The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Cervical Lips

See also:

• Stenotic Cervix

Subsections on this page:

• Preventing a Cervical Lip
• General Cervical Lip
• Swollen Cervix
• Anterior Lip
• Positional Changes to Resolve Cervical Lip
• Herbs/Homeopathics
• Sterile Water Papules to Resolve Cervical Lip
• Ice to Resolve Cervical Lip
• Manual Dilation

Preventing a Cervical Lip

The best way to avoid a lip? Keeping mom active and helping her change positions if she's resting -- rotate positions every half hour at least. Next best way? Don't look[Grin]! If a lip is holding things back you will find out very quickly.. if it isn't you'll see the baby soon.

General Cervical Lip

My experience shows that cervical lips are common.  I have helped them manually and never had cervical tearing.  You can wait and have a woman not push while it goes away, which can assist with maternal exhaustion, or you can hold it back.  The way you do that is to hold it up before the next cont begins, then keep it there when the head comes down past it.   Cervical lips aren't indicators of problems, but usually a cx that stays at 7 or 8 cms is telling you something is up.  Posterior, military, ascynclitism, cockeyed. I just had my biggest baby ever yesterday, just 10 1/2 #,  and the mom was 7-8 when I arrived, and 7-8 3 or 4 hours later.  I gave her blk cohosh tincture, she laid on her left side, the baby rotated and I held the cervix back while she pushed.  The guy del'd in 11 minutes.  Anyhow- sometimes these slight angled posterior will rotate, and sometimes they wont.  Sometimes the mom dels a posterior (persistant posterior) and sometimes the baby needs to get sectioned.  But doing nothing for a real long time isn;'t in my repertoire, because if we can't get affect change, and knowing the hospital takes HOURS to get things rolling, it can comprimise the moom and baby to just hang out.

I know I have posted this suggestion before, but it bears repeating. If you detect a lip on the cervix, it indicates that the head is not symmetrically applied (creating unequal pressure of the dilating forces). What you need to do is change the angle of the fetal head against the cervix before the fundus cranks down impressively against the butt and shoves the head through the pelvis at the wrong angle (creating decels, and nasty cervical and vaginal tears, among other things).

My time honored trick to reposition the head against the cervix is the have the mom blow through two contractions on her left side, two contractions on her right side (you can do this even with an epidural running for those of you in the hospital), then two contractions on hands and knees, and the last two in knee-chest position (not possible with the epidural, but you can roll her back to the right side and adduct the left leg into the frog (McRoberts)position for the two contractions and do the opposite on the left side instead of H&K and KC. Or you can elevate her hips with pillows higher than her head for the last two sets of two contractions). Then check her again. I have never had to run through more than two sets of the eight contractions as set out above to correct the asynclitism. A whole lot nicer than attempting just to shove the lip back, which encourages the head to come down while failing to correct the asynclitic presentation. The anterior lip is a dead giveaway that the peg is not fitting through the hole at the correct angle. So if you can't directly change the angle of the head, then change the angle of the mother. Something will give. Saves icing the lip and manipulations, etc. Manipulation of a cervical lip can make it more prone to tearing, etc.- not someplace any of us doing OOH births really want to go or repair!! If it helps you to visualize this, try it with a doll and a pelvis and see if you can observe that an asynclitic head (usually anterior) will creat the unequal cervical pressure and the anterior lip.

Swollen Cervix

There appears to be some anecdotal evidence that mother-directed pushing can be done without fear of swelling her cervix.  So...  What, in your experience, makes cervixes swell?  If a swollen cervix presents itself, what do you do about it?

Evening Primrose oil to the cervix--has worked every time almost immediately.  I love it.

Dystocia as in feto-pelvic disproportion..........a swollen cervix (like a fat donut), in its true form, is NOT a good sign! Prayer, frequent change of position, drugs to relax mother, more prayer.

Your answer surprised me!  A caput usually spells a malpresentation with a cephalo/pelvic disproportion.  Not a cervical lip.  I have never seen a swollen cervix when my babes won't descend.  Just caput.

In my experience, I have to disagree with.  A caput can obviously form with a correct presentation and a large baby who has to accommodate to the size/shape of the pelvic inlet.  While this can indicate a malpresentation as well, it can also be a normal occurrence.  A cervical lip usually indicates that the angle of approach to the pelvic brim is not correct (asynclitic) and the pressure of the contraction is not equally distributed around the circumference of the cervix, resulting in unequal dilation.  I usually suspect either a nuchal hand/arm changing the angle of the approach, or with multips with lax abdomens, simply that the abdominal muscles are not holding the baby's body at the correct angle.      Both problems can be addressed by using the "Pancake Flip" - changing the mother's position (2 contractions on the left side, 2 on the right side, 2 on hands and knees, and 2 in knee-chest position) and reassessing the situation.  It is necessary to back the head off the pelvis a bit to allow it to realign properly, and this will usually do the trick with one round of 8 contractions.  If the lip is truly swollen, it may be necessary to apply Evening Primrose Oil to the cervix, and I have also used ice successfully to reduce the swelling.

I have always felt that a caput was a healthy adaptation of the baby to the particular size/shape of the mom's pelvis.  BUT it can be a clue that there is some disproportion here as well.  With experience, a midwife will learn to distinguish true descent from increasing caput as far as progress is concerned.

I hardly ever see swollen cervixes ..... But I also strongly encourage my moms to "blow the baby out", or use open mouth pushing if they cannot blow through the contractions.  Much easier on the baby's head and the mom's bottom - assuming that the FHT's are acceptable of course.  Does make for slightly longer second stages, but the trade-off is well worth it.

Nothing in my post referred to 'caput' OR 'cervical lip'; only 'swollen cervix'.

In my experience, the 'Swollen cervix', like a 'fat donut' or 'bagel' doesn't occur that often but usually somewhere between 4 and 8 cm, in conjunction with either feto-pelvic disproportion (which doesn't mean it can't be overcome), with or without caput (that would depend on a number of other factors such as Vicki described well) and/or possibly a malpresentation like an OP, just plain tight fit OR a labor providing a great deal of force from above with a great deal of resistance from below as in 'rigid' cervix. I think of the 'swollen cervix' in the mother as similar to the 'caput' in the fetus; both are caused by 'extreme' pressure' and some people's bodies are no doubt more susceptible to forming edema in the labor process. I don't like seeing it because it usually means more work for mom AND me and I, for one, am getting old, impatient and tired (of seeing women have to struggle through dystocia). The whole 'cervical lip' thing is yet another conversation, may or may not persist with a complete, evenly swollen cervix and I would have to say again, Vicki summed up that scenario very well. I see (usually small) caputs on some babies who are completely OA, not asynclitic and come out without too much fuss, sometimes in labors commencing with PROM/AROM, pit indxn/augs and just lots of pressure against a particular spot with subsequent physiologic response. Not always pathologic. As far as why our 'differences'? although we service widely divergent patient populations,  birth is birth and these situations will just come along, it's the 'luck of the draw'.

I think a swollen cervix is a symptom of disproportion or uterine dysfunction -- rather than a "cause" of delay. If we can fix the dysfunction with herbs/meds/relaxation/time  -- or fix the disproportion by finding a better angle or position -- then we might actually fix the problem and get a vaginal baby.

A anterior lip is kind of a different problem -- sometimes it ain't anything other than just the last bit of cervix to get out of the way, and sometimes it's easy to treat with position, our hands, or time -- but sometimes it's got the same cause as a swollen cervix and is gonna be a big battle.

My experience with lips is they either go away in a couple contractions with repositioning -- or they go away within a few minutes if we hold them up - or they aren't gonna budge no way for nuthin.

And of course == if we don't do so many vaginals, then we don't find so many lips to begin with... ... at least not the transient kind which are going to disappear shortly on their own without any "treatment".

but what do I do for stubborn lips and swollen cvxs?

Sometimes time is the best treatment, so I monitor carefully, keep mom eating and drinking. try to get her to relax in whatever position works best. Maybe try resting in bath,  Maybe try squatting or other position to bring more pressure on cervix. Maybe try the opposite and take pressure OFF the cervix by getting mom on hands or knees or elevated Simms. Maybe try ROM (or else wish I had not done ROM).

I don't know what works. Sometimes nothing does.

I have tried various herbs and homeopathics but haven't had the miracle success that others have. Once tried ice but it didn't work.  One time got mom positioned on side with butt in the air and a good-sized swallow of rum and she went to sleep. That seemed to work a treat.

I haven't had to transport often, but this is the most common reason -- a cervix nearly dilated, or dilated with a remaining lip, or just no further progress and beginning to swell. Oh -- usually the baby is posterior too. (As we've been able to reduce the numbers of posteriors, this scene becomes less common of course.)

re caputs -

A caput is a pretty normal process in labor -- normal enough with primips to be expected - at least the small to moderate ones are. Big ones can be a sign of a tight fit though -- and sometimes you think the baby is coming, but all you got is caput. That's not a fun scene at all.

True, a caput doesn't mean the head won't come in, but can mean it won't.  In its own right it can be a 'failure to progress'.  You can have a caput that progresses and then you can have those that don't.

After reading everyone's description of a swollen cervix, I can only conclude that I have never had one.  I have had lips and yes they can be caused by a head that isn't entering 'right on'.  I have mom push with contraction as I push them up, babe comes down and it is all over.

My experience with CPD is that although the cervix may feel like a donut, it's been a rather floppy, formless donut rather than a fat, swollen donut.

I have not had swollen cervix for sooo many years I am not sure how to answer you except to say that I think that the cervix gets trapped between the head and the pubis.  The head CAN go around it or someone can push it up.  The longer it sits there the more swollen it becomes.  I, personally, just push it up and don't let it swell.

Give counter pressure to unswell it, hold up over head (even between conts), and have push past the cx.

I have had lips and yes they can be caused by a head that isn't entering 'right on'.  I have mom push with contraction as I push them up, babe comes down and it is all over.

Wish I could say the same as you, but not my luck. maybe you're pushing harder than me, but I've had a couple of stubborn ones over the years.

Hmmm.  I never had one I could not get up.  I may have to go with a position change, but still, with a contraction, I push them up as mom pushes and once the head passes that point, it doesn't come down again. The position change seems to make it easier for mom to know how to push.

Anterior Lip

The Anterior Cervical Lip: how to ruin a perfectly good birth [Midwife Thinking blog from 1/22/11]

The anterior portion of the cervix is the last part to get out of the way... it's not pathological -- it's just the way they are made. Give them a
bit of time and the lip will disappear.    Tincture of time is my usual remedy for  a lip. Getting mom to relax, rest and wait. Water and darkness are great tools at this point.   I think something needs to change -- either the position of the baby (kid probably needs to complete rotation), or time or better contractions, or a rest in order to "get" better contractions later, or better maternal position.

Pushing on hands and knees will help!

I rarely use time . . . if the mom is pushing, I hold the cervix back between contractions and allow the head to slide right past - usually in one contraction.  I totally agree that if it doesn't work in 1 or 2 contractions, it's not ready, but it's rare for it not to work.

I was taught to hold it out of the way also.. went through the same process of discovering that "most" of them will go away just as fast if we do nothing as they will if I held them up (man, does this cause cramps in the midwife's shoulders, arm, fingers and back[Grin])! We try positioning and getting mom to relax and breathe through a few contractions.. we do add "side lying" to the above list of positions. Also a good time to float in a tub[Grin]..

I think that "usually" a lip will resolve itself more easily on mom and at least as quickly if we use the hands off approach. (Again, not always, and there's the unusual situation where holding the lip is needed.. but I think it's rare).

How do I decide whether to attempt to hold a lip or rest the mom? Waiting for a few contractions to see if the uncontrollable pushing urge kicks in often decides the issue[Grin] but "if" I feel a swollen lip I might try lifting it. If it melts away and stays away during the next contractions, then I'll try that for perhaps one or two more. If it is tense or if the lip comes right back down during-or after-- a contraction, then I think it doesn't do a lot of good to keep holding it -- it will eventually go away if I do that (or not).. but I think that sort of lip will go away just as fast without me in there...

RE -- observing a lip come down with the baby.. Actually that's not too uncommon and probably wouldn't matter whether you tried to move the lip out of the way or not. It's not impeding birth and you probably couldn't have avoided it anyway (ever held a lip up "forever" got it out of the way, mom pushed well and lip STILL was visible with baby? It happens sometimes... might even be a normal variation).

I believe cervical lips are sometimes a sign of an OP/OT/asynclitic position, and I don't believe they impede progress. Don't forget, that last centimeter or so is not dilatation in the horizontal plane, but the cervix being slipped past the baby's head as it descends vertically. If they get really, really edematous, I believe they should be slipped up just so they don't get so edematous that they get trapped by the symphysis. It is easy, and not terribly painful, if you push them up between contractions, hold them up past the symphysis, and have mom push with her next contractions.

If you are open to homeopathy, arnica 30x given throughout labor helps reduce swelling, thereby helping to reduce cervical lips. I also had a midwife who would have the woman roll flat on her back for one contraction and try to put her knees to her ears. The theory is that by curving the back, the baby's head is lifted out of the pelvis enough that it gives the lip room to slide back on its own. Haven't tried it, but she says it works every time, and in one contraction. And is significantly less painful than pushing it manually.

If positioning & Arnica don't work, and the lip can't be reduced over the baby's head during a ctx ( or the mom is toooo uncomfortable), I've used an ice cube applied directly on the lip with fast results. The ice melts quickly, and the mom usually loves the coolness where there is sooooo much heat.

When I use Arnica for a swollen anterior cervical lip, it's homeopathic arnica 30c, 3-5 pellets under the tongue and repeated in 20-30 min if necessary.

We have had to transport in for pit to get her to the pushing stage. First time we went in at 7 cm. Monday we made it to just a rim but couldn't get past that. Baby does fine no problems at all so I waited and waited and waited. She was at 9 for 24 hours. I know that is outrageous but she was not in labor. She slept a good 6 hours and when she awoke had contractions only 7-10 minutes apart.

I've seen them do this.. and the general consensus here is that IF THE WATERS ARE NOT BROKEN and if there have been NO or very limited internal exams; then there should be little stress on the baby -- and the decision then is based on how the mother feels. If labor is light with weak and sporadic contractions, and mom is sleeping and eating and willing to wait for good labor to kick in - - - well; I think most would wait.

I lot o f "if's" there though...

I did have one woman who stopped at 8 cms... We left the place and gave privacy (not much point in us being there if there are not good contractions)..... Good labor started again the next day..

Some would call this uterine inertia -- some would call it a normal but uncommon labor pattern.. Gotta figure out what's going on and if there is any problem contributing to it (for instance, a tight fit -- but then you would expect to see GOOD contractions, which peter out as the uterus and mom get exhausted. Doesn't sound like what you describe).

Best advice for this type of labor is to do no internals until contractions are consistently under five minutes and/or mom is showing transition signs.. Assuming intact membranes, the major risk of this easy, light labor is infection -- so no internals until CONSISTENT labor pattern!

My non-invasive methods of reducing a lip are: arnica 30c po q15 min, change in position first left lateral and later if needed (mom doesn't like lying on side) hands and knees. If I have a fat lip, and mom's circumstances are that I need to get it out of the way, but I will take more than just slipping it over the head during one ctx......I'll set her on the toilet, and hold it during and between 3-4 ctx. If it's not gone by 4 ctx, we take a rest......her body and my hand need a rest by then. If I feel any increasing edema, I will stop immediately and go back to the position changes. I always give the arnica though.

Anterior Lip in Hands-Off Birth

Positional Changes to Resolve Cervical Lip

From Polly Perez - Here is the tip I use the labor support workshop I do:

• Mom stands with hands on her waist
• Bend in knees
• Legs as far apart as she can handle
• Lean way back (like yoga movement where you look up in the sky)

Rock forward straightening legs and leaning down looking at the ground

When contraction starts- "hang" from someone with your arms around their neck
(the second movement help the baby descend/

Hands and knees works well for me.  I have had several mothers use this and the lip was reduced with minimal cervical trauma (as can be the case when manually reduced by a nurse/doc) and reduced fairly quickly within a couple of contx.

So how many of you subscribe to the theory of putting pressure on the lip helps get it out of the way? And how many subscribe to letting the pressure off helps get it out of the way? Translated means: Who has her do hands and knees and Who has her semi-recline?

I do arnica and hands and knees. If she can't stand hands and knees I will ask her to stay way over on her side (practically on her belly).

When I was interning, I saw lots of ladies who would come to delivery with an urge to push. On VE I would feel no cervix on one side, and about 2 -3 cm on the other. Generally it was because in labor they would lay on one side and stay there (they didn't have much choice, they often shared two to a single size hospital bed, so each would lay on one side and avoid disturbing the other lady. ) The side they laid on was invariably the side that was more dilated. We would just make them lay on the undilated side for about 15 minutes, and voila! they became complete.

I haven't used it in relationship to posterior cervix, but I don't know why it won't work for the same reasons.

What I have had experience with is when there is 8-9 cm cx that is more on one side than the other. What I find is that it is like that because the weight of the baby is on the cervix, so that if they are lying on their left, there is more cervix on their left side. Usually removing the weight of the baby (turning them to their other side) remedies this. So I don't know why the same things won't work for the posterior cervix. (provided that the baby is well applied to the cervix)

Therefore my vote is for the semi-reclining to take the weight off of the anterior lower uterine segment.

I'm not so sure that hands and knees, or side lying, helps a lip or poorly dilating anterior portion of the cervix "by putting pressure on" the region -- I think the reason it might help is because we seem to see more efficient contractions (for most women) in this position. Not sure where the "pressure" really is in various positions...

Herbs/Homeopathics

Several midwives in my area have taken to giving arnica 200 c. or triple potency's Muscle and Joint Injury when labor starts, and at the beginning of second stage, and just after birth. They have all been noticing that there have been fewer anterior lips... we are all wondering, but it makes sense!!

I have used these Homeopathics with good results over 18 years for cervical lips: Aconite 30 when it's due to fear, tension and it's a tight dry lip that won't budge. Gelsemium 30 can be used when it's a real tight lip, or it's one of those loose floppy lip that still won't move. Each one of these can be used with several doses, but don't give them together. Take them orally.

I have on occasion used oil of Primrose to soften up the rim.

Evening primrose oil doesn't work 100% of the time, but I would say at least 80%.

Sterile Water Papules to Resolve Cervical Lip

See also: Sterile Water Papules

I just saw the sterile water injections done for the first time by one of the midwives in my new job. It worked amazingly well. The Mom felt instant relief and was able to rest for a bit, allow the lip of cervix to go and push out a beautiful baby 7-5 who rotated right before delivery.

Ice to Resolve Cervical Lip

I put on a sterile glove, pick up some ice, and put on another glove so that the ice is between my fingers. Then I rub the cervix with the ice. It seems to decrease the swelling, and the head moves on, so to speak. Occasionally ice feels good on the perineum if the mom's experiencing the 'ring of fire'. Yes, instead of warm packs, I try cool ones. Work for some women.

Manual Dilation

I have recently heard of a very experienced midwife who routinely manually dilates the cervix to speed up labors. The mom who had been attended by this woman was very grateful, since she felt her labor would have been very long, otherwise. Something about this doesn't "sit right" with me. I know that any unnecessary intervention (and I would, in this woman's case, call it unnecessary) only hinders normal labor, and can affect mom's emotions in many ways that we do not even see. Can you tell me what the physical risks of manual dilation are?

Most attempts at manual dilation are a matter of pressing the cervix open during a contraction while the uterus pulls up on the cervix and the head presses down through it. Many midwives consider it an "intervention" that would only be used when progress was slow enough to be considering transport. In any case, it would not be done vigorously enough to tear the cervix. Sometimes it works beautifully, and sometimes it only seems to work. That is where the danger of cervical tearing comes in. If the cervix opens all the way with your manual assistance, then gradually closes and swells up, then pushing could cause a tear. This wouldn't usually happen, since even pushing on an 8cm cervix wont usually cause a tear. Tearing of the cervix is pretty rare in a non-forceps delivery. But that would be about the only physical danger from manual dilation. To minimize the chance of cervical tearing, manual dilation should be fairly gentle, the cervix should continue to be assessed after the procedure, and the mother should not push until she feels the descent of the baby. As far as using manual dilation to START a labor, I don't know why this would cause tearing several hours later at birth unless it was torn just a little with the manual dilation (remember the excessive bloody show) and then the little tear spread to a bigger one during pushing. We must remember that all interventions, even midwife ones, can have some risk. We are always trying to balance out the risks of what we do at home against what we suspect will happen in the hospital.

I wonder if "holding a lip" causes the baby's head to deflex?

I think it is probably the other way around....a deflexed head causing the lip to start with.

I assume we are talking anterior lip that is getting caught and starting to swell when the woman pushes down.... and a good pushing urge. This is an interesting question. Possibly this could happen if the baby was OP, but then posteriors are often not as well flexed, but it seems like the reverse might be true if the baby were OA, don't you think?

I often find that it's even the head that is just trying to turn to OA from LOA or ROA that will drag down that lip that just won't go, no matter how strong the urge or how "push-backable" the lip seems to be. We usually have the woman lie on her side for a contraction or two to assist in completing the rotation, which generally gets rid of the lip very nicely and - voila - a baby! This, BTW, seems more often to be a problem with multips than primips, in my experience.