Asynclitism is diagnosed when the suture lines of the fetal
skull are not felt to be aligned exactly halfway between the symphysis
pubis and the sacrum. If the baby's head is tilted up toward the pubic
bone, it is called anterior asynclitism; if tilted toward the mother's
sacrum, it is a posterior asynclitism.
If the baby is not deeply engaged in the pelvis, the head
may be adjusted by the midwife manually lifting the baby's head upward
if posterior or moving it downward if anterior. Having the mother climb
up and down a flight of stairs may easily correct the asynclitism. If
no stairs are available, suggest that she duck walk: while being supported,
the mother bends her knees, broadens her stance, and walks, swaying
from side to side, rotating her hips out and forward. Another trick
as demonstrated by Penny Simkin is to have the mother place one foot
on an elevated surface, with the lifted foot higher than the other knee.
This position is held for several contractions and then the alternate
leg is elevated. I once had an interning midwife who thought the stair
thing was really silly. When she returned to her practice, the second
woman she was assisting had a marked lack of progress, and when it was
determined that the baby was asynclitic, the midwife thought, Well,
let's try it, since the mom was on the second floor of her home. "Stuck"
at six centimeters, the mom made it down the stairs and promptly delivered
her baby right on the stairs, halfway back up!
These techniques will help reposition the head in cases
of incomplete flexion and military presentation as well. Don't be afraid
to use your hands to adjust those crooked little heads.
- Valerie El Halta, Midwifery Today Issue 46
E-News asked readers, What do you do when the baby's head
is not deeply engaged in the pelvis, but is tilted up toward the pubic
bone or tilted toward the mother's sacrum?
Leave the water intact, generally my advice anyway, if there
hasn't been spontaneous rupture of membranes. Mom should move around,
getting in different positions that help the baby turn: squat flat-footed
(increases the diameter of the pelvic outlet as much as 10-20%), assume
hands and knees position, side-lie (one side and then the other), sit
on the toilet, sit on a birthing ball (bouncing or moving side to side),
put one foot up on a chair and lunge, slow dance (arms around partner
and swaying back & forth). I call it "jiggling the baby into
- Donna, CBE, RN, SNM
Asynclitism is best found when the baby isn't deeply engaged,
for that is an excellent time to wiggle the baby's head to a different
presentation. The book Heart and Hands (Elizabeth Davis) describes how
a woman can kneel with one knee up, one knee down and "walk"
on her knee. This helps maneuver her little one.
My midwife, Susan, gets the mother into knees and chest
position for a few minutes. With hands on the sacrum/lower back, she
sways the mom's hips. This will unstick a malpresenting baby.
- Connie Dello Buono
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At what point during pregnancy is a placenta truly considered to be
getting old? What are the signs? What are the risks? I am familiar with
the tests performed to come to this diagnosis. How accurate are they?
Are they necessary? My true feeling is that a healthy mom will go into
labor when her baby is ready. I am a doula who is frequently experiencing
scheduled inductions because a mom is told that her placenta is old. This
seems to be happening even with moms who are barely two weeks post date.
To share your thoughts and experience, go to Midwifery Today's Forums.
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Question of the Week
A friend suffered with obstetric cholestasis in first pregnancy from
32 weeks and baby was delivered at 36 weeks, fit and well. Now on her
second pregnancy it has returned at 16 weeks. At present although she
has high phosphate levels, bile salts are not being deposited in areas
causing risk to the baby. Does anyone have previous knowledge of this,
and any advice, comfort to offer?
Send your responses to:
Question of the Week Responses
Q: I was very ill with Grave's
Disease (hyperthyroidism) after my third pregnancy, took an anti-thyroid
drug for a year, and have been in remission ever since. I had three wonderful
homebirths, but wonder if for future pregnancies I would need to be monitored
by a doctor and if I am likely to have thyroid trouble during the pregnancy.
A: I am a family physician who strives to
follow a midwifery model of maternity care. I also occasionally back up
a homebirth but have not yet attended one. I recently saw a woman who
is planning a homebirth with a local nurse midwife in attendance and has
a similar history. After doing some research and speaking with one of the maternal-fetal medicine specialists in my medical practice group,
I learned the following:
Women with a history of thyroid disease, particularly Graves' disease
(it can recur and also can be followed by hypothyroidism, which is an
under-functioning thyroid), have nothing to lose by obtaining thyroid
testing (TSH, T3 and free T4) early in the pregnancy. Better yet, I would
recommend preconception testing, as the baby is most sensitive in the
first third of pregnancy. Undetected thyroid disorders where there is
either over- or under-functioning can be insidious, have profound negative
consequences on growth and proper brain development, and, most importantly,
can be treated successfully in most cases. If the thyroid testing is within
normal levels and the woman has no symptoms, then that's that....
....Except with a history of Grave's disease. Because Grave's disease
is essentially an autoimmune disorder, people develop antibodies against
thyroid tissue as part of the illness. Usually these levels drop dramatically
with treatment, but not always. Checking for blood levels of anti-thyroid
antibodies is easy to do once sometime during the pregnancy or prior to
If there are detectable levels of antibodies, then, as we all know, these
can cross the placenta and, theoretically, attack the fetal thyroid gland.
The OB explained that this can lead to fetal goiter (an enlargement of the thyroid gland), which could cause problems with breathing and require
aggressive airway management (possibly intubation) at birth. She stressed
that she had never seen a case and would first obtain a third-trimester
ultrasound looking for such a circumstance--only if the antibody levels
in the mother were elevated.
By the way, the woman I saw had normal thyroid functioning and negative
antibody levels. Hope this helps address your concerns.
- Meg Parker, MD
A: My husband had/has this disease. He was
ill for about six months and lost about 50 pounds before we figured out
what it was. We had to fight the doctors to avoid radiation treatment
to kill part of his thyroid to reduce function. A doctor finally (reluctantly)
agreed to put him on medication to lower the thyroid levels, and warned
us that *IF* it worked (there was only a 10-15% chance), he would have
to take it for the rest of his life (and the radiation treatment was so
much quicker and easier and more effective....). He took PTU for about
two years (after about six months he became very lax, taking only about
half the doses), then weaned himself from it completely. He has been off
it for about a year and is healthy, and his blood work shows his levels
are fine. We are glad we did not kill part of his thyroid when it wasn't
I do not know specific implications of pregnancy, but I do know that
hyperthyroidism is easier to control, and likely completely possible to
get rid of, than the doctors will admit (not to downplay its dangers).
He still avoids excess iodine because it encourages thyroid function,
and medications like Sudafed because it can cause excess thyroid function
as well, and we'd hate to encourage a "relapse." But he has
had no further problems with it.
Coming E-News Themes
1. An E-News reader submitted the following description of her concern
for hospital-birthing women. Please share your thoughts on this issue,
and let's get some problem-solving dialogue going: I AM A MIDWIFE WHO
ATTENDS TO THE NEEDS OF WOMEN BIRTHING IN THE HOSPITAL. I would find it
useful and interesting to include "ways to inspire confidence and a sense
of the inherent power and brilliance" of women into the Midwifery Today conference section on women who care for women in the hospital. I work
hard at this endeavor every day....I fully support homebirth and would
love to see a movement to take normal birth out of the hospital and into
the home. [But] there are women who don't have a home suitable for homebirth....I
hope there will always be midwives willing to attend these women in the
hospital....There is a strong need to remind midwives why they are midwives
and ways to bring those midwives back to the fold. Comments? -Zora
2. PRECONCEPTION COUNSELING: What do you tell the aspiring parents who
ask you for preconception services/advice? (Thanks to Sarah, an E-News
subscriber, for this topic.)
Send your responses to:
Know a strong woman? Helping empower one? If you haven't already done
so, please forward this issue of Midwifery Today E-News to one or two
of your friends or business associates. Thanks so much!
Question of the Quarter for Midwifery Today Magazine
How can midwives best facilitate the bonding process of motherbaby in pregnancy, birth and postpartum?
Deadline: March 31, 2001
Send your response to email@example.com
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In response to Tiffany Collins's "confusion" about
the difference of "opinions of outcome" between different caregivers
(midwives, OBs, etc.): I think sometimes obstetricians give an opinion
based on the personal experience he/she has had and not on the professional
dogma of the AMA. Obstetricians often see many of the most high-risk women
birthing, those who probably would not be attended by a midwife, as well
as those with very bad prenatal care (unfortunately many still exist in
spite of the available resources) and many other situations, so the ideas
they develop about birth are different.
On the other hand, there is the extreme among midwives as well. I think
that "too much" of anything isn't a good idea. The ideal way
to learn and live is to develop the intuition of being able to see the
best of all situations and learn from it. This avoids boxing up hospital
birth practitioners (ob/gyns, CNM, doctors etc.) as part of the dogma,
and developing the humility to learn even from those you deeply and innately
disagree with. This also promotes unity among birth caregivers instead
of the typical groupies of midwifery, doulas, CNMs, OB/GYNs, etc. Humility
(to be humble) is the best way.
Also, in reference to having a doula and a midwife at births (Issue 2:44):
Be they home or hospital, there is marvelous potential to create a very
powerful caregiving team with a midwife and a doula as the caregivers.
They each have their own specialty, health care, and emotional care, assuring
that the mother is safe, loved and protected during her birth experience.
I don't know how much conflict there is between doulas and midwives, but
I sincerely hope it isn't prominent. If we as midwives and doulas maintain
the humble delivery of love and care that is part of our ideal, conflicts
will melt like snow.
- Megan Aiyana
Could it be possible that evening primrose causes constipation? I've
never experienced constipation before, but since I'm pregnant and take
EPO, I have some difficulties with this.
I am trying to locate the international ranking for infant mortality
and morbidity. Where is a website that I could find such a thing?
- Nikki Lee RN, MSN, Mother, IBCLC, CIMI
Elkins Park, PA
It is not known what causes preeclampsia/ eclampsia [Issue 2:50], but
we know that poor nutrition can be a contributing factor. A primip is
more likely to develop the symptoms than a multiparous woman, unless the
pregnancy is with a new father. Then statistically the woman is as likely
to develop symptoms as a primip. With good prenatal screening, excellent
nutrition, and acute awareness on your part, there is no reason that you have to go to a high-risk physician. I have cared for many women with
histories such as yours throughout pregnancy, and have been with them
for delivery of their babies at the hospital. You'll have to check with
your local homebirth midwives to see what they are comfortable with.
- Carolyn, CNM
In response to your question concerning the wife of an obstetrician who
had unexplained premature rupture of membranes (PROM) at approx. 35 weeks
gestation: I am an RN in an L&D unit. One of our patients had PROM
at 29 to 32 weeks with each of her pregnancies. She would then deliver
a premature baby that required months of care in an NICU. The fourth time
this happened the newborn definitely had a large scratch on the top of
his head. It was finally discovered that she was intentionally rupturing
her own membranes in a "Munchausen by Proxy" type of response
to a mental illness. I am not saying that the patient you are caring for
also ruptures her own membranes, but I do find it interesting that she
is married to an OB and would have the knowledge and equipment necessary
to perform such a procedure. She would also be aware that her baby had
a pretty good chance of a good outcome at 35 weeks and might consider
this a way to skip the last month of pregnancy and deliver a smaller baby.
I read with interest the questions and comments of many of your readers
who mention medical issues that have arisen during their pregnancies (such
as thyroid disease or diabetes). Many of these women are on their third
or more pregnancies and wonder how to prevent the problem from occurring
the next time they conceive. Have any of them considered that the medical
problems might be nature's way of telling them it is time to stop having
babies? And the only way to prevent serious medical complications from
occurring again is to not get pregnant anymore?
While I would never presume to tell other women (or want anyone to tell
me) how many children they should have, I wonder if anyone else is considering
the ramifications of having large families, not only to their bodies and
their families (whom they must care for and who care for them when they
are ill) but to the environment in which we live? My husband and I are
very concerned for the environment and climate change and after much discussion
decided that two children gave us a full parenting experience and was
a responsible, lower-impact number to add to the population mix. The effects
of humans on the environment and the need to reduce the population of the earth have been well established.
My midwives and doula included birth control discussions/population issues
and the impact of multiple pregnancies as part of their childbirth education.
Do any other midwives do the same? Shouldn't it be a moral obligation
to discuss it with clients? Even if only for the safety of the woman and
the children she would have?
- Anonymous student
Although most doctors are scared of the scenario of VBAC with a vertical
incision [Issue 2:50], they weren't 40 years ago! I was born 44 years
ago by c-section. I was breech, the OB was an expert at external version
and tried it a few times but I wouldn't turn. She suspected a short and
tangled cord so she was worried about a vaginal birth. She delivered me
by c-section (the cord was short, and tightly wound around my neck), then
assisted my mother with a vaginal birth two years later. I think when
we are trying to do something which the medical profession finds too scary,
we have to rely on anecdotal support because there aren't so many medical
Comments about bags breaking early reminded me of my first pregnancy.
A cold started the same day labor started. Lack of vitamin C makes tissue
less strong--my water broke, which started the labor process, the only
time it did out of all five pregnancies. But worst of all, a whole batch
of ugly stretch marks popped out on my last day of being pregnant! I never
got a single stretch mark with the other pregnancies. So keep the vitamin
C up for strong bags, stretchy skin and tissue flexibility. I also tore,
which never happened again either.
- Kathy Galbraith
Having been a student in the field of women's studies and preparing to
be a first-time mom any day now, I do not feel that breastfeeding is an
issue of empowerment to women or of tying us to the home. For one who
has chosen motherhood, it is necessary to seek what is best for our children.
The American Pediatrics Association stands by breastfeeding as being the
most beneficial to our children. Even though certain health benefits have
been documented for nursing mothers, it is not a matter of what is best
for the mother, but what is best for her child. That the choice we make
when we choose motherhood.
- Serena DeGarmo
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