I have a strong aversion to mnemonics. I get particularly frustrated by mnemonics that don’t fit the letters to actions = actions being crow-barred into the word, or another letter being added so it is no longer an actual word. In the case of HELPERR the first E is for ‘evaluate for episiotomy’ – which I am yet to see anyone seriously do in real life. Firstly, you would have to be very brave to attempt putting scissors in such a tight space next to a baby’s head/face. Secondly, if you really need to get your hands in – you will, and a tear will be the least of your worries in that moment. In addition, HELPERR assumes the woman is on her back – which I guess she usually is if the baby is stuck.

OK, rant over. I know that some people find mnemonics assist them to remember sequences, and that hospital staff are expected to follow them. In addition, for legal purposes (see above article) it looks good if you have documented evidence of working through the HELPERR sequence. Because HELPERR is the standard approach I will not list ‘how to’ here – the links provided at the beginning of this post give instructions to follow. However, I have added a movie showing how McRoberts works (with classical music!?):

A HOLISTIC APPROACH

The limitations of the HELPERR approach become apparent when assumptions about position (reclining/on back) and environment (on a hospital bed) are removed. If a shoulder dystocia occurs in a small toilet cubical with an upright woman – how do you perform McRoberts?

So, considering the range of positions, environments and situations birth takes place in, we need to be able to think and act beyond the mnemonic. When a shoulder dystocia occurs one or both of 2 things need to happen to release the shoulders:

1. Change the size and position of the pelvis (mother)

This can be done by encouraging the mother to move and change position. The best option will depend on the position she is already in. Often just the movement of getting into a position will release the baby. You can ask or assist a mother to change her pelvis by:

  • Lifting a leg up and/or outwards eg. onto the side of the birth pool or chair. This can be accompanied by a rocking back and forward of the pelvis (thrusts).
  • McRoberts is easy if the mother is already reclining. If on all fours, flipping over onto her back might be possible and the baby may release during the movement.
  • Gaskin manoeuvre – rotating onto all fours from a reclining position (a bit like a reverse McRoberts). If upright, dropping to all fours might work.
  • German approach – a German midwife friend sent me an interesting article about maternal movements for shoulder dystocia. A German midwifery student has kindly translated/explained the text and provided more pictures. I’ve made a pdf of the information.

2. Change the size and position of the shoulders (baby)

Adducting the shoulder/s will make the diameter of the shoulders smaller. Rotating the shoulders into the oblique diameter of the pelvis will make use of the extra space available (see pelvis info in previous post). Again you can find explanations of the following manoeuvres in the links provided at the beginning of this post.

  • Suprapubic pressure (sometimes called Rubin’s I)
  • Rubin’s manoeuvre (sometimes called Rubin’s II because it is attempting to do the same as the above manoeuvre only internally)
  • Woodscrew manoeuvre
  • Reverse Woodscrew manoeuvre
  • Removal of the posterior arm
  • Axillary traction (described in Ansell 2009 Chp5 of thesis)

There is no particular order in which you can try the above positions and actions. It will depend on how well the mother can move; the position she is in; and the access you have into her pelvis ie. how and where you can get your fingers in (if needed). For example, Rubins (II) will be easier to do than suprapubic pressure on a forward leaning mother.

A holistic approach means taking in the situation and using the appropriate movement or action at the time.

FlipFLOP

Gail Tully has devised an approach to shoulder dystocia that changes the size and shape of the pelvis and of the shoulders. It also comes with a mnemonic for those who like them – FlipFLOP. You can find information, pictures and a movie on the spinning babies website.

DRASTIC APPROACHES

There are options if all else fails which usually involve damage to the baby or mother (again, see links provided). These desperate measures have their place – after attempting everything else. I know a healthy 2 year old who’s mother had a c-section following a successful Zanvanelli manoeuvre. In this case the umbilical cord was most likely intact and functioning. Unfortunately sometimes regardless of what is done a baby will not survive.

MOVIE

You can watch a movie of a shoulder dystocia occurring during a home waterbirth here

Posted in birth, intervention, midwifery practice | Tagged , , , , , | 64 Comments

Testing, Testing…

Posted on November 14, 2010 by

I am visiting the BaBs Sunshine Coast group tomorrow to talk about the tests offered during pregnancy and afterwards to newborns. You can download my antenatal tests summary information if you are interested. The summary will provide you with an overview of tests offered routinely in Australia.

From the moment a woman is pregnant she is offered an ever increasing variety of tests. I use the term ‘offered’ despite the reality that the tests are rarely presented as options. When I ask women about the tests they had, they are often unsure about the whats and whys. The GP takes some blood for the ‘pregnancy bloods’ without explaining or gaining consent (ie. explaining each and every individual test). The ultrasound is ordered without the rationale for the procedure being discussed never mind any risks.

These tests are on offer. Women can choose to have all, some or none of them. We need to stop referring to women who decide not to test as ‘refusing’ a test – I hear this all the time ‘she refused…’. This implies it is wrong to decline something that does not fit with your needs as an individual mother. It is not our responsibility as midwives, drs etc. to ensure a test is carried out (and tick the box). It is our responsibility to offer the test along with adequate information and support the woman’s choice either way.

Antenatal care has become about screening out risk to ensure perfection – an impossible task. Antenatal care should be about supporting women to build self confidence in their ability to grow, birth and nurture a child.

You can read and listen to parents’ stories about different aspects of antenatal screening here.

Posted in intervention, midwifery practice, pregnancy | Tagged , , , , , , , | 29 Comments

The Curse of Meconium Stained Liquor

Posted on October 9, 2010 by

Dear unborn baby,

Please consider holding your poo in until after you are born. The big people on the outside get very stressed about your poo and will want to change the way you are birthed if they find any evidence that you have failed to keep it in. Your mother will be told that you are in danger, and will be strapped to a CTG monitor. This will: reduce her ability to help you through her pelvis by moving; prevent her from using water to relax; and increase your chance of being born by c-section. Your mother will also have her time limits for labour tightened up. This may lead to labour being induced or augmented which will put both of you at risk of further interventions. You will be expected to get through your mother’s vagina quickly and if you take too long you will be pulled out with medical instruments. As you are being born you will have plastic tubes pushed into your nose, mouth and throat to suction your airway. Once born, your cord will be cut immediately and you will be given to a paediatrician who may also put tubes into your nose and mouth. You will only be given back to your mother once you are crying effectively. You may not feel like breastfeeding after being suctioned – don’t worry, this is normal. In the first 24 hours after birth you will be disturbed regularly to have cold items put onto your skin to monitor your temperature, breathing and heart rate. In some hospitals you will be taken away from your mother to be observed in nursery. So, if at all possible do your mother and yourself a favour and try to hold on to your poo until after you are born.

Meconium facts

Meconium is a mixture of mostly water (70-80%) and a number of other interesting ingredients (amniotic fluid, intestinal epithelial cells, lanugo, etc.). Around 15-20% of babies are born with meconium stained liquor.

There are three reasons (theoretically) that a baby will open his/her bowels before birth (Unsworth & Vause 2010):

  1. Because their digestive system has reached maturity and the bowel has begun working. This is the most common reason and 30-40% of post-term babies will have passed meconium in-utero.
  2. Because their cord or head is being compressed (during labour) ie. a vagally mediated gastrointestinal peristalsis – the same reflex which causes variable heart rate decelerations. This is a normal physiological response and can happen without fetal distress.
  3. Fetal distress resulting in hypoxia. However the exact relationship between fetal distress and meconium stained liquor is uncertain. The theory is that intestinal ischaemia relaxes the anal sphincter and increases gastrointestinal peristalsis = passage of meconium. However, fetal distress can be present without meconium, and meconium can be present without fetal distress.

Meconium alone cannot be relied on as an indication of fetal distress: “… meconium passage, in the absence of other signs of fetal distress, is not a sign of hypoxia…”(Unsworth & Vause 2010). An abnormal heart rate is a better predictor of fetal distress; and an abnormal heart rate + meconium provides an even better indication that a baby may be in trouble. In addition, thick meconium rather than thin meconium is associated with complications. Despite this, babies who are known to have passed meconium (of any variety) without any other risk factors are treated as if they are in imminent danger. I am guessing this is because if a previously unstressed baby becomes hypoxic during labour it may result in the dreaded MAS.

Meconium Aspiration Syndrome (MAS)

MAS is the major concern when meconium is floating about in the amniotic fluid. It is an extremely rare complication – around 2-5% of the 15-20% of babies with meconium stained liquor will develop MAS (Unsworth & Vause 2010). Of the 2-5% of the 15-20%, 3-5% of babies will die. OK enough %s of %s – basically it is very rare but can be fatal.

MAS occurs when the baby inhales meconium stained liquor during labour, birth or immediately following birth. You can see a simple explanation of MAS in utero (where it usually happens) here. However this animation does not detail why aspiration might take place.

Babies make shallow breathing movements during pregnancy. Breathing movements slow down in response to prostaglandins before birth. During labour and birth it is very unlikely that a baby will inhale liquor (and any meconium in it). This will only happen if the baby becomes extremely hypoxic and begins to gasp in utero in an attempt to get oxygen. So, meconium alone is not a problem. Meconium + a hypoxic baby = the possibility of MAS (Davies & MacDonald 2008).

Bizarre Practice

So you would think that the sensible thing to do if a baby has passed meconium (for whatever reason) is to create conditions that are least likely to result in hypoxia and MAS. This is where I get confused because common practice is to do things that are known to cause hypoxia, for example:

  • Inducing labour if the waters have broken (with meconium present) and there are no contractions or if labour is ‘slow’ in an attempt to get the baby out of the uterus quickly.
  • Performing an ARM (breaking the waters) to see if there is meconium in the waters when there are concerns about the fetal heart rate.
  • Creating concern and stress in the mother which can reduce the blood flow to the placenta.
  • Directed pushing to speed up the birth.
  • Having extra people in the room (paediatricians), bright lights and medical resus equipment which may stress the mother and reduce oxytocin release.
  • Cutting the umbilical cord before the placenta has finished supporting the transition to breathing in order to hand the baby to the paediatrician.

Suctioning the baby’s airways?

I am unsure whether this is common practice or not. Evidence based clinical guidelines generally recommend NOT suctioning a baby’s airways unless they are unresponsive, floppy and require resuscitation. And then only to do so using a laryngoscope so that you can see what you are doing. Guidelines: NICE guideline, Resuscitation Council UK, more guidelines. Key research: Wiswell et al. 2000, Vain et al. 2004. So, I would assume that practice would be informed by these guidelines.

However, on my frequent youtube birth-surfing trips I encounter suctioning of babies often (without meconium present). Both ‘on the perineum’ and following birth. I have seen this being done at hospital births, homebirths, and even unassisted births. You can see an extreme version of suctioning in this previous post. A more conservative method using the suction bulb pictured above seems to figure in a lot of the homebirths on youtube. So, I am guessing that this is a common routine practice in the US. Therefore, I feel obliged to reiterate why this is not only invasive and pointless but may also be detrimental. Suctioning at birth does not reduce the risk of MAS but can:

In addition I am guessing it is not a very pleasant experience/welcome for the baby. Anyway, the birth process takes care of the mucous and amniotic fluid in the baby’s airways. As you can see from the photo below the airways clear as the head is born and while waiting for the next contraction – the chest is compressed, squeezing the fluid out and gravity helps it to drain. Babies born by c-section miss out on this and are more likely to end up with problems associated with fluid in the airways and stomach.

From Navelgazing Midwife's blog (hover on photo for link)

Suggestions

All babies deserve to have the least stressful arrival possible. It is even more important that a baby who has passed meconium does not become stressed and hypoxic during labour and birth because it could lead to MAS. The following suggestions apply to all births including when there is meconium stained liquor.

  • Avoid an ARM during labour so that any meconium present is not known about until the membranes rupture spontaneously (hopefully this will happen after much of the labour is complete). If there is meconium present it will remain well diluted and the amniotic fluid will protect the baby from compression during contractions.
  • Ensure that the mother knows meconium is a variation and not necessarily a complication.
  • Create a relaxing birth environment.
  • Avoid any interventions that are associated with fetal distress – ARM, syntocinon/pitocin, directed pushing.
  • Offer continuous CTG monitoring if the meconium is thick – or if the meconium is thin and there are other risk factors (eg. pre-term).
  • If the meconium is thin and there are no other risk factors offer intermittent fetal heart rate auscultation as usual.
  • In hospital do not allow others into the room unless the mother wants them there. If there is a policy to have a paediatrician present they can wait outside the room to be called if needed.
  • To assist with airway clearing encourage a slow birth of the baby’s head in a position that allows drainage of the airways (ie. mother not lying on her back). Do not pull the baby out – allow the mother and baby to wait for the next contraction whilst the airways clear themselves.
  • Once baby is born leave the umbilical cord intact until it has stopped pulsing to allow a gentle transition to breathing.
  • Keep baby skin to skin with mother following birth.
  • Encourage the mother to let you know if she is concerned about her baby in any way over the next 24 hours (eg. feeling hot, noisy breathing, etc.)

Posted in baby, birth, intervention, midwifery practice | Tagged , , , , | 61 Comments

Induction of Labour: balancing risks

Posted on September 16, 2010 by

In Australia 25% of labours are induced. The most common reason for induction is a ‘prolonged pregnancy’. That’s an awful lot of babies outstaying their welcome and requiring eviction. I am not going to get stuck into the concept of a ‘due date’ and how accurate or not they are, otherwise this will be a very long post. I also think the EDD (estimated date of delivery) is here to stay – it is deeply embedded in our culture and health care system. You can read about the history of timelines in birth here. This post will focus on induction for prolonged pregnancy and the complexities of risk.

A quick word about risk

I don’t particularly like the concept of ‘risk’ in birth. There are all kinds of problems associated with providing care based on risk rather than on individual women. However, risk along with due dates is here to stay and women often want to know about risks. Risk is a very personal concept and different women will consider different risks to be significant to them. Everything we do in life involves risk. So when considering whether to do X or Y there is no ‘risk free’ option. We choose the option with the risks we personally are most willing to take. In order to make a decision we need adequate information about the risks involved. If a health care provider fails to provide adequate information they could be faced with legal action. Induction for prolonged pregnancy is not right or wrong if the choice is made by an individual woman who has an understanding of all the options and associated risks. As a midwife I am ‘with woman’ regardless of her choices. It is my job to share information and support decisions.

What is a prolonged pregnancy?

Before we go any further lets get some definitions clear:

  • Term (as in a ‘normal’ and healthy gestation period): is from 37 weeks to 42 weeks.
  • Post dates: the pregnancy has continued beyond the decided due date ie. is over 40 weeks.
  • Post term: the pregnancy has continued beyond term ie. 42+ weeks.

The World Health Organization definition of a ‘prolonged pregnancy’ is one that has continued beyond 42 weeks ie. is post term. I am pretty sure that this is was not the definition used when collecting the above induction rate statistics because most hospitals have a policy of induction at 41 weeks which is before a prolonged pregnancy has occurred. Very few women experience a prolonged pregnancy.

The idea of a prolonged pregnancy also assumes that we all gestate our babies for the same length of time. However, it seems that genetic differences may influence what is a ‘normal’ gestation time for a particular woman. Morken, Melve and Skjaerven (2011) found “a familial factor related to recurrence of prolonged pregnancy across generations and both mother and father seem to contribute.” Therefore, if the women in your family gestate for 42 weeks so might you.

However, in theory after term ie. 42 weeks the placenta starts to shut down. There is no evidence to support this notion and Sara Wickham gives a great critic of this theory if you ever get the chance to attend her workshops. I have seen signs of placental shut down (ie. calcification) in placentas at 37 weeks and I have seen big juicy healthy placentas at 43 weeks. There is also the idea that the baby will grow huge and the skull will calcify making moulding and birth difficult. Again there is no evidence to support this theory and babies are pretty good at finding their way out of their mothers expandable pelvis.

The risks associated with waiting

Essentially the main risk associated with waiting beyond 41 weeks gestation is the death of the baby (perinatal death). A Cochrane review found that: “There were fewer baby deaths when a labour induction policy was implemented after 41 completed weeks or later.” However, it goes on to say: “…such deaths were rare with either policy…the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks.” Hands up all the women who had a discussion with their care provider about the relative and absolute risks of waiting vs induction… hmmm thought so.

I am also going to fail to clarify the absolute and relative risks for you. I am a qualitative researcher by nature and find numbers difficult to grasp. Therefore, I contacted a couple of statistician colleagues who attempted to explain the differences in simple terms. The end result = they got a little frustrated with me and told me to forget relative risk because it is not helpful and to stick with absolute risk. So here goes:

The absolute risk of perinatal death was: 0.03% for the induction group and 0.33% for the waiting group. Either way we are talking about a less than 0.5% risk of perinatal death whether you induce or wait… or a 99.5+% chance of a live baby.

Sara Wickham discusses the flaws in the research on a free MIDIRs podcast you can download  here.

The risks associated with induction

It can be difficult to untangle and isolate the risks involved with induction because usually more than one risk factor is occurring at once (eg. syntocinon, CTG, epidural). I did attempt to create a mind map but it ended up looking like a spider had spun a web while under the influence. So I have stuck to a written version:

Risks associated with the actual procedure of induction

The induction process is a fairly invasive procedure which usually involves some or all of the following (you can read more about the process of induction here). There are a number of minor side effects associated with these medications/procedures (eg. nausea, discomfort etc.) There are also some major risks:

  • Prostaglandins (prostin E2 or cervidil) to ripen the cervix: hyperstimulation resulting in fetal distress and c-section.
  • Rupturing the membranes: fetal distress and c-section (see previous post)
  • IV syntocinon / pitocin: Mother – rupture of uterus; post partum haemorrhage; water intoxication leading to convulsions, coma and/or death. Baby – hypoxic brain damage; neonatal jaundice; neonatal retinal haemorrhage; death. There is also research suggesting that there may be a link between the use of syntocinon/pitocin for induction and ADHD (Kurth & Haussmann 2011)

The most extreme of these risks are rare but fetal distress and c-section are fairly common.

Risks associated with factors that commonly occur during an induction

A woman having her labour induced is more likely to end up with a c-section. This is particularly significant for women having their first baby. A recent research study by Ehrenthal et al. (2010) found an increased c-section rate of 20% for women being induced with their first baby. They concluded that: “Labor induction is significantly associated with a cesarean delivery among nulliparous women at term… reducing the use of elective labor induction may lead to decreased rates of cesarean delivery for a population.” Another study by Selo-Ojeme et al (2010) found induction increased the chance of a c-section x3 for first time mothers. It is now well established that there are significant risks associated with c-section for both mother and baby. Childbirth Connection provide an extensive and evidence based list.

Induced labour is usually more painful than a physiological labour. Syntocinon (aka pitocin) produces strong contractions often without the gentle build up and endorphin release of natural contractions. In addition unlike natural oxytocin, syntocinon does not cross the blood-brain barrier to create the spaced-out, relaxed feelings that help women to cope with pain (see previous post). First time mothers are more than 3x more likely to opt for an epidural (Selo-Ojeme et al. 2010). A Cochrane review found an association between epidural analgesia and instrumental birth. There are significant risks associated with ventouse and forceps birth both for the mother and baby – RANZCOG lists them here.

The study by Selo-Ojeme et al. (2010) also found induction = increased risk of uterine hyperstimulation; ‘suspicious’ fetal heart rate tracings; and haemorrhage following birth. Not surprisingly ‘babies born to mothers who had an induction were significantly more likely to have an Apgar score of <5 at 5mins and an arterial cord pH of <7.0′ (basically not in a good way on arrival). Another recent study by Elkamil et al (2011) ‘found that labour induction at term was associated with excess risk of bilateral spastic CP [cerebral palsy]..’ Remember we are inducing labour to prevent harm to the baby…

The experience of labor

Once again the Cochrane review states: “Women’s experiences and opinions about these choices have not been adequately evaluated.” This is becoming a theme across Cochrane reviews. However, one thing is certain – choosing induction will totally alter your birth experience and the options open to you. Women need to know that agreeing to induction means agreeing to continuous monitoring and an IV drip, which will limit movement. Induced contractions are usually more painful than natural contractions and the inability to move and/or use warm water (shower or bath) reduces the ability to cope. The result is that an epidural may be needed. An induced birth is not a physiological birth and requires monitoring (vaginal exams) and time frames. Basically you have bought a ticket on the intervention rollercoaster. For many women this is fine, but I encounter too many women who are unprepared for the level of intervention required during an induction.

Alternatives to waiting or medical induction

Before labour begins the uterus and cervix need to make physiological changes ready to respond to contractions. It is now thought that the baby is the controller of the labour ‘on’ switch. So, the baby signals to the mother that he/she is ready, oxytocin is released and the uterus responds. In comparison to other mammals, humans have the most variable gestation lengths. This suggests that other factors such as environment and emotions (eg. anxiety) also influence the start of labour. This would make sense considering what we know about the function of oxytocin (see previous post). It is also something most midwives are aware of – a stressed out mother is more likely to go post term than a relaxed and chilled out mother. Having said that, post term is probably the normal gestation length for many women regardless of what is going on. Creating anxiety and stress around due dates and impending induction is probably counter productive to labour.

As a midwife I don’t personally recommend methods to encourage labour for women who don’t want induction. Instead I encourage them to trust their body/baby and to ‘look after themselves’ ie. relax and eat well. My general approach to birth is – trust, patience and acceptance. However, I know that many women want to try something to start their labour and there a number of alternative methods in use - BellyBelly covers most of them here.

In Summary

A significant minority of babies will not be born by 41 weeks gestation. Whilst the definition of a prolonged pregnancy is 42 weeks+, induction is usually suggested during the 41st week. Women need to be given adequate information about the risks and benefits involved with either waiting or inducing in order to make the choice that is right for them. There is no risk free option. The risk of perinatal death is extremely small for both options (less than 0.5%). I know women who have lost a baby in the 41st week of pregnancy, and women who have lost a baby as a result of the induction process. Each individual woman must decide which set of risks she is most willing to take.

For further information: NICE clinical guideline (UK) for professionals on ‘induction of labour’; Maternity Coalition information sheet for parents.

Stories of birthing beyond 41 weeks

Cas’ story (43 weeks)

Tara’s story (44 weeks)

A news article: ‘I was pregnant for 10 months’

Posted in baby, birth, intervention | Tagged , , , , , , , , , , | 65 Comments

Information Giving and the Law

Posted on September 15, 2010 by

I was writing a blog post on induction for prolonged pregnancy but got side tracked reflecting on a recent study day I attended about law. So, I will get this out of my system before finishing the induction post.

It seems that many health care professionals are routinely putting themselves at risk of legal action in relation to information giving (or not as the case may be). Either they are unaware of the implications, or they think women will never hold them to account. This post is a very brief and basic overview of law (Australian) in relation to information giving. Although I have based the contents on McIlwraith & Madden (2010) the information is available in most law books and on the internet.

Consent

If consent is not gained prior to a procedure it could lead to an action for ‘trespass to the person’ (ie. assault and/or battery). For consent to be valid it must have at least 3 elements:

  1. be voluntary and freely given
  2. come from a competent person
  3. be specific to the treatment/procedure.

The first element is where I think most breaches take place in maternity care situations. In order for this element to be satisfied:

  • the person must not be under any undue influence or coercion
  • there must be no misrepresentation (whether deliberate or mistaken) as to the nature or necessity of a procedure.

I am sure I don’t need to list the common real life scenarios in which this element of consent is not satisfied in relation to maternity care. By the way, to sustain a civil action alleging assault and/or battery harm does not need to caused by the procedure.

Negligence – lack of information

A health care practitioner who fails to provide adequate information to a woman can be sued for negligence. In order to have a successful case the woman must demonstrate that:

  1. the health carer had a duty of care to provide the information
  2. that duty was breached by failure to provide the information
  3. the woman would not have agreed to the procedure/treatment if adequate information had been given
  4. and as a result, the woman or baby suffered harm.

What is reasonable information?

The High Court states that patients should be told of any ‘material risk’ inherent in the treatment. A material risk in relation to maternity is one:

  • to which a reasonable woman in the woman’s condition/situation would be likely to attach significance;
  • to which the health carer knows (or ought to know) the particular woman would be likely to attach significance; or
  • about which questions asked by the woman reveal her concern

What do you think?

Considering the routine use of tests and procedures in maternity care (eg. ultrasound scanning, induction, c-section, etc.) I would be really interested what readers think…

  • Are women coerced by practitioners into tests/procedures?
  • Are practitioners aware of the law, or do they rely on women not knowing the law?
  • Would common practice around information giving change if legal actions were brought against practitioners who fail to adequately inform?
Posted in law, midwifery practice | Tagged , , , , , | 32 Comments