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Thursday
Sep252008

VBAC (with a whiff of pit)

Mom's membranes ruptured without contractions for 18 hours before I called Dr. Wonderful (who was also seeing the client) to chat about what to do next. He verified what I thought we needed to do and that was go in for a "whiff of pit" - just the tiniest amount to tip the uterus over into a productive (and successful) VBAC. Happily, her cervix was very effaced and soft, although only about 2 centimeters dilated. (I only did the one exam right before calling the doc.)

Of course, my client was worried about the research that says 1) induction leads to cesarean and 2) induction is contraindicated in VBAC women. I have seen pitocin do wonders, even in VBAC moms. (The only two ruptures I've seen were with primip moms being induced with enormous amounts of pit.) When pitocin is used judiciously, it can work safely and efficiently.

So, in order to preserve my client's VBAC possibilities, we went in to the hospital.

By the time the pit was hooked up, it had been 24 hours post-rupture. Contractions began pretty quickly after that and you can now see her birth unfold in the following pictures. Dr. Wonderful is in the white tee shirt.


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Reader Comments (40)

Hey--can I ask a question? This is not meant snarkily, but I really am curious: why are his hands inside the mom as the baby's head is emerging? Was there a SD or something else going on? Just curious, because that certainly doesn't look all to comfortable to be doing "just because."

How long between the Pit beginning and the birth? Did you turn it off/down once contractions began or leave it going?

September 25, 2008 | Unregistered CommenterRixa

Me again--just noticed the monitor belt tucked up in her bra. I remember reading about that somewhere else, and now I finally see a picture of it. Seems like it helps hold things snugly in place so the mom can move about without dislodging the monitor?

September 25, 2008 | Unregistered CommenterRixa

Awesome. As a doula and a VBAC-hopeful (this March), this was beautiful to see. I personally would choose a gentle pit induction over a second cesarean, if it came down to that. Not an easy decision, and sometimes a scary one, but like you, I do not believe that pitocin is always bad. Like nearly every birth intervention, it was designed for a purpose, and when used judiciously and as intended, it can be helpful to those women who need it.

September 25, 2008 | Unregistered CommenterJackie

Yeah, even Dr. Wonderful has his (frustrating) quirks. I've encouraged him to be more hands-off-the-perineum, but he continues using the (sterile) oil with perineal massage. *sigh* This mom didn't tear (or even have a skid mark), but others of his moms have torn exactly where I thought they would - and (in my not-OB opinion) were because of the perineal massage.

No, no shoulder dystocia... the hand position(s) would be very different than that. Hands (plural) go in in a flat, fingers together way, and downward/upward pressure on the *shoulders* occurs. Depending on how far back the baby is will determine how far *in* the hands go, but they can be pretty deep since the shoulders are behind the pubic bone. Dr. Wonderful's fingers are the only thing barely entering the vagina (in the picture).

Does that help?

September 25, 2008 | Registered CommenterNavelgazing Midwife

Oh, forgot the time frame question!

It was about 3.5 hours after starting the pitocin and it remained on the absolute lowest amount after once turning it up for 15 minutes. The contractions were lovely, rolling and not excruciating for the mom and when the pit was slowed down, contractions slowed slightly, certainly affecting why not to turn it completely off lest the labor peter out. I think that in this case it was an appropriate use of the pitocin and was a LOT less than any of thought she would need. The labor was also so smooth, yet quick (in a first-time cervix's sort of way) that I wasn't at all concerned about a rupture.

September 25, 2008 | Registered CommenterNavelgazing Midwife

I was going to ask about Dr. Wonderful and why his hands are always up in the vagina during the birth, but I see someone already did. Can you warn your clients about this so that they can tell him to keep his hands to himself?

September 25, 2008 | Unregistered CommenterJennifer (mama blogess)

I have and I will! *thumping self on head* I should have been more vocal about it before... certainly "mentioned" it, but hadn't suggested women tell him, "Hands off!"

(He reads my blog, so maybe he'll hear them now!)

September 25, 2008 | Registered CommenterNavelgazing Midwife

Lovely to see...I so appreciate Rixa's questions - they are good ones. I have a few favorite (hospital) care providers & they have their quirks too regarding being more hands on than might be necessary (in this doula's opinion)...in spite of this, I think I have a crush on Dr. Wonderful. I'm hoping my SIL (who lives in SD area) will be pregnant soon (fertility treatments) and perhaps have you all as care providers...

September 25, 2008 | Unregistered CommenterDoulaMomma

Lovely! Just lovely. Your photographs are amazing! What a gift for the family to have!

Honestly, your client looks amazing throughout her labor. From the first image to the last, she looks radiant! What a difference support makes in a hospital birth. I love it!

Congrats to her on a successful VBAC.

September 25, 2008 | Unregistered CommenterElizabeth

What's on her necklace?

September 25, 2008 | Unregistered Commenterchristine chapel

Thanks for the responses Barb. I didn't think it looked at all like a SD and it was as I had guessed--his style of doing births. Yes, keep encouraging him to try a more hands-off approach, especially if it's something women want. I know a wonderful family practice doc who has done this, and now most moms either catch their own babies, or just gently release them onto the bed with no one catching. Perhaps he'd be interesting in talking to her about how she made the change, and why?

September 25, 2008 | Unregistered CommenterRixa

Love the pictures. Pit can be a great asset. I had a friend who experienced SROM with mec, and no contractions. A bit of pit and a lot of patience from her OB allowed her to give birth vaginally. It's not always bad.

September 25, 2008 | Unregistered CommenterDoreen

The necklace was made at her Mother Blessing about a week before the birth. Everyone brought (or sent) beads and one of my other clients made her necklace for her, bringing it to the hospital when we arrived. Is is much more beautiful in person!

September 25, 2008 | Registered CommenterNavelgazing Midwife

Firstly I love this and how would not- but why is USA obsessed with perineal massage everyone is from doc to nurse to midwives if its not hand pulling and stretching its oil or hot wash cloths please use leave it well alone- ok if mum got an heavy epidural apply a bit of pressure to show her how to push- but stop the stretching believe it or not the head will do all the stretching required- no cloths or oil- In my 10 yrs of midwifery practice in the uk I have never seen anything like it.

es obsed

September 25, 2008 | Unregistered CommenterLost

I am always amazed at how gorgeous birthing women are! What a sweet birth.

September 26, 2008 | Unregistered CommenterColleen

Beautiful! Just look at her ecstatic face!

September 26, 2008 | Unregistered CommenterRebekah

Wow! I think if we all had a Dr Wonderfuls working on behalf of our
clients, and their, the birth world would be good ,Yes?
Great photos!
MW in Texas

September 26, 2008 | Unregistered CommenterSandra Elkins

Beautiful birth - congrats to mom and everyone else involved on another successful VBAC. We are one of the few providers in our area doing these - such a shame! But fortunately, we do have a very high success rate.

Perineal massage - I do this on occasion, but mostly aim for a more hands-off birth....I enjoy just watching that head crown :)

September 26, 2008 | Unregistered CommenterCiarin

When I was at Casa, we learned birth by massaging and stretching... plus, it was all I'd seen (besides an epis) in the L&D (as a doula that watched everything like a hawk), so didn't know any different until I began reading even more natural birth stuff and then attending homebirths regularly.

I really do find women tear more with any perineal hands-on stuff, except support, which some women like and, honestly, some fast birthers can need.

And I don't often get to see the head crown! The mom always seems to be in the water!

September 26, 2008 | Registered CommenterNavelgazing Midwife

I work at Casa, even now, as a visiting staff midwife, I don't stretch or message unless there is a good reason. I get real nauseous seeing interns and other midwives having their finger in a vagina without good reason. In my mind there seems to be a certain vulgarity to it.
Its been my experience that there’s less trauma when moms are allowed to push without
coaching, and without massage. Those primaps are great at taking care of their bottom when left to their own resources!

September 26, 2008 | Unregistered CommenterSandra Elkins

What a beautiful birth--and I love how willing Dr. Wonderful is to birth in upright positions in the hospital. It's rare to see in my L and D unit in the midwest, even with a hopping CNM practice.

Re: perineal massage. I also find that with epidurals, many mom's prefer to have a gentle finger to indicate where to push. I always ask if they'd like to try it if they are looking lost after pushing through several contractions. I was surprised at how often women asked for it back.

September 26, 2008 | Unregistered Commentercileag

could someone (Barb?) please explain for readers the differences between & rationale for perineal massage versus digital stimulation of ferguson reflex? they are 2 separate procedures/maneuvers. I would write more but I'm NAK & slowly typing one handed with lots of backups & deletes for errata. thanks!

September 26, 2008 | Unregistered Commenterabundant b'earth

I am in a season of life with six children at home and I homeschool, but the more I read this blog and others the more I want to work in some way with birth. I might doula some day or something.

I know my nursie did massage (and baby wasn't crowning). I found it very offensive and painful, and couldn't figure out why I'd need it when I'd had five births already without it. Baby didn't come for over an hour after the massaging (or pushing my vagina into my anus is more like it, what the?). I know I'll want more hands off next birth and am switching providers to one that has a midwife and OB on staff...and the OB is known to be into letting it go naturally as much as possible. Believe me, we'll be talking (if I ever get to be pregnant again) about the hands off thing. I've had three babies anyway without OB in the room due to how fast I go from 4 cm to baby out...and didn't need hands on to get that baby out without tears. Of course, I tore in my 2nd birth because the nurse had me curl up and push with all my might...and baby gave me a "sunburst" labia tear with a long time of sutures after and a hole in my labia...hematoma (sp) and silver nitrate 6 weeks later to heal. Never had any problems after that, babies slid out...

Blessings!
Dawn

September 26, 2008 | Unregistered CommenterDawn

Abundant B'Earth,

I was *just* going to do that!

Perineal massage differs from low, deep pressure towards the rectum in that the low, deep pressure *can* assist a woman's urge to push... doesn't always. Dawn expresses her dislike of this maneuver in the above comment. Women who have epidurals often benefit from the added sensation two fingers pressing down on the pelvic floor can afford.

HOWEVER, one has to understand vaginal integrity and know when to stop if the tissues begin "shredding" underneath your fingers. (Women with poor nutrition can have the vaginal tissue literally break apart like tissue paper, right under your fingers. It's a horrifying feeling!) Try suturing wet tissue paper! Ack! Sometimes it feels like the vaginal tissue is melting like melting butter with your fingers in it, sinking through the layers of cells as the broken tissue encompasses your fingers.

Now, perineal massage is taking two fingers and "sweeping" the opening of the vagina... sometimes pulling the tissue out towards the practitioner... stretching it, "making room" for the baby's head. Perineal massaging fingers move from side to side, from about 4:00 to 8:00, back and forth, inside the vaginal opening. Almost always, some sort of lubrication MUST be used or friction can tear the tissues. (I find that even *with* lubrication - oil of some kind [olive, mineral], Astroglide [my favorite] or some other type of lubricant - the tissue tends to swell [certainly from "over-use"] and tear more than when left alone.) Often, the harder a practitioner pulls and sweeps, the sooner the tear.

Did this make sense? I should take pics and put them up, eh? But, I'd have to have a model! Hmm... think not.

September 27, 2008 | Registered CommenterNavelgazing Midwife

Can I ask about the monitoring? It seems that there is no toco picking up uterine contractions? And apparently no internal pressure monitor either. Is that right? If so, how are you recording uterine contractions on the trace? (is someone doing that manually?) And if no record, how are you distinguishing between earlies and lates? I just ask because, much as I dislike continuous CTG in low-risk labour, if there is an indication for using it (arguably there is in VBAC) then presumably there is a reason to want full picture given by toco also?

September 27, 2008 | Unregistered CommenterYehudit

Opps, and should have added, there is certainly indication for CTG with syntocinon drip - and would definitely want the information given by toco+FHR in that scenario - not just the FHR alone.

September 27, 2008 | Unregistered CommenterYehudit

Can I just tell you now how MUCH sentry work I apparently give up when I am in the hands of Dr. Wonderful?

I thought for sure you were just missing the second monitor, but I went and looked at the picture and sure as shit, THERE IS NO TOCO ON HER! How flippin' weird is that?!

The *only* explanation I can give you is the doctor was in the room almost the entire time and... would have seen something? I am just baffled.

Good eye, Yehudit. Good eye.

September 27, 2008 | Registered CommenterNavelgazing Midwife

Well, you can hear a decel if the sound of the monitor is turned up (was it?) and every midwife (who has worked in a hospital) knows what that sounds like, and I guess you can say if it follows a contraction, assuming that woman is in active labour. But.....no record, nothing to review? I wouldn't want to insist that what I heard was early/late on that basis - I'd like to see the pattern on the trace - CTG interpretation is mostly about visual pattern recognition - being able to classify that a trace is normal, suspicious or pathological. Not sure how easy that would be to do without the toco pattern.

September 27, 2008 | Unregistered CommenterYehudit

If the toco is uncomfortable for mom - or monitoring if uncomfortable in general, I will leave the toco off if the fetal heart rate tracing is fine. If there are no decels, there is no need to find if they are early or late. I will even use pitocin with no toco as long as mom is unmedicated (and if the monitor is not uncomfortable, I put it on - I'm just saying if it bothers the mom or she'd prefer not, if there's no reason I can do without it.) Most of my labor nurses are "old-timers" and they trained in the age of palpation for the strength and frequency of contractions, and plus an unmedicated mother certainly can tell when she's having a contraction. If we see decels, the monitor goes on to help figure out what's going on. I usually do use an internal monitor for pitocin in a VBAC, but not always - in a case like this with minimal pit and a mom who can feel her contractions I'd feel comfortable without it. Often the first sign of a uterine rupture are subtle fetal heart rate tracing abnormalities, so as long as the tracing is normal and mom is feeling normal labor sensations, I'm good.
It's nice to see some births that look the births I attend in hospital! (Minus the hands in the vagina.) I always tell my clients and the new nurses, and any med students I get that there is certainly nothing safer about lying in a bed - and women in general don't like it, so there is no reason to make them. It's great to learn all the little tips to monitor as needed while not restricting the mother. We have all kinds of tricks that we use, but the monitor through the bra strap thing is one I learned on the internet (maybe here?)

September 27, 2008 | Unregistered Commenterdoctorjen

One of the first things I ask for when I get a mom in the hospital is the squat bar. That thing is the BEST for so many situations... turned the "right" way (with the bar leaning towards the top of the bed), women can use the "arms" of the bar to push their feet on. I rarely have women squatting with it turned this way.

Instead, I turn it the other way (as seen in the photos) and then moms can stand and use the bar as a support (stronger than arms and backs!), lean on it, dangle from it or we can thread a sheet on the upper bar, leaving the two open ends for moms to pull on when needing some guidance with pushing. That push/pull seems to really help some of the women who try to push all in their necks and faces.

I hadn't ever seen the belt through the bra trick until this mama and I did put the pic up as soon as I found it. Magical! I won't forget it.

Now, to make you all laugh (and to verify what I've always said about my being a horrid witness in a robbery), I asked my apprentice how many belts the client had on and she also said two! I *swear* I can "see" two in my mind... both of us remember the one with the bra strap trick, but *swore* she had a lower belt on, too.

It provoked a really, really good conversation about abdicating responsibility when we transfer to the hospital and how we need to not do that anymore. We need to chart, pay attention (not just to mom's feelings, which are, of course, vital, too) and stay present with everything, including the doc's fingers in the mom's vagina. We said we would let each of our clients know this quirk about Dr. Wonderful - and decided we were on a mission to STOP IT!

September 27, 2008 | Registered CommenterNavelgazing Midwife

The thing is, there very often are early decels late in second stage when the head hits the pelvic floor - and I would not want to be faffing around trying to get a toco on and picking up accurately while a woman is pushing her baby out. On the other hand, the evidence that cEFM is both predictive of uterine rupture and makes a difference to outcomes is equivocal (Guise et al summarize this, presenting conflicting findings of Leung and Bujold) - so if a woman attempting VBAC (without induction) wanted to forego the CTG monitor entirely in favour of intermittent monitoring, that would seem reasonable - given that the monitor itself is likely to decrease her chance of successful VBAC (since it raises the CS rate independently of other factors).

On the other hand, induction significantly increases the risk of uterine rupture, and I wonder what the balance of risks is between more expectant management of prelabour ROM and VBAC with induction. (Where I am we offer induction at 48 hrs post SROM, but we are likely to move to 24 hours in line with recent national guidelines)

September 28, 2008 | Unregistered CommenterYehudit

YAY, another Dr. Wonderful post! And what a beautiful laboring mom! I'm struck by what pretty shades of blue the cord is, it looks like jewelry. Great great pictures, I love it.

September 28, 2008 | Unregistered CommenterJill

this looks like a really busy birth that is quite managed

first question ... third pic from the top where the Mom is standing by the bed ... did you smudge around her pubic hair? I would like to know why, especially, given the fact that there are pictures of her vaginal opening and baby passing through. I just don't get this.

second ... do you really think that this Mom's experience is that her body is working just fine, thank you very much, or is it ... there is something wrong still as this time I did need a pit as the contrax would not come.
what was the rush to induce her and keep her on the drip? Was she in danger of an infection? I guess with the vaginal exam the risk was all of a sudden higher ... but why induce just after eighteen hrs/ even 24 hrs without any sign of trouble?

Thanks again. Some interesting posts. :D

September 29, 2008 | Unregistered Commenteranarkissed

re: perineal massage
a midwife that I learned from and my own midwife refer to perineal massage as a method to get an idea of how it feels when the vaginal opening is stretched out and the pressure that comes with it. They teach it to clients and recommend to do it in the third trimester when the tissues are softening up and opening.
They claim that this is the only form of effective 'perineal massage', the only one that has any effect besides a tear or a skid mark.
Why cannot we keep the fingers out of sphincters!!!

September 29, 2008 | Unregistered Commenteranarkissed

Re: "really busy birth that is quite managed":

It *was* a managed birth - there was pit, monitoring, an IV and antibiotics, but it was still an empowered birth for the mom because *she* made choices plus had full freedom of movement without anyone directing her. She also had a VBAC when many (most?) women would have had a repeat cesarean.

There are private reasons why we went to the hospital, but in order to stay on track for a safe VBAC, it was appropriate for us to go.

There was one sterile exam before we went in and weighing the risks and benefits, the benefit was greater than the risk. The infection rate does go up, but it isn't horrendous when the exams are kept to a minimum.

While *your* definition of success might be that your body "works" without help, that isn't every woman's definition. She knows her body works just fine! She simply needed a nudge from technology and that doesn't bother her at all. Thank goodness there *is* technology to be tapped into at times; it doesn't mean if we do that we are defective in any way. It means we are wise to use the information and knowledge that's available!

It is also important to know that babies (and mothers) do better with induction BEFORE there are signs of problems. Waiting until the baby is compromised doesn't allow for pitocin because even more stress is put on the baby. This is one of the major reasons we went in (and a reason why going in sooner than later when going in seems to be becoming more likely than not).

Good questions/observations. Thanks for letting me clarify more.

September 29, 2008 | Registered CommenterNavelgazing Midwife

to me, i would rather have a small amount of pit rather than an automatic repeat c-sec.

and you bet i would want to be managed and monitored if i chose to augment with pit after a previous c-sec.
i think she had a beautiful and perfect birth! (other than the perineal massage, i may have kicked doctor wonderful in the face if he did that to me!

September 30, 2008 | Unregistered CommenterJackieD

Nawww, you wouldn't have had to kick him. I would have absolutely let him know your preferences. It's part of my job to do so! The other women never stated they had an issue with their perineums - and women who do, say something - so it was a non-issue with them. However, Dr. Wonderful is *so* easy-going, if a woman *said* she didn't want any touching, I am sure he'd be perfectly fine with that.

However, we won't know 'til it happens, will we. I love the man, but sure don't want to see him again anytime soon unless it's at a prenatal!

September 30, 2008 | Registered CommenterNavelgazing Midwife

I've had 7 VBAC's between 1994 and 2008. 4 with pit. The first a full-on pit induction on an unripe cervix 16 months after my C-section including 3 hours of purple pushing.
Next VBAC was cervidil induced.
next two unaugmented/ one induced. with AROM
then an augmented VBAC
then two induced VBAC's because of pre-e.

The last one made my L&D nurse REALLY nervous but ob and I had a master plan and knew where we would draw the line.
My uterus has help up through it all.

That was a beautiful birth and reminds me of a couple of mine, namely my first pre-e birth. I managed to labor hanging over the back of the bed or squatting despite mag and a broken foot.

October 10, 2008 | Unregistered CommenterKaren

I know that this post is rather old, but I wanted to thank you for it nonetheless. I read this post (along with your outstanding guide to a modern birth plan) the day before my waters broke. 30+ hours afterward, I was still not having productive contractions, so my midwife suggested a "whiff of pitocin". If I hadn't read this post, I might not have made the informed decision to go for it. We used 2 micrograms/hr, which kicked me right into active labor. I had a triumphant VBAC. I birthed him upright, without pain medications, and with my husband catching our son.

Thank you for your stories, and for including hospital births in your blog. They're a great reminder that hospital births can be respectful and informed by natural birth practice, as long as women are educated and prepared, and are blessed to have dedicated providers like you and Dr. Wonderful.

May 12, 2010 | Unregistered CommenterSarah

Sarah! You made my day! What a wonderful gift you gave me today. I am so, so glad your birth went well and that in some way, I was there with you. What a joy your new baby must be.

If you ever get the hankering, send me a pic of your scar and what it means to you. www.CesareanScar.com I'd love to add you.

Congratulations!

May 12, 2010 | Registered CommenterNavelgazing Midwife

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