Ornament

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

Ornament

For a Stalled or Dysfunctional Labor


Easy Steps to a Safer Pregnancy - View e-book or Download PDF - FREE!
An interactive resource for moms on easy steps they can take to reduce exposure to chemical toxins during pregnancy.

Other excellent resources about avoiding toxins during pregnancy

These are easy to read and understand and are beautifully presented.


See also:

Subsections on this page:



Resources



See also: TENS for Prodromal or Inco-ordinate Contractions

See also: Comfort Measures For Labor, especially Staying Warm - Hot Packs and Staying Cool - Cold Packs



Serum Lactate Dehydrogenase Profile as a Retrospective Indicator of Uterine Preparedness for Labor - A Prospective, Observational Study
Jeremy L Neal, Nancy K Lowe, Elizabeth J Corwin
BMC Pregnancy Childbirth. 2013;13(128)

Conclusions: In this study, parturients progressing most slowly after being admitted for labor appear to have LDH isoenzyme profiles that are less equipped to contend with contraction-related anaerobic conditions compared to those parturients progressing most rapidly after admittance. Although serum LDH profile assessments cannot prospectively benefit clinicians in their admission decision-making, the findings presented in this study suggest that watchful patience rather than early intervention seems prudent when there is uncertainty regarding whether active labor has begun. Such patience may allow the time needed for important physiological changes within uterine muscle to more fully manifest.



Diagnosis of Labor: a Prospective Study

Antonio Ragusa, MD; Mona Mansur, MD; Alberto Zanini, MD; Massimo Musicco, MD, PhD; Lilia Maccario, MD; Giovanni Borsellino, MD

Accurate diagnosis of the onset of labor remains a problem in obstetrics.  . . . An incomplete understanding of labor may lead to unnecessarily early intervention.



The Effective Labour Contraction - I don't like to assess contraction strength because it involves putting pressure on a contracting uterus, and this doesn't feel good.  I also agree that other signs of progress are more useful.  I check to see if her nipples are erect, which is a sign that these are oxytocin contractions instead of adrenaline contractions.  And, by the way, some toning contractions can feel very hard to the touch, but they're not effective in opening the cervix; their benefit is literally to tone the uterine muscle so it's powerful for labor/birth/postpartum.

Management of Protracted Active Labor With Nipple Stimulation: For Midwives?


ACOG Releases Report on Dystocia and Augmentation of Labor by Genevieve W. Ressel from American Family Physician - March 1, 2004


Vaginal Delivery Possible Even If Active Phase Labor Arrest Exceeds 2 Hours [Medscape registration is free]

Because oxytocin-augmented labor proceeds more slowly than spontaneous labor, 2 hours of active phase labor arrest with at least 200 Montevideo units is not a rigorous enough criterion for cesarean section, US researchers maintain in the October issue of Obstetrics and Gynecology.

Active phase labor arrest: revisiting the 2-hour minimum.
Rouse DJ, Owen J, Savage KG, Hauth JC.
Obstet Gynecol. 2001 Oct;98(4):550-4.


Leilah McCracken wrote a response - So Whose Truth Will You Seek Out? Whose Birth Will You Choose to Give?  [Ed: birthlove.com is not available at this time.]



General



DeLee (Principles and Practice of Obstetrics) speaks of some odd things now abandoned -- packings, colpeurynters, bougies etc. -- and of other techniques such as amniotomy, ambulation, enemas, and pituitary preparations still used today.

But this was a new one for me - - "a hot water bag to the fundus"; Has anyone ever tried this one?

He also discusses a "trick" we've used on occasion. He describes it better than I could!

"Occasionally in a primipara, the head will be deeply engaged, but the cervix is far back in the hollow of the sacrum and very thin, the membranes are tightly stretched over the head and there are no forewaters . By pulling the cervix gently to the middle of the pelvis, separating the membranes around the lower uterine segment for 2 inches, and pushing up the head a little to allow some liquor amnii to run down and make a pouch, the mechanism of labor is started right and the pains improve at once."

I think this is what is often accomplished when we refer to "massaging the cervix" etc.....

He also says a "hot milk and molasses enema" is "very effective".



Biochemical Basis for Dysfunctional Labor



Lactate implicated in dysfunctional labor
Source: Obstetrics & Gynecology 2004; 103: 718-23


This would explain some of the old "wisdom" about using pitocin.  Sometimes it seems to become less and less effective, and you need to stop it altogether, take a break, and then start it up again later.


Possible New Clue to Higher Cesarean Risk in Obese Women
Obese pregnant women may have weaker contractions

Explanations for the undeniable and significant difference in the cesarean rate in obese women can be controversial and debatable.  The real reasons probably lie somewhere in between all of them.  But a recent study published in the British Journal of Obstetrics and Gynecology adds another possible explanation to the pool:  inadequate uterine contractions, possibly due to high cholesterol.  More research is needed, the study authors state, to confirm this link, and to determine if lowered cholesterol might also lower obese women's risk of cesarean section.
[Summary from ICAN eNews



Mother Holding Baby Back



"Cervical dilation and effacement are produced from vertical fibers in a relaxed woman.  Stress causes horizontal and vertical fibers to contract, creating non-productive first stage labor."  [Osborne-Sheets, C. Pre-and Perinatal Massage Therapy.  Body Therapy Associates, 1998.]


From a story about "quilling" a woman nearly completely dilated with strong contractions coming only every 6 or 7 minutes and little progress:  "Quilling" was apparently using a quill as a tube to deliver cayenne pepper - imagine using a regular straw.  Dip one end of the straw into cayenne pepper, insert the other end into the woman's nostril and give a big blow.  This will cause sneezing that overcomes the woman's pelvic floor resistance to allow the baby to descend into position to be born.  [Some might argue that this is interfering with the normal lull between transition and pushing.]


About 10 years ago I was assisting a 70s era DEM at a home birth in the hills above Los Angeles.  Our client was a primip who was complete and pushing - and pushing - and pushing.  It was beginning to look like we were going to need to transport for forceps or vacuum as the contractions were getting weaker and weaker.  The MW asked me if I had any tricks up my sleeve - all I could remember was that the MW who attended my own home births had mentioned that cayenne was a uterine stimulant.  I couldn't remember or hadn't learned what dose, what route, etc. - but we figured that we had nothing left to lose and could always transport (actually the sr MW had been on the phone once already to her OB consultant).  Dad put a teaspoon of Tabasco (which is really just aged vinegar tincture of cayenne!) in an ounce of chicken broth, and mom chugged it down.  In 5 minutes we had stronger contractions and mom proceeded to push the baby out in about 25 minutes.  Oh, and she had tears running down her face and the clearest sinuses in the world!



Chinese Medicine for Dysfunctional Labor



Chinese Medicine for Dysfunctional Labor



Essential Oils



Geranium is good for uterine inertia and any uterine probs. I've got some good stories about that. Just rub on lower ab. and lower back.


when i was in labor with my daughter, jasmine oil massaged into my feet did WONDERS!!!!! one of the properties of jasmine is to lift the spirits of the laboring woman, and renew her confidence.



Addressing Anxiety



Ina May Gaskin says: Put your hands on both sides of her hips (on the fat) and shake your hands up and down quickly (moving her fat, not rubbing her skin) so the fat jiggles. It makes your whole pelvis relax. Use words like "pudding" "Puddle" or about something melting.


ENERGIQUE (phone 800-869-8078) is a company in Iowa that makes different herbal singles/combinations and homeopathic singles/combinations. I use their "ANXIETY HP" homeopathic tincture (30x combination of arsenicum, phosphorous, pulsatilla, lachesis, ignatia, kali carb, cal carb, nat mur). In my experience, it has worked nearly every time I have used it by immediately stopping the woman from being hysterical, calming her, allowing her body to do its work without her tension making it more difficult. I have felt the energy in the room change dramatically when she uses it. I am also a fan of WISHGARDEN HERBS herbal combination "CENTERED MAMA". It contains Valerian, Wild Lettuce and Lobelia, and works to calm down a hysterical mama very well in ways that the same herbs singly don't seem to match. (WISHGARDEN, PO BOX 1304, Boulder, Colorado, 80306).


I second this recommendation!  I've seen women having strong, painful, adrenaline-based contractions for hours with no progress, and then, after a dose of Centered Mama, they calm down, we get a progressive labor pattern, and a baby within a few more hours.  I love Centered Mama!


Or you could try a homeopathic muscle relaxer - Formula 303 by Dee Cee Labrotories, White House, TN 37188



Acupressure/Spleen 6



I first learned about Spleen 6 10 years ago when a midwife pressed that point during my own labour. Wow! did it ever work! Within a few minutes of her pressing on the point my contractions (which had plateau-d) moved into high gear and my son was born soon after (and I don't think it was a coincidence).

With my own clients, I've found it has the greatest effect with "high risk" women who are having a very long slow drawn-out labour. It really works to increase contractions. But if I stop using the Spleen 6 point with these women, the contractions usually peter out altogether. I have this intuition that, in these cases, pressing the spleen 6 point is not very helpful because it's forcing the labour (pain with no purpose). My friend who is trained in Chinese healing says you must first understand any underlying problems with the labour before you use spleen 6. So, now I make sure we fix any positional problems (i.e. posterior, transverse, etc.) before I use spleen 6.

By accident, I found that pressing the Spleen 6 point will bring on a period. So now I make sure I don't really press hard on my own leg when I'm demonstrating the point in prenatal class!



Enema for Sluggish Labor



Try a milk and molasses enema - or try substituting a cup of peppermint tea.


Well, an old trick here to pick up a sluggish labor is to have mom drink labor tea from both ends (so to speak). You know I'm not terribly impressed with herbs for labor in general, but used this way I think they work "pretty well".

You make up about a quart of strong red raspberry tea, with a few droppersful of labor enhancer tincture (the common mix -- B&B, squawvine ,etc.). Add a good slug of honey. Mom takes a cleansing enema, then a very slow pint of tea PR, and then sips the rest over the next hour.


I had good success with a shot of cayenne in chicken broth; the labor shifted back into high gear immediately.



Stenotic Cervix



A fully-effaced stenotic cervix is amazing the first time you feel it!  It's almost as if it's not really there.  My labor coach client had a bulging bag behind a stenotic cervix; I was checking her at home and felt that she was 8 cm with a bulging bag.  Because I didn't want to risk breaking the bag, I didn't feel around the center at all, thus missing the very thinly defined os.  When we got to the hospital, the nurse also got 8 cm with a bulging bag.  It wasn't until the OB came and did a very thorough check around the edges that he announced it was fully effaced at 1 cm.  Wow!  I could feel that bag bulging under the pressure of the fluid, and it's just amazing to me to think the cervix was so thin that it felt exactly the same as membranes.


Stenosis = a scarred sphincter that won't open. i think some people feel when a q-tip will not go in an os for pap or chlamydia or whatever then maybe the cx is scarred and stenosed. I have only seen one os that would not open for a long time, the 17yo (Deadhead) was in full blown labor contractions and 100% effaced and I finally called in the OB cuz I was concerned, he finally squeezed a laminaria in, which also broke her BOW. an hour later she was complete and pushing.


I've seen one true case of cervical stenosis. This lady was an attempted VBAC, whose first birth had been attempted in a BC with an MD who transported only on threat of death. This was back in the olden days, before the threat of malpractice. She was in rip roaring labor and that cervix never even began to soften. It felt like a non-pregnant cervix of a twelve year old. It was some kind of cervical hypoplasia. Another interesting cervix was a double. One above the other. She started labor at 2 cm's and the second one never opened at all. If I hadn't experienced this I wouldn't believe it, because both were relatively thinned out. Both ended up sectioned. Both were attempted homebirths. Oh well.


Cervical stenosis can happen from any cervical trauma, and after menopause from atrophy. Since this lady is pregnant I assume we are talking about trauma. I've had two women who had some problem with this after cones or LEEP procedures for severe dysplasia. Both of them effaced just fine, but didn't even begin to dilate, so the exam was really weird - it almost felt like I was touching the baby's head, but it was perfectly smooth, like cervix, just completely effaced. I couldn't feel where the os even was. Both times we looked really hard with a speculum, located the os which was tightly closed, and worked the tip of a small hemostat into the opening. Then we quickly opened the hemostat, breaking up the scar tissue which had held it closed. It hurts for a second, but do it quickly. It's not really any worse than stripping membranes. Both women went from closed to 6-8 cms within seconds once the scar was broken, and went on to deliver normally. One has since had a second child, with no problems.


The Cryo or Leep Procedure often will leave scar tissue which is tough and resilient.  It does not mean however it cannot dilate and in fact, what happens often is that the cervix with contractions becomes thinner & thinner & thinner without opening, until someone puts their finger inside and breaks the scar tissue up.

There is usually some bleeding but no long term harm as far as I am aware. Once a finger goes inside however, it is then  - whoosh - ad the baby comes along pretty quickly thereafter. It can mean a long drawn out labor and if the woman doesn't know this she can get very discouraged.


I had opportunity to work with a woman 3 or 4 years ago who had had a cryosurgery on her cervix. She was my preceptor's client.

It remains the weirdest thing I have ever felt. It felt as though she were complete. I could feel fontanelles and sutures clearly..even the hair on the baby's head. But the actual os ( wasn't sure it even was the os) felt like a tiny ring about the size of the hole in notebook paper floating on the surface of the baby's head. With some massage and stripping she dilated just fine. But I have often wondered how much danger is involved in this situation.

If a woman has a cervix that is staying closed, and her labor is progressing without her cervix and she is effacing like that...how does that affect the possibility of lower segment rupture if allowed to continue without progress?


When I was apprenticing, I attended the birth of a G3P1 who had an uncomplicated SVD with baby no. 1, followed by abnormal PAP and conization, SAB, and her current pregnancy. For several hours, I don't remember how long, but not long enough to cause concern, she was dilated 1-2cm with a paper thin cervix in early labor. When the course of labor changed, the picture didn't add up. She acted like she was in transition, yet her cervix remained virtually unchanged. Over the next few hours, after all the usual position changes, shower, and EPO, nothing changed. We began to wonder if the conization had left her with some cervical adhesions that were holding the cervix up. To make a long story short, my supervising midwife recommended manual dilation. I stretched the cervix just to see how pliable it was and it began to dilate!!! As long as I manually stretched it, it dilated.


My experience with these stenotic cervixes (which can be a result of conization, previous instrumentation of any type, hysteroscopy, TABs, etc.) is that they remain paper thin and anywhere from a dimple to 2 cm. and feel very rigid after many hours of painful labor. I deal with this by forcing one, and then two, fingers into the os. The stenotic scar tissue will disintegrate under this type of pressure and the cervix will immediately go to 3 cm. It's a remarkable and dramatic change. After this, progress is usually normal and no further manipulation or intervention is needed. I've encountered this situation many, many times. This problem does not recur in future births unless something happens to scar the cervix shut once again, but it's rare in multips.


Management of postconization cervical stenosis by laser vaporization.
Luesley DM, Williams DR, Gee H, Chan KK, Jordan JA
Obstet Gynecol 1986 Jan;67(1):126-128

In 18 patients with symptomatic cervical stenosis after conization, laser vaporization of the stenotic segment was performed. Total relief of symptoms was achieved in 12 patients and partial relief in four. In seven cases there was no evidence of stenosis at follow-up, and in a further nine cases the degree of stenosis was less. In seven cases it was possible to visualize the squamocolumnar junction at follow-up. This had not been possible in any cases before the procedure. Vaporization using the carbon dioxide laser provides a useful conservative management technique for  ostconization stenosis.


It is not unusual to find hard spots on the cervix during examination of a woman in labor. If the woman does not have condylomas, most often what you are feeling are small cervical scars from previous births or gynecological procedures. The use of instruments for dilating the cervix or delivering the baby often causes small tears to occur, as does pushing a baby out prematurely (before complete dilation). These adhesions most often will break down during the active phase of labor. If you feel they are causing a lack of progress (the woman remains at 5-6 cm for over an hour), you might consider simply pressing the adhesion against the presenting part during a contraction. You will feel the adhesion break up under your finger. This causes no pain and readily resolves the problem. There may be a spot of blood as this is done, but this is of no concern. The labor will usually progress rapidly after the adhesion is gone.



Very Stretchy Cervix



There's a type of cervix that stretches amazingly under your fingers, even with a weak or irregular labor pattern.  Sometimes the labor stalls out altogether. Have any of you come across cervixes of this type before?  How did you measure them and what did you tell your client?  How did they end up? ( always baggy to the end, finally stretched, etc..?)


On occasion. They are kind of neat. Sometimes these women are so stretchy they can open to nine or ten centimeters with a slight stretch of your fingers. Sometimes they even rest there at 8 cms or so and can walk around for days or weeks.

I finally learned (after many experiences with false labors and stalled labors , and many times of rushing to the home because I thought the baby would be born within minutes, etc.), that these women are different, and we should measure their cervix in a different way. Their cervical dilation is irrelevant to their labor. They can be at 8 cms with contractions and then completely quit. Their cervix may even go backwards and tighten up again. They may get to where they seem to be fully dilated and then quit contractions. Or they can have labor and go from 4 to 9 in one contraction. I think the type of contractions they have is really important --- because it's the type of contractions they have which gets and keeps labor going -- not the dilation of the cervix.

Eventually all of these women had normal labors -- usually about two hours. It seems as if they just went into "real" labor without all the preliminary stuff. And the babies really didn't fall out like we thought they might - -mom still had a couple hours of labor. A couple of them had many bouts of start-and-stop-labor--- I remember one woman who we spent several overnights on several occasions when she finally went (or stayed in) the real thing and had a two hour labor, but she'd been "nine cms" for a few weeks and on a couple of occasions I thought we'd see a baby within a few minutes!

To me the key seemed to be the type and quality of contractions. In all of them so far they were completely unpredictable until they started having strong contractions well over 60 seconds long. Anything shorter than that could peter out and stop at any moment.

And I also found that I think it's best to discount the cervical dilation with a loose and baggy cervix - -unless it is also well thinned (thinning seemed to be the key with some of these women).  [The loose and baggy cervix may be the "shirt sleeve" cervix associated with an ill-fitting or malpositioned head.]

I've also known people to just AROM with these women when folks get tired of feeling like they are "always on the verge of labor but the baby will never come" (I say of course the baby will come and true labor will begin). It's too much stress for some midwives and for some moms. They are frantic about being so far dilated and not in labor -- or of being in start-and-stop labor -- and they can't handle it emotionally and some will go for induction (home or hospital). If AROM she will probably go into labor, but she might not and she is disposed to malpresentations. Some of the women I've worked with (or known of) handled things very well. Others got stressed out -- and we all ended up wishing there'd never been a cervical exam in the first place! 


I have had women with start and stop contractions who walk around half or more dilated for weeks.  The key is the word 'labor'.  If labor stops I walk away.  I have also found that women who have stretchy, thick cervices and are 4 cms, may have taken something to initiate labor.  If that is the case, again, I go home.  They will deliver in a few days, usually.

> Their cervix may even go backwards and tighten up again. They may get to where they seem to be fully dilated and then quit contractions.

Again, I have only seen that with women who have taken something to initiate labor.  And I have only had 2 ladies who got to full dilation and quit.  Both wanted to push their babes out in hospital.

> To me the key seemed to be the type and quality of contractions. In all of them so far they were completely unpredictable until they started > having strong contractions well over 60 seconds long. ANything shorter than that could peter out and stop at any moment.

I agree.  Fooling around with irregular contractions is nothing but trouble.

> And I also found that I think it's best to discount the cervical dilation with a loose and baggy cervix - -unless it is also well thinned (thinning seemed to be the key with some of these women).

Thinning of the cervix, to me, is the true key.  During a contraction you can gage that on a VE.  During true labor you can feel it thin. If not, I ask her what she took :0).

Yes, both midwives and docs AROM with the 'hope' that it will "get things going".  BIG mistake.  Membranes should never be ruptured until the women is close to birth with strong contractions where there is no doubt that she will continue. I have talked with midwives who have ruptured membranes at 8 cms to get stronger contractions but instead all labor stopped.

Here's a scenario, tell me if I am off.

Your lady started in labor.  Good chance she was already taking or began, with labor, taking something to 'move her labor along'. Nothing was moving along so the midwives encouraged her to take blue cohosh, B&B labor extract or whatever.  Finally she is up to 6-8 cms, between contractions (not checked during).  Then somebody AROM'd the lady thinking it would move her along and then tried different positions to hopefully correct whatever was slowing her down. Finally, everything stopped.

Midwives have been there wayyyy too long and now everyone is exhausted, but all vitals are good.  Transport.

Wanna know something that is rather interesting?  If you had given her 2 ms of pit say, 4 hours after you got there and without doing AROM, contractions would've ceased immediately and she would have fallen asleep.  Two days later she would have delivered just fine.

I have done VEs on the stressed out ones.  Sometimes they get mad at me because I will not push them.  If they want pushed into labor I tell them to go to the hospital. 


Yes. Not that infrequent.

I do a VE upon arrival and then again 30-60 minutes later during a contraction.  Those, in my opinion, are the most accurate.  I do the 2 VEs because it tells me how fast, or slow, she is moving.

Those 'baggy' cervixes in a multip are corrected by themselves fairly quickly, once mom pushes.  With a primip not always so.  That being said, I have intervened when needed.

In all cases when I ask the mother if she is feeling the contractions at the top of the uterus she will say no.  I supply those contractions and the birth is over.  there are 2 ways to supply such.  One is with a couple of drops of pit and the other is with fundal pressure applied while mom is pushing.  With the pit the birth should be over within 1 


But you do this only if mom is actually having good contractions right? You wouldn't do if if contractions have almost stopped or are few and far between or short (under sixty seconds)? Or does the contraction pattern matter? 


The contraction pattern is everything!  If the lady is having contractions 10 minutes apart or less (yes, I have had some ladies whose contractions never got closer than 10 minutes but that was before I intervened), thinned out with head well applied to the cervix, good bloody show in OBVIOUS labor, I will intervene.  When I intervene it is usually over in 90 minutes or less, with most delivering within 20 minutes.

I also many times ask them which hip is hurting?  Then I have them lift that foot onto the bed or chair and lean into each contraction.


I think labors may appear to stall with a very stretchy cervix because the contractions don't have to be very strong to stretch the cervix enough to get the brain to produce more oxytocin, thus setting up a feedback pattern for a feeble labor.  But, even though the contractions are strong enough to stretch the cervix, they're not strong enough to mold the head, so if the baby's head doesn't fit easily into the pelvis, the labor will appear to stall.  I saw this happen with a cervix that was 5-6 cm without a contraction, and then 8-9 cm with a contraction, but the head was still not engaged and very, very round, although there was no caput.  After 28 hours of an irregular labor pattern, we transported for just a little pit for about 4 more hours of labor and 3 hours of pushing.  When born, the baby's head was very molded - 38cm worth!  The baby also had a very large anterior fontanelle and wide spacing of the sagittal suture - not sure if that had any bearing on the labor, though.



Cervical Reversal



I don't think it's the cervix "undilating" as much as a stretchy cervix that changes significantly depending on the flexion, descent and position of the baby's head which, in turn, can be affected by the muscle tension, position and attitude of the mother in labor.

I think anyone involved in birth has seen these kind of changes;  when one exam is less than a previous one, consider what the head is doing in there (and why and what you can do to help it!)


There was a midwifery professor who teaches that there are at least four reasons for the cervix "undilating"....

  1. Exam not done at height of contraction - a stretchy cervix in between contractions may be significantly smaller.  If you really want to know true dilation, you have to do it with a contraction, even though it's uncomfortable.
  2. The position of the head may have changed; this would likely result in a change in station as well as dilation.
  3. Rupture of a bulging bag of waters which was acting as a wedge; cervix will be less dilated after ROM
  4. Cervical edema from involuntary pushing or obstructed labor

You are right, we all have a story to tell about cervical regression.  As we get "older" in midwifery, especially homebirth  midwives, we learn to prepare our clients for this possibility explaining  in advance what will be said.

My very first client was a first time mom transport from the birth center where I was doing my internship.  She labored beautifully and within 6 hours was complete and -1 station.  She pushed for an hour with no progress so I rested her for about 30m and when I checked her again she was 7!  I thought I was crazy!  Within 2h she was complete again and pushed for about an hour with no progress.  We repeated this whole thing for 7 more hours.  When we transported of course she was 7cm upon admission.  About 2h later, you guessed it, she was complete and pushing.  Well.....................she made no progress and regressed to 7!!!  I was sooooo glad she did that at the hospital too!!!!  They repeated the scenario with her for another 7 hours and finally sectioned her.

One thing for sure, I was very convinced of the possibility of cervical regression when the presenting part does not move down to give consistent pressure.  When this happens, I believe the uterus (without pitocin) gets tired and allows regression.


The stress of transport will often cause a cervix to reverse in dilation.


I've done 8, soft and stretchy, and back to 6 and rigid when mom got scared by a sudden dip when nurse was listening to FHT while I checked.  I could actually feel it change. Reversed again shortly.

Also had mom who was checked at complete at home by neighbor/midwife, came to hospital (planned to birth there) and was 7 when she got there.


And maternal position really influences this too; to get the most accurate dilation mom probably should be on a firm surface with the small of her back flattened. That's a pretty uncomfortable position in labor and most of the time we end up doing a "quickie" VE -- one reason for varying estimates.


Really? what is the max. I've got a pliable, soft 9+ to a tight 6. Same examiner.


Pliable, stretchy, sl/ puffy 8 to a tight, thin 4 on planned transport for hospital birth, same examiner.


This is a well documented phenomenon - the new MANA dataset of over 24,000 labours (hopefully soon to be published and should give us all some real ammunition against the partogram/alert line business) shows that it is not that unusual. If you think about it, the cervix is 70% slidey collagen fibres but 20-30% muscle, which is responsive to catecholamine production and will contract down when a mother is stressed or frightened - just like an animal will clamp down its cervix and stop labour when disturbed. Many midwives will know this happens when you transfer a mother in from a homebirth for some reason - she may be 7cm at home, for example but by the time you get to hospital and the doc examines her her cervix has clamped down to 3cm... and then the doc looks at the midwife like she's an total idiot...!!!.


I agree that there are at least two separate phenomena that can cause "cervical reversal".  The one I've seen most often is the one caused by the rupture of membranes - the scenario is as suggested . . . the baby's head is not applied to the cervix due to malposition or a tight fit into the inlet, the membranes are intact, and strong contractions fill the balloon "above" the baby's head, effectively dilating the cervix.  Then the waters break (or are broken), and there's no head holding the cervix open, so the dilation reverses.  When I see this at home, I know we need to work on realignment of the head, and maybe consider going in to the hospital for some pitocin.
The other phenomenon - tension causing "the opposing muscles" to tighten up and close the cervix - can be addressed a little more easily - the herbal tincture "Centered Mama", which contains lobelia.

I cannot rave enough about "Centered Mama".  When I see a "primip" whose "labor" starts off with painful contractions 2-3 minutes apart, and the cervix is still closed (and sometimes thick and rigid!), I know she's scared out of her mind, and the adrenaline is racing.  In addition to sensible support/comfort measures, I'll give a dropperful of Centered Mama every 15-30 minutes until the labor pattern normalizes a bit, usually shifting to longer contractions 5 minutes apart, and then gradually getting closer to bringing a baby.


Rupturing membranes is a very common cause of cervical reversal. Many Healthcare professionals seem to believe that this speeds up a slow labour but there is no evidence that justifies this procedure in a labour that is progressing well.



The Transport Maneuver



Sometimes it seems like you can go a few hours with a stall in labor, and then you get to the hospital and find that the cervix has opened and the mom is ready to push.  Maybe we should just get her in the car and drive around a bit?


Had a birth like this in January. Baby was caught up tried many different positions, finally she decided to go in. As we were in the mountains and about 45 minutes from hospital we left, as we got to the end of the long mountain road to the freeway he stopped the car. I got out and asked if all was okay and he said NOOOOOO so I said to park under bridge out of the snow (as it was snowing) when I opened the back door the baby's head was there. I caught baby, wrapped baby in a blanket and we went back up the hill to home.

Every time I pass that spot on the freeway I think of his birth.

So sometimes moving and going over rough roads will get things moving again.


Very true.  It's one of those effective “Tricks of the trade” we've all seen work.

I've often wondered though if it's the physical effects of movement, or whether it might partially be due to the psychological effects on the mom.
When the woman who is having trouble in labor  is finally “on the way” to the hospital, she may experience an unconscious relaxation or release. She knows/believes she is going to get help – and there may feel a reduction of fear and anxiety.  Some women literally have a sense of giving up – surrendering. The contractions often cease. And sometimes – this is exactly what's needed.

Then  factor in the additional time it takes to travel and slip into the hospital scene, and we often find the trip to the hospital got the baby born!


I think these work because probably the baby was asynclitic and the side-to-side and back-and-forth and climbing in-and-out moves the baby and the baby aligns itself better.  I have seen it work....last year had a baby born in my car on the way to the hospital.


Maybe the position of sitting in a car is a good position for some women for getting the head fully into the pelvis?


Maybe the adrenaline levels climb with the change of scene, the cold, the anxiety about going into a hospital where she doesn't know anyone?



Friedman's Research Flawed



Active Management with Pitocin Does Not Reduce Cesarean Rate


This is in response to an old post (I am slowly catching up), which put me in mind of Friedman's original article, giving times for labor and birth, which eventually resulted in a "standard of practice" firmly stating that women who go beyond the time table are risking their health and that of their child. Interestingly, I have heard a rumor that Friedman has repudiated his research (or at least it's inappropriate application from and observation to an edict governing labor "management"); kinda puts me in mind of the guy who "invented" dynamite, never foreseeing the terrible consequences. Wasn't he Nobel, of the Peace Prize, trying to make up to humanity for the terrible harm his "discovery" caused, putting the profits into stimulating/rewarding humanitarian behavior?

Anyways, I digress. I happened upon a copy of Friedman's original work (which is at home right now, and I, sadly, am not, so sorry no reference), and from memory I can state with certainty that there were a) only 100 women in his sample b) 86% were "delivered" with forceps c) I can't remember the number of cesareans, but I remember thinking that 95% of the babies were "delivered" rather than pushed out d) almost all of them had "medication".

What shocked me so much in reading this was the brazen attempt to use this observational study to draw conclusions about how long the second stage "should" be when the majority of the study participants were a) under the influence b) "helped" along by the use of instruments. Is this research-based clinical practice???????

What a joke !!!???? But not actually very funny considering the vast number of women who have been forced to undergo surgery because they "fell off" the Friedman curve.

I say it is high time we "re-evaluate" the "norms" for labor. A CNM has started the process (I can't remember the name) by recently publishing a report on the length of labor and birth among low-risk women in a hospital setting, that was published (if memory serves) in OB/GYN (the green Journal). We need this sort of evidence to back up our practice, not only to "allow" women physiological labor without unnecessary intervention, but also to cover our butts, legalwise.


Dr. Leah Albers is that CNM writing in The Green Journal in conjunction with Dr. Melissa Schiff and writing in JNM as well. She is from the University of New Mexico and I am PROUD to say I collect data for her! She comments in her oral presentation of this information that no-one has been able to duplicate Friedman's curve and that in his information he describes "Data cleansing" wherein he got rid of stuff that didn't fit ;0. The WHO data and several other studies describe a curve that isn't ;). It seems to be a more linear process which demonstrates a need for more time to complete the birthing process than Friedman describes as the END point of normal.

Our data base is from a three center study, All CNM practices, All "normal" or low risk birth. A slightly different population than that described by Dr. Friedman......

 




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