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

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 advised 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 now she is coached to push. The end of the story is usually an instrumental birth (ventouse or forceps) for an epidural related problem – fetal distress caused by directed pushing; ‘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 assumption has been taught to midwives since the 1930s and Ina May herself warned against ‘early pushing’ in Spiritual Midwifery. 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

Presentation2The 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 2011). 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 tilted – 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 sometimes 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). There is very little research about pushing before full dilatation. Downe et al. (2008) report research conducted in the UK in 1999, and recently Borrelli, Locatelli & Nespoli (2013) published a small observational study. These studies found that the incidence of ‘early pushing urge’ EPU (as it is referred to in the literature) is between 20% to 40%. Interesting Borrelli et al. (2013) found that the sooner the midwife performed a vaginal examination in response to a woman’s pushing urges, the more likely they were to find the cervix still there. They also found that ‘early pushing’ was much more common with primips (first labours)… perhaps because they are likely to take longer pushing, therefore be more likely to have a vaginal examination? And early pushing occurred in 41% of women with OP babies.

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.
  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. Borrelli et al. (2013) found no cervical lacerations, 3rd degree tears, postpartum haemorrhages in the women with an EPU. A recent review of the available research (Tsao 2015) concluded: “Pushing with the early urge before full dilation did not seem to increase the risk of cervical edema or any other adverse maternal or neonatal outcomes.” 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 anyone’s control. You either let it happen, or start commanding the women to do something she is unable to do ie. stop pushing.

I can only find one study that examined women’s experiences of an ‘early’ pushing urge (Celesia et. al 2016). The women in this study women were told by their midwives not to push: “In coping with EPU, women found it difficult to follow the midwives’ advice to stop pushing because this was conflicting with what their body was suggesting [to] them. Throughout their attempts to stop pushing, women were accompanied by the conflicting feelings of naturalness of going along with the pushes and discomfort of going against their bodily sensation. Women were confused by the contradiction between their physi- cal perceptions and the need to hold back pushes suggested by the midwife at the same time. Moreover, they reported difficulty in realizing what was happening. This confusion was sometimes related to the feeling of not being believed by health care professionals” (p. 23)

Telling women to push or not to push is cultural, it is not based on physiology or research. For example, in some parts of the world 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 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. It is like telling someone not to blink. 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. She may be in a forward leaning position because it relieves the back pain associated with an OP presentation and be reluctant to move. This is one of the rare times a suggestion/direction is appropriate.
  • 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 – by her or you. This is extremely uncomfortable! Be aware that this may allow the baby’s head to move into the vagina before he/she has rotated which could create further problems.

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 a cervical lip are caused by identifying it, and managing the situation as though it is a problem.

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VBAC: making a mountain out of a molehill

VBAC (vaginal birth after caesarean) is big. A google search for ‘vbac’ results in ‘about 795,000’ results. Reviews, guidelines, policies and statements are being produced by every organisation with an interest in birth. Support groups and networks are growing. I am not going to add to this wealth of information. Others are doing a fantastic job and I will provide some links at the bottom of this post. This post is really aimed at putting VBAC into perspective risk-wise and discussing how we can best support women planning a vaginal birth after caesarean. I haven’t personally experienced the VBAC journey and would welcome some input from mothers who have via comments, suggestions and links. This is written from my perspective as a midwife.

With a c-section rate of around 1 in 3 (Australia) a significant proportion of women approach their subsequent birth with a scarred uterus. Of those women, 84% will have another caesarean. I can’t find the stats re. how many of these repeat c-sections are planned vs emergency. But, considering the 50-90% ‘success’ rate for VBACs, I am assuming that most repeat c-sections are planned. I wonder if more women would choose to experience a vaginal birth if they had adequate information and support from care providers who believed in them?

Guidelines suggest that women should be counselled about the risks of VBAC, and they should have additional monitoring and intervention during labour. The big concern is uterine rupture, and this is what I am going to focus on. By the way – unless I provide a reference/link you can assume I am getting my numbers from the NIH Consensus Statement (US) or Having a Baby in Queensland (Aus). Both of these resources are based on current research evidence. So, if you need the original research sources check out their reference lists.

What happens during a uterine rupture?

Considering this is the risk associated with VBAC is worth briefly describing what is involved. Uterine rupture can happen at any birth, even when no scar is present (particularly if syntocinon is used). There are two types of uterine rupture associated with VBAC (Pairman et al. 2014):

  1. Catastrophic (symptomatic) – the old scar separates long its length, the amniotic sac ruptures and the baby is pushed into the abdominal cavity. This results in significant bleeding, shock and the baby is in grave danger.
  2. Asymptomatic – the scar separates partway along its length, the amniotic sac stays intact and the baby remains in the uterus. Bleeding and shock is minimal and the baby usually survives. This is the most common type.

Here is a youtube clip of what happens during a catastrophic uterine rupture. For more information about uterine rupture (including symptoms) check out this article on BellyBelly.

Risk by numbers

Risk is a difficult concept. You can have odds of 1 in a million, but if you are the 1 it is 100% for you. It’s also impossible to eliminate all risk from life (or birth) and every option has risks attached. All women can do is choose the risk that feels right for them – there is no risk-free choice. There are many ways of presenting risk and some ways may mean more than others for individuals. For example, if we look at the overall risk of uterine rupture for a woman who has had 1 previous c-section. By overall, I mean without adding or subtracting factors which increase or decrease an individual’s risk (eg. syntocinon during labour, transverse scar). The risk can be presented like this:

  • 50 out of 10,000 will rupture
  • 9,950 out of 10,000 will not rupture
  • 1 in 200 will rupture
  • 199 out of 200 will not rupture
  • 0.5% will rupture
  • 99.5% will not rupture

Which of these versions would help you conceptualise risk? I know when I look at the picture versions of risk I assume I’m the ‘red person’. Personally I like the 99.5% intact uterus odds.

As stated above these figures are the taken from the NIH Consensus Statement (US) or Having a Baby in Queensland (Aus). A more recent UK study (Fitzpatrick et al. 2012) found an even lower overall risk of rupture – 0.2%.

The risk of rupture may be even lower in labours that are not induced or augmented (the stats above are a mixture of all labours). An Australian study (Dekker et al. 2010) found that the risk of uterine rupture during VBAC was 0.15% in spontaneous labour, 1.91% in augmented labour and 0.88% in labour induced using prostin and oxytocin. Fitzpatrick et al. (2012) also found an increase in rupture with induction and augmentation. In contrast a US study (Ouzouian et al. 2011) found no different in rupture rates between spontaneous and induced labours – but found a significantly greater vaginal birth rate following spontaneous labour. Another study (Harper et al. 2011) found an increased chance of rupture during induction when the woman has an ‘unfavourable’ cervix. There are also other risks associated with induction which need to be considered before heading down that pathway.

For women who have had multiple c-sections: Landon et al. (2006) suggest the risk of rupture rises to 0.9%. Fitzpatrick et al. (2012) also found a slight increase in risk for women how had had 2 or more previous c-sections. However Cahill et al. (2010) found that: “Women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and as those delivered by elective repeat caesarean.”

The story looks a little different again when you look at the mortality and morbidity caused by uterine rupture.  Guise et al (2004) conducted a systematic review of research relating to VBAC and uterine rupture. They found that uterine rupture resulted in: 0 maternal deaths; 5% perinatal deaths (baby); and 13% hysterectomy. They conclude that: ‘Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.’

So, out of the small number of women who experience uterine rupture, an even smaller proportion will lose their baby or uterus because of it. When the uterus ruptures 94% of babies survive. The RCOG guidelines state that: “Women should be informed that the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous [first baby/birth] women in labour.” 

VBAC vs planned c-section: uterine rupture

Most resources and guidelines compare the risk of a VBAC with the risks of a repeat c-section. This can be a brain-twister because of the multiple and complex risks associated with c-section for mother and baby. Childbirth Connection cover them well, so I won’t. It is also important that women know a c-section increases the chance of stillbirth in subsequent pregnancies (Moraitis et al. 2015). Having a Baby in Queensland directly compares VBAC with planned repeat c-section for a number of complications.

I’m trying to stick to the risk of uterine rupture (the ‘big’ one). So, planned c-section wins with a 2:10,000 uterine rupture rate compared to 50:10,000 for a VBAC. That’s if you are happy to take all the (more frequently occurring) risks associated with c-section in exchange.

Uterine rupture vs other potential birth emergencies

A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations compares uterine rupture with other potential complications. You are more likely to experience a placental abruption, a cord prolapse or a shoulder dystocia (not associated with previous c-section) during your vbac than a uterine rupture. Your baby is also more likely to die from the placental abruption or cord prolapse than from a uterine rupture.

Anecdotes

Anecdotes often hold more power than numbers. I can guarantee that I will get a comment telling me about a poor outcome associated with a VBAC. They do happen (see the stats above). Unfortunately when care providers have been involved in a traumatic situation, it can be hard not to let that experience colour their perspective and approach. The memory of one uterine rupture will be stronger than all of the uncomplicated VBACs they have seen. The only uterine rupture I have personally been involved with was an induction of labour – not a VBAC. So, I emotionally associate uterine rupture with induction rather than VBAC.

Obstetricians in particular have to deal with the fall out of major complications because this is their area of expertise. They also miss out on seeing physiological births which end well because this is the realm of the midwife (I know this is different in the US/private sector). This can lead to fear-based counselling and practice, and a general fear of normal birth. It is interesting that a poor outcome associated with a c-section does not seem to elicit quite the same response – ie. fear of c-section.

When parents find themselves the 1 in how ever many, it is even more devastating. Their stories are powerful and need to be heard. However, it can be difficult for other parents to contextualise the story without also hearing stories with good outcomes.

The real risks of VBAC (according to me)

I am a bit confused about why such a huge deal is made about the risk of uterine rupture during VBAC. Why are these women subjected to serious (and often biased) discussions with fearful practitioners about the dangers of attempting birth? Why are they categorised as ‘high risk’, limiting their care options and imposing additional monitoring and intervention during their labour? If we agree that this is the right approach, then we also need to treat all women like this because the risk of placental abruption or a cord prolapse is greater than the risk of a uterine rupture during a VBAC.

To be honest, as a midwife uterine rupture is the least of my worries when caring for a woman having a VBAC. I actually think the mountain that has been built out of the risk-molehill requires more energy and attention. These women do need special treatment, but not in the form of disempowering fear-based counselling or practice. They have often had a previous traumatic birth experience and are dealing with fear from family, friends, and the medical system, in addition to their own worries. They have been labelled ‘high risk’ and are constantly reminded of the potential disaster waiting to occur. They also risk ‘failing’ if they encounter any complications or end up having a repeat c-section. This impacts on their ability to trust their body, follow their intuition and allow the physiology of birth to unfold. Often these women need more nurturing, reassurance and support from those involved in their birth.

Suggestions

During pregnancy

It is important to not only help women to prepare but also their partners and/or other close family members who may be at the birth. Often the partner was present at the previous birth, which may have been traumatic to witness. For a partner their priority is the safety of the woman they love – not a particular birth experience. Winning them over may be difficult. In some cases the decision the mother makes may be that the partner should not be present. OK – some suggestions:

  • Find out the details of her previous birth experience. If she needs debriefing help her do so, or refer to someone who can. Knowing about her previous experince and her fears can help you know what she needs during her labour.
  • Offer to discuss ‘risk’ and present the statistics in a number of ways. Find out what they (mother and partner) find most useful and empowering. I could say ‘don’t mention risk’ but to be honest ,unless she is living in a cave she will already be aware that VBAC is ‘risky’ and will need to explore this. In addition, it is a legal requirement for midwives to provide evidence based information about risk.
  • Make sure she is aware that she has a very good chance of having a vaginal birth – 72-75% if she has not previously had a vaginal birth, and 85-90% if she has (RCOG). Overall, she has a greater likelihood of a vaginal birth than a woman having her first baby and no previous c-section.
  • The RCOG guidelines state that: “Women should be made aware that successful VBAC has the fewest complications and therefore the chance of VBAC success or failure is an important consideration when choosing the mode of delivery.” Therefore it is important to consider previous birth scenarios and contexts to evaluate the chance of success for the individual woman.
  • The woman also needs information about factors that can increase her chance of VBAC eg. choosing supportive care providers (and setting) and not having her labour induced or augmented.
  • Talk about the possibility of the pregnancy going beyond the prescribed ‘due date’. This is often a feature of VBAC pregnancy. Some hospitals or midwives consider this to be a risk factor because the chance of a repeat c-section is about 9% greater (Coassolo et al. 2005). However, the risk of uterine rupture is no greater.
  • Make sure she knows that having a c-section after labour has started holds more health benefits than a planned c-section. Her baby will have had a chance to initiate labour and make the physiological changes needed for life outside the uterus. They will be less likely to suffer respiratory distress and end up in special care (Senturk et al. 2015). In addition, both mother and baby will have the important cocktail of hormones that assist with bonding. Even if she chooses a repeat c-section she can insist on going into labour first.
  • Talk to her and her partner about what actually happens if the uterus ruptures. They may be imagining all kinds of horrific scenes such as the baby bursting out of an exploding abdomen.
  • If she is worried about ‘failure’ reassure her that she doesn’t need to tell anyone she is planning a VBAC. She can say she’s not sure and will decide in labour.
  • If she is planning to birth in hospital she needs to know what the hospital policies are and decide what she will or won’t go along with. This means talking about the risks of the usual interventions such as CTG monitoring. A very clear birth statement can help the staff to support her wishes. It might be helpful to find out the VBAC rates at the hospital to gain some idea about how supportive they are likely to be during labour.
  • Encourage her to talk to other women about their experiences of VBAC, read positive birth stories and watch beautiful VBAC birth movies.
  • Do not use disempowering language such a ‘trial of scar’ or constantly refer to her birth as a VBAC. She is a woman having a baby, not a disaster waiting to happen.

During labour

The physical care of a woman having a VBAC should be no different (although I know it often is in hospital). Yes, I’m watching for signs of a uterine rupture: unusual pain, unusual contraction pattern, fetal heart rate abnormalities, unusual bleeding, a change in maternal observations etc. But, those symptoms in any birthing woman would be concerning, so this is not different care. In addition, if a woman is unmedicated and connected to her body/baby she will usually be the first to notice a problem. I have found that women having a VBAC may have additional psychological needs. For example, they may request vaginal examinations, particularly if their c-section was for ‘failure to progress’ (aka failure to wait). Even with information about how poor VEs are at indicating progress they may want that dilatation number – some non-VBAC women do too. They may also want more frequent fetal heart rate auscultation to reassure them the baby is well. In general, these women, and even more so their partners need reassurance and a birth attendant who believes in them. Of course some women don’t need any of this and choose freebirth.

Is homebirth a safe  option for VBAC?

No – birth is not ‘safe’ regardless of the setting. Different risks are associated with different options. In hospital there is greater risk of unnecessary intervention and associated complications. At home, if you are the 0.2% and need to transfer, there is the risk of complications due to a delay in medical intervention (including death of baby and/or mother). Bear in mind that this delay may also occur in a private hospital out of hours when theatre staff are not on site. Women also need to be aware that when it comes to homebirth, having a uterine scar places them in a ‘high risk’ category. The Australian College of Midwives classify a previous c-section as ‘B’ ie ‘Consult’ with a ‘midwife and/or medical practitioner or other health care provider’. This does not mean that a privately practising midwife cannot provide care. And the woman can decline a consultation if she wishes. Some midwives appear to be unaware of this, and tell women that they are not allowed to attend VBAC homebirths – this is not true. However, if you choose an eligible midwife, you may have problems securing a collaborative agreement from a medical practitioner so that you can claim medicare rebates for care. Likewise, homebirth services run from hospitals or birth centres may be unable to accept you as a client. Whilst VBAC homebirth is generally not supported in clinical recommendations, many women choose to birth at home. Keebler, et al. (2015) examined women’s reasons for choosing a homebirth after caesarean and the full text is available here.

VBACs are usually immensely healing and empowering for a woman and her partner. I wonder whether this aspect of birth is discussed at the ‘risk consultations’ along with the numbers.

You can read a birth story and watch the film here. I may be biased but this is a beautifully filmed/edited birth: Madeleine’s birth

Here is another couple’s VBAC journey (have a tissue handy). This is the most likely outcome of a VBAC – particularly a homebirth:

Further Reading/Resources

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In Celebration of the OP Baby

How many times have you heard “I had to have an epidural/c-section/ventouse/etc. because my baby was facing the wrong way”? An occipito posterior (OP) position occurs when the baby enters the pelvis facing forward with his back towards his mothers back. The back of the baby’s head is referred to as the ‘occiput’ and is in the back of the pelvis against the sacrum. Between 15-30% of babies start labour in an OP position, but less than 5% will remain in this position at birth (Sizer & Nirmal 2000). An OP position is associated with medical intervention during labour: syntocinon infusion; epidural; forceps; ventouse; c-section. This post will discuss whether an OP position is actually a problem, or if the problem lies in our beliefs about, and management of this common position.

A bit of anatomy and physiology

I’m assuming that readers of this blog are midwives, doulas, and/or birth nerds  who have an understanding of the pelvis. If you don’t, it doesn’t really matter – knowing the names of the bones doesn’t help you understand how the pelvis works. Basically, the pelvis is shaped in a way that requires the baby to rotate during labour. If you look in textbooks you will find diagrams with exact measurements of various pelvic diameters – this is nonsense as every woman’s pelvis is different. I find it is more helpful to consider that there are 3 areas of the pelvis: the brim, the cavity and the outlet. These areas have slightly different shapes, as I’ve tried to demonstrate below: The baby usually enters the brim with her head mostly facing sideways ie. transverse  (to fit the shape). It doesn’t really matter which way the baby’s head is when entering the brim – once her head is in the cavity she can rotate. The downward pressure of the contractions, and the tension and shape of the pelvic floor will guide her into a direct occipito anterior (OA) position and through the outlet. A very small number of babies will rotate to a direct OP position and come out facing the front of the pelvis (see below).

Usually the baby will take the shortest rotation into a direct OA position. So, a baby entering the pelvis in a ROA (back = front/right) does this:

Whereas a baby entering the pelvis in an ROP (back = back/right) position does this:

Of course OP and OA babies may use this turning space to do all kinds of interesting things from turning OA to OP, to rotating all the way around the back of the pelvis to end up OA. The baby will work out the best way to move through her mother – even if we don’t understand it.

Being born OP

Some babies are born in the OP position either because they stay in that position, or because they rotate into that position during labour (from OA). Here is a birth of a baby in the OP position and born in the caul:

Emma Kwasnica also shares some amazing photos of her daughter being born in this position.

The ‘problems’

Labour pattern

It is difficult enough for a woman with a baby in an OA position to fit prescribed patterns of labour progress. A baby who enters the brim in an OP position may not fit quite so snuggly on the cervix and this may lead to:

These situations only become problematic when we apply generalised expectations about how labour should be to an individual woman, baby and situation. The solution is often to augment labour with syntocinon – increasing the risk of fetal distress and increasing pain ie. creating a problem. Another solution is to encourage the woman to get into various positions to assist with rotation. However, the use of prescribed positions to ‘fix’ an OP position is not supported by research (Desbriere et al. 2012; Science & Sensibility).

Pain and interventions

Some women will experience pain differently when their baby is in an OP position. However, it is difficult to determine if this experience of pain is due to the position of the baby, or other factors. A study by Lee, Kildea & Stapleton (2015) into back pain in labour concluded: “The assumed relationship between fetal position and back pain in labour is a dominant discourse, albeit one which is lacking in empirical credibility.” Plenty of women with an OA baby complain of back ache in labour, whilst many with an OP baby do not. Unfortunately, women are told that an OP labour is ‘worse’, and are told horror stories like the one I started the post with. Given the psychological and emotional aspect of pain perception this cannot be helpful. Every birth experience is also different. I cared for a mother during two births. Her first baby was in an OP position and she had a four day stop-start pattern before labour established. Apart from being tired she coped well with the pain throughout. Her second baby was OA and labour established quickly. She was shocked and distressed by how much more pain she experienced with her OA baby compared to her previous OP baby.

Women with an OP baby are more likely to opt for (or be pursuaded to have) an epidural. This is not surprising, considering they are led to believe their labour will be more painful. They are also more likely to be subjected to interventions that increase pain and risk. For, example, a woman with an OP baby is less likely to meet prescribed progress timeframes, and therefore, have her labour induced or augmented by ARM and/or syntocinon (pitocin). An ARM reduces the fluid surrounding the baby, making rotation more difficult, and increases pain. Syntocinon increases the risk for mother and baby in many ways, and increases pain. These interventions further increase the chance that an epidural will be needed. Once an epidural is inserted, the ability of the baby to rotate into an OA position is reduced (Lieberman et al. 2005). The woman is unable to instinctively move her body and work with her baby to rotate him. In addition, the pelvic floor is anaesthetised and loses it’s tone, taking away the resistance that assists rotation.

Early urge to push

As the OP baby descends through the pelvis the back of his head puts pressure on nerves creating an urge to push. This pushing may be the body’s way of helping the baby to rotate by increasing downward pressure onto the cervix and pelvic floor – the baby is able to pivot against this tension. However, this urge to push is managed as a problem, and the result is often an epidural. See this post about pushing before full dilatation of the cervix.

Blame

Women can blame themselves for their baby being in an OP position. They question what they did (spent too long in the car) or didn’t do (scrub floors). Often the advice they are given antenatally about ‘optimal fetal positioning’ implies that they have control over the position their baby is in, when there is no research evidence to support this notion. In fact, the little research that has been done demonstrates that hands and knees posturing in pregnancy makes no difference (Hunter, Hofmeyr & Kulier 2009Kariminia et al. 2004). I have even heard of women being told that their baby has assumed an OP position because of their unresolved emotional issues!

Suggestions

We need to stop defining OP as a problem or a ‘malposition’. It is a common variation to the more common OA position, and the OP baby is probably in that position for a good reason. When caring for a woman with an OP baby:

In Pregnancy

  • Reinforce the woman’s trust in her body and baby to birth.
  • Discuss the possibility that her labour may be different (not better or worse) and might not fit general expectations about labour patterns/progress.
  • She can try a variety of techniques to encourage the baby to turn (even though the research suggests it may be ineffective). You can find some suggestions here. However, if he doesn’t respond it’s because he has chosen his optimal position for labour. He will turn once he gets into the pelvic cavity in labour, or he may even be born OP.
  • Tell her birth stories and connect her with other women who have experienced positive OP labours.

In labour

  • Trust the mother and her baby to birth.
  • Provide an environment where she can instinctively move and work with her baby to rotate her.
  • Don’t tell her not to push if she is spontaneously pushing – regardless of cervical dilatation.
  • Back pain can be relieved by: a forward leaning position (Stremler et al. 2005); warm water; sterile water injections; gentle sacral pressure. Avoid applying strong pressure to the sacrum as this may reduce the space available in the pelvis for rotation.
  • If the woman requests help or would prefer you to ‘do’ something there are a number of techniques you can use to create more space in the pelvis. I have provided a list here. Note that these techniques/positions are about increasing the space in the pelvis rather than rotating the baby – they provide an opportunity rather than making the baby move.
  • Occasionally, despite everything a baby will become ‘stuck’… and this happens to babies in an OA position too. In this situation more invasive interventions such as digital rotation (Reichman et al. 2008); instrumental birth or c-section may be necessary.

In summary

An OP position is not wrong or a problem. It is not caused by anything the woman does or does not do. Instead, it is a common variation that occurs when a baby gets into the ‘optimal position’ for her journey through her mother’s unique body. After all, she has more knowledge about the interior of her mother’s pelvis than we do. If we want to improve the experience and outcomes associated with an OP position we need to rethink our approach to it. Let’s celebrate the OP baby’s wisdom and allow the birth to unfold as it needs to, only intervening if it is truly required.

Further resources:

You can download a review of research relating to ‘management’ of OP by Simkin (2010) here.

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The Placenta: essential resuscitation equipment

Resuscitation Equipment

Knowledge about the short-term and long-term benefits of ‘delayed cord clamping’ is finally making it into practice. Midwives and in some cases obstetricians are realising the importance of allowing the placenta to finish circulating blood before intervening. I personally don’t like the term ‘delayed cord clamping’ and prefer the term ‘premature cord clamping’ to describe the alternative practice. However, whatever you choose to call it, babies are benefitting from the practice. The main physiological benefits are summed up in a Cochrane review that concluded there were:

“…some potentially important advantages of delayed cord clamping in healthy term infants, such as higher birthweight, early haemoglobin concentration, and increased iron reserves up to six months after birth.”

The review also notes that ‘delayed clamping’ is associated with an increased risk of jaundice in the newborn. In contrast Mercer and Skovgaard (2002) cite research findings that dispute this link. I also wonder whether giving an injection of syntocinon/syntometrine while the placenta is still circulating blood to the baby may influence the risk of jaundice. IV syntocinon/pitocin in labour has been linked to jaundice since the 1974s (do a google search for more research). All the studies in the Cochrane review were carried out in hospitals where the vast majority of women have an oxytocic injection for management of the third stage. I very rarely come across anything more than mild jaundice following a physiological birth. Anyone need a research topic?

Resuscitation and premature cord clamping

This post explores the the practice of premature clamping when a baby is perceived to need resuscitation. I often hear birth stories which include “They (or I) had to cut the cord because the baby needed resuscitation”. In hospital-based neonatal resuscitation workshops practitioners are taught to 1. assess the baby, 2. summon help 3. clamp and the cut cord, 4. take the baby to resuscitaire, etc. For obvious reasons resuscitating a baby is stressful, and I understand the benefits for midwives and doctors of doing it on a nice neat, ‘clean’ area without worried parents watching and/or asking questions. However, this approach makes no sense if you consider the physiology of transition to extrauterine life, or the importance of the mother in the baby’s transition and any necessary resuscitation.

The physiology of newborn transition

This is extremely complex and probably very boring for those not interested in science/physiology. So, if you want a full scientific version please see the article by Mercer and Skovgaard (2002). Here’s the simple version…

The baby/placenta has a separate blood system from the mother. The placenta does the job of the lungs by exchanging gas (oxygen and carbon dioxide) via the intervillous space between the baby’s and the mother’s blood system. Before birth, a third of the baby/placenta blood volume is in the placenta at any given time to facilitate this gas exchange.

After birth the ‘placental’ blood volume is transferred through the pulsing cord into the baby increasing the baby’s circulating blood volume. This has two major effects:

  1. Provides the extra blood volume needed for the heart to direct 50% of it’s output to the lungs (8% before birth). This extra blood fills the capillaries in the lungs making them expand to provide support for the alveoli to open. It also aids lung fluid clearance from the alveoli. These changes allow the baby to breath effectively.
  2. Increases the number of circulating red blood cells which carry oxygen. This increases the baby’s capacity to send oxygen around the body.

This transfer of blood volume from placenta to lungs takes place over a number of minutes following birth. Textbooks will tell you 3-7 minutes, but I have felt some cords pulse for longer than that. While these changes take place, oxygen continues to be provided by the placenta until the baby is ready to begin breathing. Stem cells are also transferred into the baby during this time. There is a theory, and some evidence that these stem cells play an important role in repairing any damage caused during birth. They may actually protect against cerebral palsy! Dr Mercer discusses this in more detail here. You can read my opinion on ‘cord’ blood collection in this post.

Most babies will initiate breathing quickly after birth and premature clamping of the cord will usually have no immediately noticeably effects. However, a recent study found that healthy self-breathing newborns are more likely to die or be admitted to SCN if cord clamping occurs before or immediately after onset of spontaneous breathing (Ersdal et al. 2014). Most babies are able to compensate for their lack of blood volume by readjusting their circulation to direct the smaller blood volume to the important organs. The effects of a reduced blood volume will be subtle but present (see the above Cochrane review). If you get a chance to hear Karen Strange speak about neonatal transition to extrauterine life – take it. She shows photos of the heel capillaries of a baby who has had premature cord clamping compared to a baby who has not. The small blood capillaries are collapsed – they have shut down in order to send the reduced blood volume to the important organs.

The need for resuscitation

There are two reasons that caregivers decide to abandon ‘delayed cord clamping’ and clamp/cut a cord in order to resuscitate a baby. In both cases this action creates difficulties for the baby. In the first it can actually create the need to resuscitate.

1. Lack knowledge, patience (and a bit of panic)

This often happens when a baby is slower to initiate breathing. The baby is still being oxygenated by the placenta but is waiting while the effects of an increased blood volume kick in. This is particularly common with waterbirth babies. These babies have good tone and slowly turn from bluish to pink. It can be difficult to even notice them begin to breathe. Their colour change may be the only obvious indication that they are making the transition. The cord pulses at the same rate as the baby’s heart, so feeling (or watching) it will reassure you that all is well. Unfortunately the usual response to this situation is to clamp and cut the cord in order to resuscitate the baby. The outcome will be that baby responds to the interruption of placental flow and the stressful journey away from mother by crying. A worse outcome is that without the placental circulation the baby is unable to complete their transition and becomes a compromised baby requiring resuscitation (see below).

This film is of an outdoor birth (the mother didn’t make it to her birth tent). The baby makes an unhurried transition supported by placenta circulation:

This baby is also able to make a gentle transition to breathing:

2. A compromised baby

This is a baby who has had a rough time during birth and might require a little external support to make the transition. This situation is often a result of interventions during birth such as directed pushing, artificial rupture of membranes, syntocinon/pitocin. It may also be a result of a tight nuchal cord reducing blood flow just before birth (a loose one does not do this). A compromised baby is floppy and heading from a blue colour to a white colour. They may also have passed meconium during the birth, and their heart rate is slow and/or dropping. This baby could probably do with a bit of help, but most importantly they need their placental circulation. While the cord is intact the baby is still receiving some oxygen, which is better than none. In addition, the extra blood volume and red blood cells will help to circulate any oxygen the baby gets into the lungs via external methods of resuscitation. You can see a very compromised baby being resuscitation with the placental circulation in this movie:

Here is another film of Rixa Freeze’s surprise unassisted birth where she resuscitates her own baby. You can read the full birth story and see part1 on her blog. Rixa had learned newborn resuscitation:

Here is a film of an unassisted birth where a mother instinctively resuscitates her own baby:

The importance of the mother and family in resuscitation

It is important that the mother, father or any other significant person is involved in the resuscitation of a compromised baby.

For baby

A baby has spent months inside his mother and learned her voice and smell. She has also learned the voice of her father and/or other family members. To be held close, spoken to and stroked is often enough to initiate breathing. Even if further measures are needed, being held by her mother skin to skin, rather than being put on a flat resuscitaire has got to be nicer.

For mother, father and/or other family members

Being able to see and touch your baby is probably less stressful than having her ‘worked on’ over the other side of the room. Being involved in assisting the baby’s transition reinforces the power of the parents. Fathers are often very proud to be the one who encourages baby’s first breath by blowing gently in her face. In addition, mothers often instinctively know how to help their baby. I remember one mother telling me she felt her baby needed to be in a certain position on her chest. When she moved him his breathing regulated perfectly.

Suggestions

  • Try and ensure that the baby does not arrive compromised by minimising unnecessary interventions.
  • Do not clamp or cut the cord.
  • Give the baby time to transition – if the cord is pulsing the placenta is providing oxygen… relax and reassure the mother if she needs reassurance.
  • Do not clamp or cut the cord.
  • If the baby requires assistance, start small – gentle stimulation, talking, blowing in his face (all can be done by a parent).
  • Do not clamp or cut the cord.
  • If further measures are needed, take the resuscitation equipment to the baby and resuscitate him in his mother’s arms.
  • Did I mention – Do not clamp or cut the cord.

Note: Routine suctioning of the baby is totally unnecessary, invasive and could potentially create problems by stimulating a vagal response (a drop in the heart rate).

I often hear that care providers are unable to perform resuscitation with the cord in tact in a hospital setting because of how the equipment is set up (ie. fixed to a wall). I think this will change. There is increasing awareness of the impact of premature cord clamping – lawyers are looking for claims. Paramedics in Queensland now resuscitate newborns without cutting their umbilical cord. If paramedics can do this in less than ideal settings, why can’t hospital staff? Hospitals need to start making equipment/staff fit around the needs of the baby – not the other way around. An interesting qualitative study explored clinicians perceptions or neonatal resuscitation beside the mother (Yoxall et al. 2015). However, implementing an evidence based practice should not depend on clinicians perceptions of that practice.

Summary

Babies are born with their own resuscitation equipment. The placenta not only helps the baby to transition, but assists with resuscitation if needed. There is no reason to clamp and cut the cord of a baby who needs help. Doing so will create more problems for the baby and mother. Anything that needs to be done can be done with back-up from the placenta, and the involvement of the mother.

Further readings/resources

Mercer and Erickson-Owens (2014) – ‘Is it time to rethink management when resuscitation is needed?’ Journal article

On Nuturing Hearts Birth Services’ website you can see a sequence of amazing photos taken of a cord after birth as it finished transferring blood.

Nicholas Fogelson (Obstetrician) gives a very clear presentation of the research regarding premature clamping in a lecture. The ethics of the research is questionable but hopefully the findings will help to inform a change in practice.

Very interesting and thought provoking interview with Dr Mercer

George M Morley has a written a very in-depth article about the physiology of neonatal transition to breathing, and resuscitation.

Science and Sensibility review the evidence

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The Human Microbiome: considerations for pregnancy, birth and early mothering

This post was co-authored by Jessie Johnson-Cash and based on her presentation at the USC Midwifery Education Day.

The human microbiome is rather fashionable in the world of science at the moment. The NIH Human Microbiome Project has been set up to explore correlations between the microbiome and human health and disease. To date the human microbiome as been associated with, amongst other things obesity, cancer, mental health disorders, asthma, and autism. In this post I am not going to provide a comprehensive literature review – this has already been done, and the key reviews underpinning this discussion are: Matamoros et al. (2012) ‘development of intestinal microbiota in infants and its impact on health’ and Collado et al. (2012) ‘microbial ecology and host-microbiota interactions during early life stages’. Instead I am going to focus on what this means for pregnancy, birth, mothering and midwifery.

What is the human microbiome?

Based on a chart by Matamoro et al. 2013. Adapted and extended by Jessie Johnson-Cash.

Based on a chart by Matamoro et al. 2013. Adapted and extended by Jessie Johnson-Cash.

Considerations for mothers and midwives

The following are not research based recommendations – the research is yet to be done. They are more considerations/questions arising from the developing knowledge around the human microbiome.

Pre-conception and Pregnancy

The commonly accepted belief that the the baby inside the uterus is sterile (whilst membranes are intact) is being challenged. It seems that maternal gut microbiota may be able to translocate to the baby/placenta via the blood stream (Jiménez et al. 2008; Metamoros et al. 2013; Prince et al. 2014; Rautava et al. 2013Zimmer 2013). And the unique ecosystem of bacteria in the placenta may originate from bacteria in the mother’s mouth. Women’s gut microbiota change during pregnancy and this impacts on metabolism (Koren et al. 2012Prince et al. 2014). So ideally, women need to head into pregnancy with a healthy microbiome and then maintain it. Unfortunately our modern lifestyle is not very microbiome friendly, and many of us have dysbiosis (an imbalance in gut bacteria). Dysbiosis and too much of the ‘wrong’ bacteria has been linked to premature rupture of membranes and premature birth (Fortner et al. 2014; Mysorekar & Cao 2014; Prince et al. 2014). Gum disease (bacteria) has also been linked to pre-term birth. Suggestions:

Birth

There is a difference between the microbiome of a baby born vaginally compared to a baby born by c-section (Azad, et al. 2013; Penders et al. 2006Prince et al. 2014). During a vaginal birth the baby is colonised by maternal vaginal and faecal bacteria. Initial human bacterial colonies resemble the maternal vaginal microbiota – predominately Lactobacillus, Prevotella and Sneathia. A baby born by c-section is colonised by the bacteria in the hospital environment and maternal skin – predominately Staphylocci and C difficile. They also have significantly lower levels of Bifidobacterium and lower bacterial diversity than vaginally born babies. These differences in the microbiome ‘seeding’ may be the reason for the long-term increased risk of particular diseases for babies born by c-section.

The environment in which the baby is born also influences their initial colonisation. A study by Penders et al. (2006) found that term infants born vaginally at home and then breastfed exclusively had the most ‘beneficial’ gut microbiota. It is likely that these babies only came into contact with the microbiota of their family during the key period for ‘seeding’ the microbiome. No one has researched waterbirth and the microbiome yet. Might it dilute the bacteria? The chance of colonisation and infection with group B streptococcus (GBS) is reduced with waterbirth (Cohain 2010Neugeborene et al. 2007). This may be due to dilution of the GBS or additional colonisation of the baby with beneficial bacteria. Another future research topic is caul birth and the microbiome. Does a baby born in the caul miss out on colonisation via the vagina?

What we do know is that antibiotic exposure alters the microbiome in adults (see above). When a woman is given antibiotics in labour her baby also gets a dose. In 2006 a medical expert review (Ledger 2006) raised concerns about prophylactic antibiotics in labour. A study in 2011 found that antibiotics given in labour increased the incidence of antibiotic resistance when treating late-onset serious bacterial infections in infants (Ashkenazi-Hoffnung et al. 2011). A more recent study found that antibiotics given during labour or a c-section are associated with infant gut microbiota dysbiosis (Azad et al. 2016). This is concerning considering the number of women/babies given antibiotics in labour (eg. for ‘prolonged’ rupture of membranes or for ‘epidural fever’). Add to that the use of prophylactic antibiotics for c-sections = a significant proportion of women and babies being exposed to antibiotics around the time of birth. Suggestions:

  • A vaginal birth in the mother’s own environment is optimal for ‘seeding’ a healthy microbiome for the baby (Penders et al. 2006).
  • Minimise physical contact by care providers on the mother’s vagina, perineum and the baby during birth.
  • Avoid unnecessary antibiotics during labour. If antibiotics are required consider probiotics for mother and baby following birth.
  • If the baby is born by c-section… Research is currently being undertaken into the use of vaginal swabs* to ‘seed’ c-section babies. The preliminary results are that the microbiome of swabbed babies are more similar to vaginally born babies. The protocol the researchers are using is:
    1. take a piece of gauze soaked in sterile normal saline
    2. fold it up like a tampon with lots of surface area and insert into the mother’s vagina
    3. leave for 1 hour, remove just prior to surgery and keep in a sterile container
    4. immediately after birth apply the swab to the baby’s mouth, face, then the rest of the body (you can see photos of this process here)
  • If a baby is born by c-section it is even more important to encourage and support their mother to breastfeed. It may also be worth considering additional probiotic intake.

*There has been a bit of hysteria about the safety of vaginal swab seeding in the media. I will leave it to Sara Wickham to address (rant about) this one.

Postnatal

After birth, colonisation of the baby by microbiota continues through contact with the environment and breastfeeding. There are significant differences in the microbiota of breastfed babies compared to formula fed babies (Azad, et al. 2013; Guaraldi & Salvatori 2012). Beneficial bacteria are directly transported to the baby’s gut by breastmilk and the oligosaccarides in breastmilk support the growth of these bacteria. The difference in the gut microbiome of a formula fed baby may underpin the health risks associated with formula feeding. In the short term, infant colic may be associated with high levels of proteobacteria in the baby’s gut (wish I’d know this 20 years ago!). Suggestions:

  • Immediately following birth, and in the first days, baby should spend a lot of time naked on his/her mother’s chest.
  • Avoid bathing baby for at least 24 hours after birth, and then only use plain water for at least 4 weeks (Tollin et al. 2005).
  • If in hospital, use your own linen from home for baby.
  • Minimise the handling of baby by non-family members during the first weeks – particularly skin to skin contact.
  • Exclusively breastfeed. If this is not possible consider probiotic support.
  • Avoid giving baby unnecessary antibiotics (Ajslev et al. 2011; Penders et al. 2006). Again, if antibiotics are required probiotics need to be considered.
  • Probiotics may also be beneficial for babies suffering from colic.

Summary

The more we understand about the human microbiome the more it seems fundamental to our health. Pregnancy, birth and breastfeeding seed our microbiome and therefore have a long-term effect on health. More research is needed to explore how best to support healthy seeding and maintenance of the microbiome during this key period. I have discussed a number of considerations and suggestions arising from what we already know. I welcome any comments, discussion and further suggestions from readers.

Further reading and resources

Posted in baby, birth, midwifery practice, pregnancy | Tagged , , , , , , , , , , | 114 Comments

Perineal Protectors?

Artwork by Dana Leggett: http://bit.ly/birthart

Updated: March 2017

Perineal tearing and/or grazing is common during birth. Two thirds of women will sustain damage to their perineum during birth (AIHW 2012). You can find out more about types/grading of perineal trauma here. This post will discuss ‘protecting the perineum’ and is based on a literature review. You can find the full literature review and reference list in my thesis.

An intact perineum is a badge of honour amongst midwives (the woman’s not their own!). When summarising a birth, midwives often end with ‘and an intact perineum’ to which the reply is usually ‘well done’. However claiming of responsibility for perineal outcome also works in reverse. If a woman sustains an extensive tear the midwife is blamed and her practice questioned by colleagues and herself. So, is there really anything anyone can do to avoid perineal damage during birth?

According to research most of the risk factors for perineal tearing are out of the control of the midwife, and to a large extent the mother:

  • A big baby
  • High weight gain in pregnancy
  • Higher socioeconomic circumstances
  • Older and younger maternal age
  • Ethnicity (Caucasian and Asian)
  • First vaginal birth

(Albers et al. 2006; Dahlen et al. 2015; Dahlen et al. 2007; Goldberg et al. 2003; Groutz et al. 2011; Helain et al. 2011; Lydon-Rochelle et al. 1995; Mayerhofer et al. 2002; Murphy & Feinland 1998; Nodine & Roberts 1987; Shorten et al. 2002; Soong & Barnes 2005)

The controllable factors that influence perineal damage are:

Preparation

For first time mothers perineal stretching massage during pregnancy can reduce the chance of tearing (Albers et al. 2005; Beckmann & Garrett 2007). Carolyn Hastie has designed an excellent leaflet explaining exactly how to do this. Perineal stretching massage can increase a woman’s confidence in her body’s ability to stretch and open for her baby. On the other hand, plenty of women don’t prepare in this way and whether you have confidence in your body of not, your perineum will stretch. It is also important for women to know that it is normal for the perineum to tear, and that if it does they have not ‘failed’.

There is a rather scary device called an Epi-No designed to use during pregnancy to stretch the perineum. The small studies (cited on the product webpage) found a slight reduction in tearing – most likely reduces the chance of tearing in the same way as perineal stretching massage – but no decrease in instrumental birth (Kovacs, Heath & Campbell 2004; Shek et al. 2011). A large RCT found that “antenatal use of the Epi-No device is unlikely to be clinically beneficial in the prevention of intrapartum levator ani damage, or anal sphincter and perineal trauma.” Personally I worry about potential long term effects of repeatedly stretching the perineum to the size of a babies head. Although a woman may give birth a number of times during her life, she will usually have more than a day between each baby’s head stretching her vagina. It is also a reflection of our technocratic culture that a ‘device’ is considered to be necessary in order to prepare for childbirth.

Positions

Lateral and hands-knees positions reduce the chance of tearing, and supine, squatting or lithotomy positions increase the chance of tearing (Albers et al. 1996; Hastings-Tolsma et al. 2007; Mayerhofer et al. 2002; Murphy & Feinland 1998; Shorten, Donsante & Shorten 2002). I have noticed that when women are left to birth instinctively they will often move from a squatting position – if they got into one – into a hands-knees position just before the head crowns. In forward leaning positions any tearing that does occur will usually be labial rather than vaginal. Labial tears sting like mad but heal well.

Warm water

A warm flannel held against the perineum during crowning can reduce the incidence of major tearing and reduce postnatal pain and urinary incontinence (Dahlen et al. 2007; Hastings-Tolsma et al. 2007). A recent Cochrane Review also supported the use of warm compresses to decrease the occurrence of perineal trauma.  However, for some women this is intrusive and irritating so make sure she is happy to have this intervention before you do it. Waterbirth is fabulous for avoiding tears – and makes it difficult for anyone apart from the birthing woman to touch the perineum or baby during birth.

Perineal Massaging during birth

Massaging the perineum as the baby is trying to be born concerns me for a number of reasons. It makes me really uncomfortable to watch lots of ‘activity’ being done to a woman’s body while she is trying to birth. I have seen some very brutal versions of ‘perineal massage’ done to women. However, the Cochrane Review above suggests that this type of massaging can reduce the chance of significant tears (3rd and 4th degree) – although this does not make it into their conclusion. These types of tearing are rare (around 1%) – so the intervention needs to be weighed up with the risk. And consent needs to gained from the mother beforehand.

Devices during birth

A company is currently trailing a device aimed at protecting perineums during birth. I will leave Katy Bowman to unpick this one!

Slow birth of the baby’s head

A slow birth of the baby’s head reduces the chance of tearing. It allows the tissues to gently stretch over time as the baby moves forward with each contraction and retracts afterwards – 2 steps forward and 1 step back.  A study by Albers et al. (2006) concluded that birthing the baby’s head between contractions slows the birth down and  ‘requires a joint effort by the mother and her clinician’. Yet another example of how misguided research can be, and a reflection of how inherent our mistrust of women’s bodies is. I can only find one study that has bothered to look at what women do when we leave them alone. This extremely small study of 4 women birthing without instructions (imagine that!) found that they altered their own breathing and stopped pushing as the baby’s head crowned  (Aderhold & Robert’s 1991). It’s a shame research into physiological birth is so limited. Instead I will have to rely on experiential knowledge…

Instinctive maternal behaviour vs instruction

Coached pushing increases the chance of perineal tearing, and this may be because it interferes with the instinctive response during crowning. The intense sensations experienced during crowning usually result in the woman ‘holding back’ while the uterus continues to push the baby out slowly and gently. Often women will hold their baby’s head and/or their vulva. I have witnessed one mother attempt to push her baby back in (you know who you are x) – it was unsuccessful but gave us a giggle afterwards. Telling a woman to stop pushing, pant or ‘give little pushes’  distracts her at a crucial moment and suggests that you are the expert in her birth, which you are not. She is the one with a baby’s head in her vagina – leave it to her.

Some women will close their legs during crowing. I have seen midwives push women’s legs back open or say ‘keep your legs open’. Closing the legs, or bringing them in from a wide-open position protects the perineum. The two positions that involve the least chance of tearing (left lateral and hands/knees) do not involve stretched out legs and therefore perineums. Try it yourself… open your legs wide and towards your chest and feel what happens to your perineum (go on I dare you). Now close your legs a little and bring them down away from your chest – feel how much more ‘give’ there is in your perineum when it is not stretched out. It can now respond to the stretch required by the baby’s head without also being stretched out sideways. As for whether closing your legs will stop a baby from coming out… it may slow it down, but that baby is coming out. I have seen a woman birth on her side with her legs crossed – her baby came out from behind.

‘Hands on’ techniques

Hands on techniques aimed at slowing the birth of the baby and supporting the perineal tissues are routinely used by many birth attendants. However, recent systematic literature review (Petrocnik $ Marshall 2015) concluded that: “The hands-poised [off] technique appeared to cause less perineal trauma and reduced rates of episiotomy. The hands-on technique resulted in increased perineal pain after birth and higher rates of postpartum haemorrhage.”

No research has compared instinctive physiological birth (no epidurals, induction etc.) with a ‘hands on’ approach. In addition, no research has explored women’s experiences of a ‘hands on’ approach. And, I am yet to hear a midwife or obstetrician ask for permission before placing their hands on the woman and baby. Ideally this should be discussed with the woman before labour and she should choose the approach she would like. For some individual women a ‘hands on’ approach may be appropriate. For example, some women with previous tearing want the psychological comfort of a ‘hands on’ approach.

Episiotomy

An episiotomy does not prevent a tear from occurring, instead it increases the chance of a third or fourth degree tear (involving the anal sphincter). A Cochrane Review has summarised the research in this area. Even in obstetric guidelines an episiotomy is not recommended as a way to protect the perineum during birth. Although an episiotomy is easier to suture, a natural tear is less painful and heals quicker. The only excuse for cutting an episiotomy is for an instrumental birth (and not in all cases) or for a baby who needs to be born quickly.

Suturing

Suturing is the most common method of perineal repair. Whether to suture or not should be the woman’s decision. In relation to 2nd degree tears (the most common) the need to suture is debatable if the tear aligns well and is not bleeding. A recent Cochrane review concluded:

“…at present there is insufficient evidence to suggest that one method is superior to the other with regard to healing and recovery in the early or late postnatal periods. Until further evidence becomes available, clinicians’ decisions whether to suture or not can be based on their clinical judgement and the woman’s preference after informing them about the lack of long-term outcomes and possible chance of slower wound healing process, but possible better overall feeling of well being if left un-sutured.” (Elharmeel et al. 2011)

In my own experience as a midwife I have found that un-sutured perineums heal very quickly and with far less pain than sutured perineums. Now-a-days my suturing skills are mostly utilised in teaching suturing.

In summary

There is very little midwives can do to protect women’s perineums so we need to stop taking the credit and the blame for perineal outcome. Instead we need to encourage women to trust that their body has an innate ability to birth their baby; that perineal tearing is a normal part of birth; and that the body will heal itself.

You can download a poster (literature review) of common midwifery practices during birth here and listen to me discuss protecting the perineum on the Birthful podcast.

Further resources

Severe perineal trauma is rising, but let us not overreact – Dahlen et al. 2015

Midwife’s Guide to an intact perineum – Gloria Lemay

References and bibliography

Aasheim, V, Nilsen, AB, Lukasse, M & Reinar, LM 2011 ‘Perineal techniques during the second stage of labour for reducing perineal trauma’. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD006672. DOI: 10.1002/14651858.CD006672.pub2.

AIHW 2011 Australia’s mothers and babies 2009, Australian Institute of Health and Welfare, Canberra: www.aihw.gov.au/publication-detail/?id=10737420870

Albers, L, Garcia, J, Renfrew, M, McCandlish, R & Elbourne, D 1999, ‘Distribution of genital tract trauma and related postnatal pain’, Birth, vol. 26, no. 1, pp. 11-5.

Albers, LL & Borders, N 2007, ‘Minimizing genital tract trauma and related pain following spontaneous vaginal birth’, MIDIRS Midwifery Digest, vol. 17, no. 3, pp. 246-53.

Albers, LL, Anderson, D, Cragin, L & al, e 1996, ‘Factors related to perineal trauma in childbirth’, Journal of Nurse Midwifery, vol. 41, pp. 269-76.

Albers, LL, Sedler, KD, Bedrick, EJ, Teaf, D & Peralta, P 2005, ‘Midwifery measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial’, Journal of Midwifery & Women’s Health, vol. 50, pp. 365-72.

Altman, D, Ragnar, I, Ekstrom, A & al, e 2007, ‘Anal sphincter lacerations and upright delivery postures – a risk analysis from a randomized controlled trial’, International Urogynecology Journal and Pelvic Floor Dysfunction, vol. 18, no. 2, pp. 141-6.

Beckmann, MM & Garrett, AJ 2006, Antenatal perineal massage for reduced perineal trauma (review), The Cochrane Collaboration.

Carroli G & Mignini L 2009 ‘Episiotomy for vaginal birth’, Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081.pub2.

Cronin, R & Maude, R 2010, To suture or not to suture second degree lacerations: what informs this decision?’ MIDIRS Midwifery Digest, vol. 20, no. 1, pp. 69-81.

Dahlen, H & Homer, C 2008, ‘Perineal trauma and postpartum perineal morbidity in Asian and Non-Asian primiparous women giving birth in Australia’, JOGNN, vol. 37, pp. 455-463.

Dahlen, H, Homer, C & Leap N 2011, ‘From social to surgical: historical perspectives on perineal care during labour and birth’, Women and Birth, vol. 24, pp. 105-111.

Dahlen, H, Homer, C, Cooke, M & Upton, A 2009, ‘’Soothing the ring of fire’: Australian women’s and midwives’ experiences of using perineal warm packs in the second stage of labour’, Midwifery, vol. 25, pp. e39-e48.

Dahlen, H, Ryan, M, Homer, CSE & Cooke, M 2007, ‘An Australian prospective cohort study of risk factors for severe perineal trauma during childbirth’, Midwifery, vol. 23, pp. 196-203.

Elharmeel, SMA, Chaudhary, Y, Tan, S, Scheermeyer, E, Hanafy, A & van Driel ML 2011, ‘Surgical repair of spontaneous perineal tears that occur during childbirth versus no intervention’, Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD008534. DOI: 10.1002/14651858.CD008534.pub2.

Goldberg, J, Hyslop, T, Tolosa, JE & Sultana, C 2003, ‘Racial differences in severe perineal lacerations after vaginal delivery’, American Journal of Obstetrics and Gynecology, vol. 188, pp. 1063-7.

Groutz, A, Cohen, A, Gold, R, Hasson, J, Wengier, A, Lessing JB & Gordon, D 2011 ‘Risk factors for severe perineal injury during childbirth: a case-controlled study of 60 consecutive cases’, Colorectal Disease, vol. 13, no. 8, pp. e216-219.

Hastings-Tolsma, M, Vincent, D, Emeis, C & Francisco, T 2007, ‘Getting through birth in one piece: protecting the perineum’, American Journal of Maternal Child Nursing, vol. 32, no. 3, pp. 158-64.

Helain et al. 2011, ‘Characteristics associated with severe perineal and cervical lacerations during vaginal delivery’, Obstetrics and Gynecology, vol. 117, no. 3, pp. 627-635.

Hillebrenner, J, Wagenpfeil, S, Schuchardt, R, Schelling, M & Schneider, T 2000, ‘First clinical experiences with the new birth trainer Epi-no® in primiparous women’, Z Geburtsh Neonatol, vol. 204, pp. 1–8.

Kovacs, G, Heath, P, Heather, C 2004 ‘First Australian trial of the birth-training device Epi-No: a highly significantly increased chance of an intact perineum’, The Australian & New Zealand Journal of Obstetrics & Gynaecology, vol. 44, pp. 347–348.

Lindgren, HE, Brink, A & Klinberg-Allvin, M 2011, ‘Fear causes tears – perineal injuries in home birth settings. A Swedish interview study, BMC Pregnancy and Childbirth, vol. 11, no. 6: http://www.biomedcentral.com/1471-2393/11/6

Lydon-Rochelle, M, Albers, L & Teaf, D 1995, ‘Perineal outcomes and nurse-midwifery management’, Journal of Nurse Midwifery, vol. 40, no. 1, pp. 13-8.

Mayerhofer, K, Bodner-Adler, B, Bodner, K, Rabl, M, Kaider, A, Wagenbichler, P, Journa, EA & Husslein, P 2002, ‘Traditional care of the perineum during birth: A prospective, randomized, multicenter study of 1076 women’, Journal of Reproductive Medicine, vol. 47, no. 6, pp. 477-82.

Murphy, PA & Feinland, JB 1998, ‘Perineal outcomes in a home birth setting’, Birth, vol. 25, no. 4, pp. 226-34.

Nodine, P & Roberts, J 1987, ‘Factors associated with perineal outcome during childbirth’, Journal of Nurse Midwifery, vol. 32, pp. 123-30.

Sampselle, CM & Hines, S 1999, ‘Spontaneous pushing during birth: relationship to perineal outcomes’, Journal of Nurse-Midwifery, vol. 44, no. 1, pp. 36-9.

Schaffer, JI, Bloom, SL, Casey, BM, McIntire, DD, Nihira, MA & Leveno, KJ 2005a, ‘A randomized trial of the effects of coached vs uncoached maternal pushing during the second stage of labour on postpartum pelvic floor structure and function’, American Journal of Obstetrics and Gynecology, vol. 192, pp. 1692-6

Shorten, A, Donsante, J & Shorten, B 2002, ‘Birth position, accoucheur, and perineal outcome: informing women about choices for vaginal birth’, Birth, vol. 29, no. 1, pp. 18-27.

Shorten, A, Donsante, J & Shorten, B 2002, ‘Birth position, accoucheur, and perineal outcome: informing women about choices for vaginal birth’, Birth, vol. 29, no. 1, pp. 18-27.

Soong, B & Barnes, M 2005, ‘Maternal position at midwife-attended birth and perineal trauma: is there an association’, Birth, vol. 32, no. 3, pp. 164-9.

Soong, B, Jacobs, J & Barnes, M 2001, ‘Reducing perineal trauma: a study of midwives’ practices at the time of birth’, Birth Issues, vol. 10, no. 1, pp. 5-12.

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In Defence of the Amniotic Sac

Holly birthing her boy in his ‘bubble’

Artificial rupture of membranes (ARM) aka ‘breaking the waters’ is a common intervention during birth. However, an ARM should not be carried out without a good understanding of how the amniotic sac and fluid function in labour. Women need to be fully informed of the risks associated this intervention before agreeing to alter their labour in this way. This post will discuss how the ‘waters’ work in labour and the implications of breaking them. Most of the information in this blog is available in any good physiology textbook (eg. Coad & Dunstall 2011). I have included references and links for additional content.

Anatomy and physiology

By the end of pregnancy the baby is surrounded by around 500-1000mls of Fluid. This is mostly made up of urine and respiratory tract secretions produced and excreted by the baby. The amniotic fluid is constantly being produced and renewed – Baby swallows the fluid; it is passed through the gut into the baby’s circulation; then sent out via the umbilical cord through the placenta. This process continues even if the amniotic membranes have broken. So, even when the waters have ‘gone’ there is still some fluid present ie. there is no such thing as a ‘dry labour’. You can read more about amniotic fluid volume in this post.

The amniotic membrane is adhered to the chorion – the other membrane attached to the placenta that sits between the amniotic membrane and the uterus. These membranes look like one, but you can tease them apart after birth.

During pregnancy

The amniotic sac protects and prepares baby by:

  • Cushioning any bumps to the abdomen.
  • Maintaining a constant temperature.
  • Allowing the movement essential for muscle development.
  • Creating space for growth.
  • Protecting against infection – the membranes provide a barrier + the fluid contains antimicrobial peptides.
  • Assisting lung development – baby breathes fluid in and out of the lungs.
  • Taste and smell – the smell of amniotic fluid has been found to have a calming effect on newborns (Varendia et al. 1998).

After 40 weeks gestation around 20% of babies will pass meconium into their amniotic fluid as the bowels reach maturity and begin to work.  This is perfectly normal and is not a sign of distress. This meconium is diluted and processed with the amniotic fluid as described above.

During labour

Around 80-90% of women start labour with their membranes intact. This is probably because the amniotic sac plays an important role in the physiology of a natural birth.

General fluid pressure

During a contraction the pressure is equalised throughout the fluid rather than directly squeezing the baby, placenta and umbilical cord. This protects the baby and his/her oxygen supply from the effects of the powerful uterine contractions. When fluid is reduced (by escaping through a hole in the membranes), the placenta and baby get compressed during a contraction. Most babies can cope well with this, but the experience of birth for the baby is probably not as pleasant. When the placenta is compressed blood circulation is interrupted reducing the oxygen supply to baby. In addition, the umbilical cord may be in a position where it gets squashed between baby and uterus with contractions. When this happens the baby’s heart rate will dip during a contraction in response to the reduced blood flow. A healthy baby can cope with this intermittent reduction in oxygen for hours (it’s a bit like holding your breath for 30 seconds every few minutes). However, this is probably not so great for an extended period of time, or if the baby is already compromised through prematurity or a poorly functioning placenta.

Forewaters

The sac of amniotic fluid is described as having two sections – the forewaters (in front of baby’s head) and the hind waters (behind baby’s head). A ‘hind water leak’ refers to an opening in the the amniotic membranes behind the baby’s head. Often this is experienced by the woman as an occasional light trickle as the fluid has to run down the outside of the sac and past baby’s head to get out.

During labour forewaters are formed as the lower segment of the uterus stretches and the chorion (the external membrane) detaches from it. The well flexed baby’s head fits into the cervix and cuts off the fluid in front of the head (forewaters) from the fluid behind (hind waters). Pressure from contractions cause the forewaters to bulge downwards into the dilating cervix and eventually through into the vagina. This protects the forewaters from the high  pressure applied to the hind waters during a contraction and keeps the membranes intact. The forewaters transmit pressure evenly over the cervix which aids dilatation. When the baby is in an OP position the head may not flex as well to block off the hind waters = pressure is able to move into the forewaters and they may rupture. Early rupture of membranes is often a feature of an OP labour.

Lubrication

The forewaters usually break when the cervix is almost fully open and the membranes are bulging so far into the vagina that they burst. This ‘fluid burst’ lubricates the vaginal and perineum to facilitate movement of the baby and stretching of the tissues.

Born in the caul

If is fairly common for a baby to be born in the amniotic sac when labour is left to unfold without interference. The photograph at the beginning of this post is my lovely friend Holly birthing her baby in his caul.

Eventually the force of the contraction and the movement of the baby will rupture the sac as the baby’s body is born. You don’t need to worry about the sac holding the baby back. A baby and uterus are stronger than the membranes. The rupture of the sac can be rather dramatic and messy and is another good reason for the midwife not to be fiddling about at the perineum during birth. Caul births seem more common during waterbirths (in my experience) and are possibly one of the most amazing sights in the world (and less messy than on land):
(note the baby above is born in the OP position)

You can see another beautiful caul birth here.

Historically being born in the caul was considered good luck for the baby. It was also believed that a baby who was born in the caul would be protected from drowning. Midwives used to dry out amniotic membranes and sell them to sailors as a talisman to protect them from drowning. You can find out more about the social history of the caul in an old journal article by Forbes (1953).

How does birth in the caul influence the baby’s microbiota?

I don’t know the answer to this question. However, increasingly research is identifying the importance of intestinal microbiota for health, including immune development and function (Bengmark 2012). I have written about this topic in more detail in another post. During a vaginal birth the baby is colonized by microorganisms as he passes through the vagina. So, this raises questions about what happens if the baby does not come into contact with vaginal microorganisms because the amniotic sac is intact? In theory, during a waterbirth the pool water is likely to contain microorganisms from the mother, therefore the baby could become colonized. But on land – I don’t know.

C-section and the amniotic sac

There are photos circulating on the internet of babies in their caul during a c-section (google caul+caesarean or cesarean). I would like to know the background stories to these photographs. There has been a study supporting this practice for preterm babies (Wang, et al. 2013), and you can see a photo from a case study here (Prabakar & Nimaroff 2012). However, there is no research supporting this method for full term babies.

Artificial rupture of membranes (ARM) aka amniotomy

Breaking the membranes with an amni-hook is a common intervention during labour. It is usually the second step in the induction process, and also done in an attempt to speed up spontaneous labour. In an induced labour, intact membranes can prevent the artificially created contractions from getting into an effective pattern. There is also the theoretical risk of an induced contraction (that is too strong) forcing amniotic fluid through the membranes/placenta and into the blood system causing an amniotic embolism and maternal death. So an ARM is recommended before a syntocinon/pitocin infusion is started (although this may not be a worldwide practice).

In a spontaneous labour the rationale for an ARM is that once the forewaters have gone the hard baby’s head will apply direct pressure to the cervix and open it quicker. However, a cochrane review of the available research states that “the evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.” .

There are also risks associated with an ARM:

  • It may increase contraction intensity and pain which can result in the woman feeling unable to cope and choosing an epidural… and the intervention rollercoaster begins.
  • The baby may become distressed due to compression of the placenta, baby and/or cord (as described above).
  • Fok et al (2005) found amniotomy altered fetal vascular blood flow, suggesting there is a fetal stress response following an ARM.
  • The umbilical cord may be swept down by the waters and either past the baby’s head, or wedged next to the baby’s head. This is called a ‘cord prolapse’ and is an emergency situation. The compression of the cord interrupts or stops the supply of oxygen to the baby, and the baby must be born asap by c-section. The only cord prolapse I have been involved with happened after an ARM (not done by me  – honest!). The outcome for the woman was a live baby born by emergency c-section. Her previous 2 babies had been uncomplicated vaginal births.
  • If there is a blood vessel running through the membranes (see picture below) and the amni-hook ruptures the vessel, the baby will lose blood volume fast – another emergency situation.
  • There is a slight increase in the risk of infection but mostly for the mother (not baby). This risk is minimal if nothing is put into the vagina during labour (ie. hands, instruments etc.).

It seems that an ARM is often performed during labour without consent. The requirement for consent to be eligible includes providing adequate information about the procedure. Have any readers been given the information above prior to agreeing to an ARM? Sara Wickham explores this issue further in her post about consent.

Summary

The amniotic sac and fluid play an important role in facilitating birth and protecting the baby. There is no evidence that rupturing this sac will reduce the length of labour. While every intervention has it’s place, including ARM, midwives need to carefully consider the risks before offering it to women. Also women must be fully informed of the risks before choosing an ARM during their labour.

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