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Entries in Mal-presentation (1)

Sunday
Jan062008

The Myth of the Vertex

There is a belief that if the baby is head down, the baby will come out the vagina. The thought continues that, if the baby didn’t come out the vagina, something was overlooked, someone did something wrong or the woman didn’t try hard enough.

The reality is – none of these beliefs is true.

Sometimes, babies that are head down simply (or complicated-ly) just don’t come out the vagina. It isn’t often, but it happens enough that natural birth advocates really should take a moment to listen.

On Empowering Birth blog, in her post "Why are moms so threatened?", Kat asks why some women are so threatened by hearing her say that their complications might have been caused by their care providers that they attack her. While I agree that folks just might not want to read her blog (or mine!) if they don’t want to hear alternatives or learning that their experience might not have had to happen, I also know that some women DID all that (the alternatives) and still had a cesarean/forceps/vacuum and don’t want to be told they made the wrong choice.

Example One:

My recent births that were mal-presenting vertexes. One was a face presentation that didn’t show itself until mom had been pushing for two hours. Some of that was because I didn’t do a vaginal exam early in pushing (my usual style, plus mom’s request), but even when I did do an exam, the baby gradually moved his face towards the outside. With each push, he wedged his face deeper and deeper in the pelvis. The pictures here show the wiggle wiggle, back and forth movement his face made over time until I was able to feel the softness of his cheek and it hit me that he was a face presentation. We quickly moved to the hospital and the wonderful doctor gave mom a couple of more hours to see if he would change from a Mentum Posterior (impossible to birth vaginally) to a Mentum Anterior. His heart rate had been great at home, but he began showing signs of distress as time passed in the hospital. By the time the decision was made to do the cesarean, he was having late decelerations (an ominous sign) and going downhill fast. The cesarean surely saved his life as he came out completely gone, needing full-on resuscitation, including CPR. The amount of meconium that came with his birth was described as sludge.

The second, a military presentation – not quite forehead, but looking straight on – could also not be born vaginally. When it was apparent there wasn’t forward progress, mom did everything from lunges, nipple stimulation to increase the power of contractions, move side to side, walking, changing positions in the water, on the toilet, on the bed, wiggling her hips and a whole lot of visualizing. No, I didn’t go in and try to move the head. She didn’t climb on the couch butt up/head down to pull the baby out of the pelvis so she could start all over again. When her membranes ruptured about 40 minutes before leaving the house, there was very thin meconium and it wouldn’t have been appropriate to purposefully stress the baby out any more.

After so much pushing, mom was really tired and I worried about the baby petering out even though the heart rate clicked right along rhythmically. After all the attempts at forward progression, including val salva pushing, we decided to head into the hospital. She’d been pushing on and off for 4 hours at that point.

When we got to the hospital, the baby was still in good shape and mom was given an epidural after trying to push for another 40 minutes or so. After the epidural, the doc tried the vacuum because the baby had a great caput to hook onto. All we saw was thin meconium up to this point. No forward movement even with the vacuum and massive pushing, so the decision to have a cesarean was made. Mom was extremely relieved. Once the uterus was opened, a pile of meconium was suctioned out and the baby’s placenta and cord were stained, showing that the baby had had something happen at least twelve hours earlier – many hours before any midwife ever arrived. Serendipitously, I hadn’t encouraged mom to tump upside down! Had I, the baby’s head and face would have been bathed in the meconium. As it was, with her face in the position she was in, most of her face was kept out of the mass of poop. Suctioning, they didn’t pull out any meconium at all.

This baby, too, would have eventually gone downhill and, if mom were still pushing hours into fetal distress, the baby would have died. I’m really thankful for cesareans.

Kat says:
“My post was prompted by the sad reality that more and more women have been reaching out to me in my neighborhood informing me that their doctors bring up induction and the big baby worry. In my mind, that is a threat. When an "expert" declares you need to induce because you are going to have a big baby he/she is making a threat, not a suggestion. The threat is, if you don't induce, your baby will "be too big" and you may "tear", "baby may get stuck," etc. (this is what the doctors say to their clients, in reality there is nothing wrong with having a big baby). Moms are going to believe the doctor/expert. You may have nagging doubts but in the end most moms seem to choose induction because "if the doctor is telling me I should be induced, I probably need to be induced." My goal is to provide more information so that moms are encouraged to question their care rather than blindly accept the opinion of an expert.”

Kat is studying to be a midwife. I’ve flatly asked her what she would do if a woman was pushing and pushing and there was no forward movement. Would she just let her keep pushing until baby and mom died? She acknowledged that there were going to be times she would have to make a decision that might make a woman angry. Blinking, I wondered why she couldn’t develop a relationship with her client that fostered a belief in each other… one where if the midwife said, “There isn’t forward progress. We need to go in,” the client would say, “Let’s go.” One where no one is angry with anyone else. One where both client and midwife know each did everything in her power to create homebirth success. One where both know the true goal is for mother and baby to be healthily alive, not just to be born at home or vaginally or without an epidural.

In ignorance, for there is no other way to say it but this, Kat says that whenever a doctor or midwife speaks about induction because the baby is getting large, that that is a threat. Only someone who hasn’t struggled with a shoulder dystocia – either in her own vagina OR with one in her hands as a midwife – would say something so amazingly dangerous. As a homebirth midwife, I am hyper-aware that threats are used in obstetrics and midwifery, but to blanketly say that “in reality there is nothing wrong with having a big baby” when a provider is speaking about how large the baby is setting a team of folks up for a fight in a possibly dangerous situation.

Kat says, “Moms are going to believe the doctor/expert. You may have nagging doubts but in the end most moms seem to choose induction because "if the doctor is telling me I should be induced, I probably need to be induced." My goal is to provide more information so that moms are encouraged to question their care rather than blindly accept the opinion of an expert.”

I ask: Shouldn’t the woman believe the doctor or midwife? If she doesn’t have the type of relationship where she doesn’t believe anything the doctor/midwife says, shouldn’t she find another provider? This is not to say I don’t want to be questioned, but when it comes down to an urgent/emergent situation, sometimes there isn’t time to delve into the psychological aspects of changing lanes. The care provider is hired to utilize his or her expertise! Why else have a care provider?

I used to try and please everyone… every client that came to my door. I submitted to interrogations about my style, my beliefs and my past choices in births. Once, I was asked what my favorite book was and what party I voted for. I knew enough to send her away, but when women came to me and said, “I don’t want you to do anything but sit in another room,” I used to obsequiously tell them I would. It is the woman’s birth, after all, right?

Then, with more experience, I woke up and figured out I couldn’t help if I didn’t monitor the mom and baby. It’s not like I’ll do vaginal exams that aren’t warranted or intrude in women’s space, but there are minimums that I feel are necessary for competent care and I no longer will compromise on that belief. Since I have gotten stronger in my skin as a midwife and not gone on to be the midwife for a woman who automatically considers me The Enemy, my births have been glorious, even when they were very complicated. When a woman pokes at me with a stick over and over, trying to make me do her bidding, thinking everything that comes out of my mouth is suspect, I release her from my care and send her on to someone else who will better be able to tolerate her paranoid thoughts.

What’s so funny is I used to be one of these women! I think I know where they’re coming from, but whenever I’ve assisted these women, I am fucked beyond repair. I worry I will have my license yanked from me long after the baby turns one year old. I worry about my reputation in the birthing community. One angry woman can make it difficult for awhile. When it was me, I was so pissed at The System, I took it out on everyone. I really didn’t think I could trust anyone at all, so I didn’t. Everyone was suspect. No one wanted me to have the birth I strove to have.

Well, I was wrong and I wonder why so many women see every care provider as a threat. If you haven’t read me long, you don’t know that I “get” birthrape and understand the amount of birth trauma out there. I do acknowledge the challenges and difficulties in finding a care provider to trust, but I wholeheartedly beg women to try and find someone they don’t have to keep at arm’s length. If it isn’t me, that’s fine! There’s a midwife for every woman. And plenty of women for each midwife. (Unless, of course, the woman is UCing… no midwife is good enough in that situation.)

Is there a way to resolve this mutual suspicion of each other? For me, I accept clients that believe me when I say, “the baby’s getting big… let’s get an ultrasound to check things out.” (For those that will tell me how inaccurate ultrasounds are late in pregnancy, the ultrasound tech I send women to has been spot on with the weight over half a dozen times, so with this tech, I know I will get an accurate weight.) The flip side is I believe them when they tell me something’s wrong or what their communication is with their baby. Trust is mutual. Should be mutual.

When I am hired to be someone’s midwife, I am being hired as a consultant. I am being asked to share my experience and knowledge, to utilize my skills – the ones that can save a life. As a consultant, one that differs from an interior designing consultant, I am being asked to take the lives of two people in my hands and to accept the consequences of the outcome whether that is a spritz of champagne or a cell in a prison. I’ve had a long time to adjust my considerations with my practice – and they might change again (I’d be shocked if they didn’t!). I see women as individuals, listen to their needs and concerns and if we both feel we could work together, I’m game to give it a go. If I find a woman lied to me about her medical or obstetric history, if she hides behaviors she doesn’t want me to know about or if she continually jabs at me questioning my concerns with her pregnancy (and all of these have happened in the last 2 years), I’m going to send her on her way. She is a liability I don’t need to take on… a risk to my profession and life.

Example Two:

A 150-pound (at term) first time mama who meticulously ate organically throughout her pregnancy had the most severe shoulder dystocia I’d ever experienced. The 10 pound 2 ounce boy took 2 minutes for the head to be born, 2 minutes for the body to be born and 2 more minutes for him to begin breathing. It was a horribly traumatic birth for mother, dad, baby, the other midwives and myself. Postpartum discussions included how to make sure that experience doesn’t happen again – how should she change her diet? Should she have exercised more? Really truly, I believe her body grew a really large child because of her and her partner’s (he’s quite tall) heredity. I can’t see a way for her to avoid that next time and told her I highly encourage her to schedule a cesarean for the next baby. Incredulous that those words came out of my mouth, all of us sitting around the table when I said that knew that that really was the best solution. In order to take care of any other questions, I am sending her to Dr. Wonderful for a second opinion. Another person any woman should believe – Dr. Wonderful – sometimes we really do have to take what someone says as gospel. Sometimes emergencies happen and someone has to be trusted to take care of them. Sometimes births need help and someone has to be there to give it. And take the liability for it, too.

For the women who trust in who I am as a human being and a midwife, I give everything in my Be-ing. I work my ass off to never betray their hearts. To me, that is what being a midwife is all about… serving women who hire me to tell my truth, to share my experience and knowledge and to sit next to them as they birth their children.

There is no greater honor.