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 start IV 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
I would love to hear your experiences of asynclitism.
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.
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.
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.
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!
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.
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. 🙁
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!
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.
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.
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?
Difficult to explain with out the visual… basically you ‘vibrate’ the soft tissue in the thighs or buttocks. You can do this with hands or a rebozzo. Maybe I need to do some photos/film 🙂
I know it as “shaking the apples”!
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!
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!
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.
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.
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.
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).
He was 8 lbs 14 oz., for the record, and I mistyped – 7 hours at 8 cm., not 8. 🙂
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!”
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!)
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.
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.
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. 🙂
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.
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.
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. 🙂
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.
Oh, I forgot to mention she was 9lb 3oz. YES!
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!
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.
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.
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 🙂
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.
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!
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.
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.
Wow – thanks for sharing your birth story… and what an amazing placenta too! 🙂
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!
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.
It sounds like your body did a great job of birthing your baby. Not sure if you have already seen these posts but they may be useful: http://midwifethinking.com/2011/01/22/the-anterior-cervical-lip-how-to-ruin-a-perfectly-good-birth/ and http://midwifethinking.com/2012/04/25/asynclitism-a-well-aligned-baby-or-a-tilted-head/
2 hours is not a long time to ‘push’ and your baby may have been moving through your pelvis with her head in a position that required more effort/time. There is probably nothing you could have done differently 🙂
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.
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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 🙁
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.
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.
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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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? 😉
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…! 😉
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 🙂
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.
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.
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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
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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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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. 🙁
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?
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.
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.
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.
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 🙂
I was induced with my twin girls. The leading twin was asynclitic for a lot of my labour (ear felt on ve). My progress was slow this is probably due to being a primip and being induced but I’m sure the position could have had something to do with it too because when she turned, i progressed to fully very quickly. I have had horrendous pain in my hips, I was not fussed by the contractions but the hip pain was so severe that I felt like someone was trying to break my bones. Once again position might have something to do with it. I’ve had the most incredible midwives and despite everything I had a normal birth with both girls, no perineal trauma and breastfed exclusively for 6 months when I had to return to work 🙂
My first two babies were born via c-section, the first for failure to wait after a relatively short induction for no medical reason other than being 40 weeks and the second was a CBAC after 58 hours of ACTIVE labor and extremely slow progress that ended when *I* couldn’t take the pain anymore (epidural failed) and birthed a 10# 12 oz baby. My third baby was a vba2c attempt that ended when, after all we could do to get baby to shift, the midwife still kept feeling an ear when she went to check his position. I spent 18 grueling hours at 7 cm, not counting the couple of days of labor prior to that. I’m pretty sure that mine was a case of true acynclitic baby but now with this article I can’t help but wonder if I just have up again… Should I have just kept laboring??
It sounds like you gave it everything you had… I think you made the right decision 🙂
Great post- as an osteopath I work during pregnancy to help the baby to find an optimal position, and often treat issues after birth- I have often thought that I would love a unique role to bring together osteopathy with doulaing and support issues such as this.
My second baby was asynclitic, and OP born. We had no idea why second stage was taking so long! Labor total was about 8 hours, and 90 minutes of that was pushing in all sorts of positions, so it wasn’t long. We didn’t know until he emerged this was his hang-up. He was 9 pounds, 9 ounces so of course I am grateful it all worked out for us with a patient midwife on a calm night with the back-up doctor held up. It is an amazing video to watch — he being born face up!
As an obstetric registrar I occasionally read blogs such as this in order to better understand and council women I see. I am also a husband and a father. I am an advocate of the natural birthing process, frequently acheiving a spontaneous birth when I have been asked by the midwife to attend with the request of intervention. Overall there are many sensible things I read on here however I am still disheartened to see the odd anti-doctor comments creeping in and thought I would offer my opinion.
I disagree a little about asynclitism. I agree it is likely irrelevant in the transverse position and would never actually comment on it on this situation, however it does become relevant in direct oa or op positions. I completely agree that the best way to correct this is labour positioning and keeping mobile particularly in the earlier stages. This can still be done on ctg or synto drip, and in hate seeing women languishing in bed.
With respect to not doing ve at all in the context of slow progress, if it was my wife and child I would like to know if my baby was brow or mentoring posterior face presentation and not physically deliverable before pushing for hours and risking cerebral palsy, uterine rupture and massive haemorrhage.
I also encourage vbac. However be cautious about having no monitoring… Foreshore cases where the uterus ruptures and baby dies the first sign is baby’s heart rate problems.
I’m sorry for those who have felt that the doctors have ruined their birth experience and just hope I have not done that to someone. At the end of the day having a baby in the UK is safe because we have medical care. I agree there is some over intervention, however if you want to know why we try to help, Google neonatal and maternal mortality rates in Africa and other third world countries.
Hi Guy – it is always good to get an obstetric perspective – thanks for commenting. A few points I’d like to address:
“however I am still disheartened to see the odd anti-doctor comments creeping in and thought I would offer my opinion.” – in my posts I am careful to talk about ‘care providers’ and ‘practises’ as opposed to particular professions or people. If people are commenting and sharing their experience… then that is their perspective and experience. Unfortunately it often does not reflect well on obstetrics, I think this should prompt professional reflection.
“I would like to know if my baby was brow or mentoring posterior face presentation and not physically deliverable before pushing for hours and risking cerebral palsy, uterine rupture and massive haemorrhage.” – I agree… hours of pushing is not physiological and a VE would be indicated if positional changes and techniques to bring baby out of pelvis do not result in progress. When a woman is spontaneously pushing progress should be clear.
“I also encourage vbac. However be cautious about having no monitoring… Foreshore cases where the uterus ruptures and baby dies the first sign is baby’s heart rate problems.” – some women don’t consider the 0.2% risk enough to have a CTG and prefer intermittent auscultation… it is their choice and their perception of risk.
“Google neonatal and maternal mortality rates in Africa and other third world countries.” – this is a very defensive comment and suggests that women should put up with unnecessary and often harmful intervention just because some women do not have access to necessary and life saving intervention.
Re. asynclitism… have you had much success with techniques to bring baby back out of the pelvis at full dilatation? I have found it extremely effective. In some cases within a few contractions the baby has re-positioned and is then pushed out quickly.
I think (and have experienced that) midwives and obstetricians can work well together – it is about respecting each other’s areas of expertise, reflecting on feedback and focusing care on the individual woman.
I agree, and you clearly missed over my comment on the importance of labour positioning. I also completely agree about working together, hence why I posted. I only highlight what I have done so so that people such as some of those in this blog do not feel like a failure if nature doesn’t play ball.
I agree that it is up to the woman to accept her own level risk and give them the final decision without coercion.
I will also certainly look up further about these techniques you speak of, and if I find good evidence would certainly use it in my practice
I always strive to maintain normality through informed choice, simply wished to highlight that this is not always possible in practice, and I have met many women who have felt like thay have failed if a bit of help is needed.
I didn’t miss your comment re. positioning – you were referring to positioning in early labour rather than after the baby has descended into the pelvis in a less than favourable position. The most effective technique in this later stage is position-hands and knees with bottom high in the air + rebozzo (use of a ‘shawl’ – towel or sheet – over bottom to ‘shake’ the pelvis). I cannot direct you to any research… this is a well used technique, the rebozzo originating from Mexico and Mexican midwifery. I can give you anecdotal examples from my own midwifery experience and others I have heard. As a researcher, I am well aware of the limitations of getting funding for research – very difficult when there is no ‘product’. And well aware of how many interventions are implemented without research (eg. CTGs), but not midwifery ones it seems.
“give them the final decision” – they already have the final decision… this suggests that you hold the power to ‘allow’ or ‘let’ them make decisions about their own body. If you read many of the comments – women often object to this kind of language and the underpinning paradigm it reflects. We do a lot of education around language with midwifery students. Do medical students get this kind of education too? This is an honest question… although in my experience in other medical specialities there is less ‘letting’, ‘giving’ and ‘allowing’ than in OBs.
“I always strive to maintain normality through informed choice, simply wished to highlight that this is not always possible in practice, and I have met many women who have felt like thay have failed if a bit of help is needed.” Informed choice is also my aim – that is why I write this blog. Maintaining normality is not my aim… that is up to the woman. Some women want induction, epidurals etc. (indeed those interventions are normal). I agree it is very sad when women feel they have ‘failed’ – there should be no failure in birth. My post on Judging Birth addresses some of these issues: http://midwifethinking.com/2011/04/09/judging-birth/
I am also aware from my own experience of working in the UK that UK OBs are generally much less interventionist and more ‘woman-centre’ – they understand their role as expert in ‘high risk’ and keep out of the ‘low risk’ care leaving it to midwives. I enjoyed my working relationship with UK OBs. Unfortunately elsewhere this is not the case. Here in Australia we have obstetric-led midwifery care. For example, in my local hospital OBs have decided to implement O’Driscoll style active management (including 1 hourly VEs until 3cm) and they don’t allow eating in labour. They would not get away with this in the UK but here they dictate midwifery practice… and the midwives follow the policy. Many of my readers are from the US, Australian and all around the world and their comments reflect OB practice in these countries. The fact that you are researching and engaging in debate around practice distinguishes you from these OBs.
I do agree. The other thing that we needlessly communicate to women is OP – ‘oh no, s/he’s back to back!’ – this induces anxiety, the babe usually rotates on hiring the pelvic floor, and if not it is perfectly possible to deliver OP.
I have previously written about OP 🙂
http://midwifethinking.com/2010/08/13/in-celebration-of-the-op-baby/
This is such an upsetting topic to me. I was having a completely wonderful, lovely, easy to manage labor, though long… then started getting some really serious pain, and had the sense that the contractions weren’t as “productive” as they had been. Though I didn’t really want them, my midwife offered a VE, which I accepted, because I wasn’t really being offered anything else (I was barely getting any help with counter pressure on my hips etc., and everyone seemed really checked out at my labor). I was almost fully dialated. So after a few more really painful contractions, with lots of hip pain, I was instructed to lay on my back and push (without urges) so my midwife could manipulate my cervix. I said, in the middle of pushing, “this isn’t right, I cannot do this…” because I had a gut sense this was a bad idea, not because it hurt, because it actually felt good to do something. I was reassured that I should keep doing it. Then I was asked for the third time (because I had refused twice) if my water could be broken. I said it didn’t seem like a good idea because then the baby wouldn’t be able to move as well (I didn’t know, it just seemed that way). I was reassured that it would be fine, because my baby was so far engaged that I would only loose forewaters. I was tired, so I gave in. Then sometime later I was told, “well, sometimes babies get stuck, there is probably a good reason”, and I transferred to the hospital. My midwife ended up saving the day at the hospital, the doctors were only going to do a c-section, but my midwife did a manual maneuver which got the baby aligned. So it ended okay (except the fact that I didn’t get the drug free home birth I wanted). The trouble is, I really think that these interventions made my labor MORE not LESS problematic, and I cannot convince myself that my baby and I couldn’t have worked it all out given more time and support. Instead, it has been blamed on my baby being Posterior and Asynclitic (Transverse was also thrown in there at one point). I just think my baby was moving around getting ready, and that we needed support to make that journey.
I don’t think any blame lies with your body or your baby. I am also sure that your midwife was doing what she believed was best for you based on the current (mis)understandings of physiology and acceptable/normal midwifery. It sounds like your baby was rotating from a posterior position into an anterior position – transverse is the position the baby would be in in the middle of the turn ie. facing your side. You might find these posts helpful in understanding what may have been happening… and that it was a perfectly normal variation:
http://midwifethinking.com/2010/08/13/in-celebration-of-the-op-baby/
http://midwifethinking.com/2011/01/22/the-anterior-cervical-lip-how-to-ruin-a-perfectly-good-birth/
My baby was asynclitic too. A planned homebirth, I had a 30 hours labour of which 24 spent at home. It was an easy labour but after about 20 hours and 2 hours of pushing my body was utterly exhausted. I had to be transferred to the hospital where I received an epidural and pitocin. My husband had to fight to Consultants so they wouldn’t give me a c section and let me birth vaginally. They said she was asynclitic and they tried turning her by hand but failed repeatedly. So they moved on to option b -assisted delivery- and turned her with forceps. They waited for the next contraction and I was instructed to push while they pulled. She was born in 3 pushes. What is very frustrating for me is the fact that the head appeared 3 times while I was pushing at home only to go back inside. I will always wonder if I could have birthed her myself with better support/ suggestions of positions instead of exhausting myself pushing. I was mobile and upright, tried different positions, my husband did ‘shake the apples’. I also had chiropractic treatment at 7 and 8 months.
I feel scared of this happening again in a future pregnancy
“They said she was asynclitic and they tried turning her by hand but failed repeatedly.” – are you sure there wasn’t more than just asynclitism going on? You don’t ‘turn’ an asynclitic baby. The problem is that they have a tipped head and need to get up and out of the pelvis, align their head then come back through. Perhaps your baby was also OP? http://midwifethinking.com/2010/08/13/in-celebration-of-the-op-baby/
Perhaps tilting your pelvis (bum in the air) and using a rebozo or towel to shake your pelvis and get her out/backwards may have helped… but may have made no difference. This situation is unlikely to happen again and you are perfectly capable of birthing your baby. I hope you can get some support to process what happened during your birth and prepare for your next birth.
Thanks for your reply. It makes me so emotional reading it and thinking about all the what ifs. From what I was told at my birth debrief my baby was definitely asynclitic and not back to back, I remember seeing on my notes she was actually LOA during labour and something else when they moved her with the forceps. My husband actually told me they moved her back in with the forceps before pulling as they said “she had her hand next to her face”. That would tie in with the asynclitism?
My GP referred me for CBT at my request. Thanks very much for your reply and kind words
Her hand being on her face was probably the main issue. I have seen this a few times… baby’s head becomes visible, then disappears or doesn’t move down. It is often a hand next to the head or an arm wrapped around the neck. Sometimes they can come out like this but more often they need to go back up and come down without the hand or arm in the way. They used forceps to move your baby back up so that she could come down without her hand and with her head aligned. In terms of worrying about this happening in the future. It is unlikely that your next baby will also put his/her hand next to their face. Asynclitism can reoccur if it is to do with the pelvic shape… but it sounds like the hand was your issue that may have created the asynclitism.
I am pleased you are getting support to process your experience. 🙂
Very interesting post 🙂
This is terrific- thanks for such a great post!
I’ll be 41 weeks tomorrow. Doctor said my cervix was asynclitism because of the position of baby’s head? I’m almost 3 cm dilated, but my cervix isn’t thinning since it’s sideways. Gravity and my light contractions aren’t helping it out. Any suggestions to get baby to move before the induce me in 6 days? I’ve been searching the Internet and everything seems to be for moving baby while in labor. My midwife is out with appendicitis.
You body is just getting ready to labour. It is very normal for a cervix to be thick (and to the side) before labour starts. If this is not your first baby your cervix may not thin much at all – even during labour. Thinning of the cervix is most significant with first labours… and then it usually only happens once labour is establishing. When you get some strong contractions your baby will move. You don’t need your baby to move in order to get strong contractions. This is a very normal scenario (based on the information you have shared). My suggestion is to relax and trust your body and baby to finish the physiological process that started with conception. Find a way to pamper yourself eg. book a massage. It would be great if you can come back and let us know what happens 🙂
Thank you so much for responding! You have eased my worries ( which my husband is also thankful for!) I’ll let you know what happens.
Hey! Also, you might want to tell them that they aren’t allowed to induce you… I am pretty sure that they can’t force you to have an induction, especially if you don’t show up at the hospital for it. My baby was 3 weeks “late”… she arrived exactly when she wanted to, and she was perfect and healthy when she did…
I totally agree about pampering too. When I was in labor with my second, I stopped being in labor for 2 hours in the middle of the night when I got an email that made me angry… I replied thoughtfully, closed my browser, and returned back to steady labor immediately… it is important to have the space to be in labor, emotionally, physically, psychologically… this can be difficult if you have other kiddos and job demands of course, but take that time if you can 🙂 your little will arrive on time, they usually do…
I too had asynclitic presentation with my first child. I had a fairly easy labor- no interventions/epidural, and after a total 10 hours of labor, spent the next two hours pushing. I had a midwife delivery in a hospital. It caused no issue with my vaginal delivery. It was very hard work but he came out a healthy 8 pounds 11 ounces, but unfortunately we did discover a few days later that he fractured his clavicle (which healed super fast!) and it may have been from delivery. The only other thing this presentation may have caused is the type of contractions I had – the shock and after shock kind…basically double contractions! However I credit my ability to deliver with my ability to walk around and move in different positions.
My first was Asynclitic which only became apparent when I was at the final stages of delivery. I had a very stop start labour spanning four days due to a baby that was predominately in OP postion but he was happily rotating right through the pushing stage. After 5 hours of trying various positions he was vaccummed out. It has been great reading all your posts especially in preparing me for my second birth.
Good luck with your next birth. Second births tend to be ‘easier’ 🙂
A challenging concept, the asynclitic head. You are right, in a hospital setting we do tend to push the syntocinon infusion especially when labour is induced. How many midwives or obstetricians think to reposition the woman to all fours etc to help move that little head out and realign ? If they do they don’t talk about it.
I know midwives who do this in a hospital setting. But you are right, we often don’t openly talk about this with colleagues. Midwives need to claim their knowledge and skills 🙂
My first baby was born earlier this year and I was induced at 40+11 I slowly went into labour overnight and by 11am I was in active labour and 5cm dilated. During one of the vaginal exams I was told the baby was asynclitic but I wasn’t concerned as the midwife didn’t seem to worry about it. Then my labor started to stall and they said I would need syntocin nobody suggested I get on all fours or any other positions to help the labor along. I had been active constantly moving and walking around up until this point. I was in constant pain on my pelvis and the contractions only made it worse, so with the thought of the syntocin making the contractions stronger I opted for a Epi. I was now immobile and the midwife told me I needed to sit down to have my contractions and the baby monitored. I am the sort of person who does as she is told especially in situations I’ve never been in before so although I had wanted to give birth on my knees I didn’t think I was able to. I dilated to 10cms and then pushed for 4hrs the baby hadn’t moved so I was told my only option now was a C-section even though the baby and I never went into distress. All this intervention I never wanted I even wrote it down in a birth plan. I was told the baby is probably big and then when she was born average size ( about the same as me my mum gave birth naturally) it was suggested my hips are too small. After reading this I am even more sad that I had so much medical intervention and no physical support to adjust the position of my baby. When she was born you could see on her head where she had been pushed onto my pelvis, poor we girl.
This situation really frustrates me. Clearly, as Midwives , we need to have a forum to discuss how we managed difficult fetal positions. I will certainly be suggesting having this discussion in the form of a case study at the hospital where I work. I can certainly see how Jackie’s experience would be one that a lot of mum’s would have.
It is unfortunate that midwives have lost many of their traditional skills. It is interesting that midwives inside the system (myself included) are (re)learning these skills from traditional birthworkers. We have been immersed in the medical approach to problems for so long now. It would be great if we could find a way to combine the traditional skills (e.g. techniques to get the baby out of the pelvis and better aligned) with medical intervention where necessary – i.e. if this does not work.
I was denied the natural birth i worked 18 hrs to have because of this. They frightened us as much as possible and made out the c-section was the only option. No one encouraged me to push on all fours which of course i had forgotten from the antenatal classes after being up all night. I love my daughter, but the c section was awful and i suspect unnecessary. I shall be even more stubborn next time ! (I had to fight my corner against misinformation and assumptions the entire pregnancy because i am a type 1 diabetic)
I sorry that you had such an awful birth experience. Be gentle with yourself. The research about antenatal classes suggests that once women are in the hospital environment their ability to resist and assert their needs is limited against the power of the environment/people. Especially with first babies… we learn about ourselves and birth with our first. You will be able to bring those lessons with you into your next birth 🙂
Thanks for the informative post! I had an emergency c-section after attempting a natural labor for ~6 hours. The contractions were strong, long, and irregular, with double peaks, there was basically no early labor. The midwife realized baby was asynclitic and had me on all fours for a few contractions, but by then the baby was in distress and had to be taken out (there was meconium discovered at c-section, confirming distress). There are a couple of questions that haunt me that I was wondering if you might give insight to – is it possible to cause asynclitic position by curb walking only on one side? I went for a long walk that evening to help start labor and the way the pathways were arranged I ended up doing 80-90% of my curb walking on one side vs the other without giving it much thought. Also, how soon can asynclitic position be determined? I had my first VE at 4cm (4 hours into labor) and second VE at 5-6m (2 hours later). I wonder if we could have known to start the hands and knees position sooner.
It is really difficult to comment on an individual birth story without having been there. However, it is unlikely that curb walking would cause asynclitism. It is difficult to determine asynclitism because many babies will have this head position at some point in labour… and as you can see in the post pictures a VE often = touching the side of the baby’s head, particularly early in labour. This is another reason that VE’s are not helpful in most cases. Babies move a lot in labour and can significantly change position with just one contraction. I doubt the distress was to do with your baby’s asynclitic position. I’m not sure how distress was diagnosed. Hopefully by fetal scalp blood (FBS) analysis because that is the only way to accurately diagnose. In 50% of CTG ‘distress’ traces, the baby is fine – hence why CTG is screening and FBS is diagnostic. Meconium is also not necessarily a sign of distress https://midwifethinking.com/2015/01/14/the-curse-of-meconium-stained-liquor/
Birth is complex and it is often impossible to know whether anything could have been different if x or y had happened.
Thank you so much for your reply! I didn’t know that about meconium, I wish I would have known to ask what kind it was. My baby as born at 41.5 weeks, so her digestive system must have been already mature. The distress was diagnosed by listening to heart using the doppler. I don’t know for sure, but it was at the birthing center and I don’t think they had the equipment to do FBS. Once the decision was made to transfer to the hospital for emergency c-section they didn’t do any additional diagnostics as far as I know. I knew about the dangers of CTG in that it can be misleading, that was one of the reasons I didn’t want a hospital birth. Would you say the doppler is more accurate for determining true fetal distress?
No a doppler is not as effective. If there is any doubt i.e. abnormal heart rate with a doppler then a CTG is recommended to get a better picture. It is a better picture but still not very accurate unfortunately.
Interesting and very good to know, thank you!
This is a very interesting read Dr Reed. Obviously it’s difficult to comment on a case you had no involvement in, but is asynclitism, dilation of 3cm, an epidural and a quote “swollen cervix” after 9 hours of only latent labour after induction a good reason to go to cesarean? I was apparently quote “never going to get past 3cm.” Another failure to progress case or in other words, failure to wait. I’m sure the epi and lying supine with a CTG for most of that 9hrs ruined my chances…
Induction involves trying to get the body to do something it is not ready to do (otherwise it would have). I’m not sure how you could be in ‘latent’ labour for 9 hours with syntocinon/pitocin. And induced labour cuts out the latent phase and goes straight into strong regulated established contractions.
Carrying on for a prolonged period with medically induced contractions is not a good idea for mother or baby. Syntocinon is the leading cause of fetal distress in labour.
It looks like you had a ‘failure to induce’… your body/cervix wasn’t ready enough to respond to induced contractions. The asynclitism and epidural look like a possible red herrings in this case.
I had the whole kit and caboodle including prostin gel the night before. Should I have actually been assessed as unfavourable from the get go and not induced at all?
I really can’t comment on an individual situation. Induction is carried out when the risk of the pregnancy continuing is great than the risk of the induction process. So, I assume there was a good medical reason for your induction. Once you have made the decision that the baby needs to come out then you are committed to the process. That involves starting with medically ripening the cervix and moves into the whole kit and caboodle. Giving that a good try then moving to c-section if the induction fails (because the baby needs out). C-section is a common outcome – for first time mothers induction more than doubles their chance of a c-section. This should be discussed with the woman in order to gain consent for her induction.
I have written extensively about this in my new book (see the side bar 🙂 )
Thank you so much for your response, I actually bought your book yesterday and am eagerly awaiting it in the mail! Even though my unnecessary induction and premature c-section has already happened I wanted to know the whys and wherefores. I did not give INFORMED consent for either of these procedures and when I make my complaint I want to be armed with the correct information. Thanks again and looking forward to reading your book.
I am so sorry that you were not properly informed… although unfortunately this seems to be very common. I hope the book helps you to find answers and understand what went on.
And yes – please do complain. One of the problems is that maternity service providers don’t worry about unnecessary interventions. They argue that they only get complaints/sued for when they don’t intervene. Women need to let them know that they expect better and it is not OK to carry out an intervention without adequate information/consent.
oh and there is no such thing as ‘informed’ consent. Adequate information is a legal requirement to validate consent. So, if a woman is not given adequate information and then agrees to a procedure… she did not consent.
Despite the toll it’s taking on my mental health, I am determined to complain to both the Obstetrician AND the hospital because this kind of intervention should be fully explained and entered into with complete understanding on the patient’s behalf. Anything less is obstetric violence.
Good on you! And you will likely change things for another woman. Often the hospital staff are totally unaware of the emotional effects of ‘routine’ (to them) procedures. Their intentions are usually good and knowing how it is perceived from the other side can change future practice.
I know feedback from women has changed my practice over the years 🙂
I had an acynclitic birth with my son. I also have an incompetent cervix, so I had dilated to 7cm on my own without labor, when my Dr. suggested breaking my water since I had been in the hospital and was finally 37 weeks. Immediately after my water broke, contractions began, full force and 1 minute apart. An hour later, I was fully dilated. I knew without being checked that I was 10cm because the contractions instantly changed (I had no pain meds/epidural). They went from gut wrenching, to very laxed. My dr thought that my labor had slowed since I was not hooked to monitors. I was still contracting every minute, but had no urge to push and no pain, so I rested until urge built. An hour later, my son was born with acynclitic presentation that left him with a cephalohematoma the size of a golf ball, that later calcified and is still there 16 years later. I needed no assistance birthing him, but my patient dr listened to my cues and let me birth at my own pace, and I know that helped.