Transverse Lie
Editor's note: We received so many responses to the question
about transverse lie [Issue 3:3] that we decided to dedicate this issue
to the subject.
[In the case of a transverse lie] If precautions are not
taken, when labour begins the fetal shoulder may be forced down toward
the pelvis. The membranes are likely to rupture early and the cord to
prolapse, while in addition the fetal arm may also prolapse. A midwife
would recognize shoulder presentation by abdominal examination, and
by vaginal examination, when the shoulder is recognized by feeling the
fetal ribs and the hand (to be distinguished from the foot because she
can 'shake hands with it'). Vaginal examination is best avoided unless
placenta praevia has been excluded.... The more advanced the labour,
the more difficult it is to correct the lie; after the membranes have
ruptured it may be impossible.
A midwife may find...after the birth of a first twin that
the second child is lying transversely. Immediate action is necessary
and she should correct the lie by external version and rupture the second
bag of membranes, thus stabilizing the longitudinal [head-down] lie
and hastening the birth of the child.
- Mayes'
Midwifery, Betty Sweet, ed,1997, Balliere Tindall
====
Persistent transverse lie is much less common than breech
presentation, occurring in only 1 out of 500 term pregnancies. Anything
that prevents engagement of the head or the breech makes transverse
presentation more likely. It is also more common in multigravidas because
of the laxness of the uterine and abdominal muscles. Factors that need
to be ruled out include: placenta previa, multiple anomaly, polyhydramnios,
pelvic contraction, and uterine abnormalities. However, cases do occur
where no such associated factors are present.
The diagnosis of transverse lie during abdominal examination includes
these findings:
- The abdomen appears asymmetrical wider than it is tall
- The fundal height may be small for dates
- Palpation of the fundus and the pelvic areas of the uterus reveal
no fetal poles, which are instead found on either side
- The fetal heart is heard below the mother's navel
- Neither the head nor the breech can be felt during an internal exam
- Anne Frye, Holistic
Midwifery, 1995 Labrys Press
Understanding and Teaching Optimal Foetal Positioning (2nd
rev ed, 1996) by Jean Sutton and Pauline Scott: A succinct and thorough
manual describing the various types of malpresentations that can interfere
with labor. Includes causes, strategies, and treatments. A must-have!
Birth Concepts, Tauranga, New Zealand. Paper, 69 pages. OFP, $12.50
Order
this excellent book
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Midwifery Today's Online Forum
I recently attended a birth as an assistant where there was a moderate
hemorrhage. Since then in discussion it has been mentioned that there
may be a connection between postpartum hemorrhage and decreased milk supply.
This mom feels that she is not producing enough milk. I have seen this
with another birth about a month ago. Both moms are grand multips in their
early 40s. I wonder if anyone else has heard of this connection??
To share your thoughts and experience, go to Midwifery Today's Forums.
Question of the Week
Q: Has anyone had a mom who bleeds excessively?
This mom has done many herbal/vitamin supplements to build her blood and
still has a history of excessive bleeding prior to delivery of the placenta.
As her uterus clamps down to deliver the placenta, there is a significant
gush of blood. Pitocin has been the only thing her previous midwife used
that was effective, but I am looking for an herbal remedy.
- Robe
Send your responses to:
Question of the Week Responses
Q: A friend is due on Feb 8 with
her first baby. She is 5' 4" roughly, average weight, and her baby
has been in a transverse position for the last few weeks. As far as I
know there are no pelvic problems in her history. She has been doing the
"lying-on-the-ironing-board" trick to try and turn baby but
is looking for other techniques. She asked about moxa and acupuncture,
which I didn't know enough about. She is seeing an OB who definitely has
the conservative, surgical mindset. She has an appointment in two weeks
where a decision will be made about scheduling a c-section. I know sometimes
there are reasons that baby stays in a certain position and turning may
not be the best thing to do for baby; however, I welcome any thoughts,
comments or ideas that might help her have a different option other than
surgical birth. She is open to alternatives, so anything is welcome.
- Marisa White
A: I've had some success turning babies using
information from an article called "Turn, Baby, Turn" published
in Midwives, November 1995, pp 389-391. The article discusses turning
breech babies, and illustrates exercises to try.
- Vicky, RM, RN
A: My baby remained transverse until a few
weeks prior to delivery. I used the slantboard, did lots of pelvic rocks
and lots of praying and talking with my baby. I let the baby know it was
getting close to the time for him/her to be born and it was important
for the baby to get into a good position for birth. I also manually massaged
the outside of the womb in the direction the baby needed to take. The
baby turned soon after. I know that talking gently to the baby was very
helpful, along with the other techniques. Babies are very intelligent
and understand what needs to be done.
- Robe
A: As a doctor of chiropractic specializing
in pregnant moms and newborns, I have found that malposition of the baby
is due to an imbalance in pelvic muscles and ligaments, causing constraint
in the mother's uterus and restricting the baby's ability to get into
the best possible position for birth.
I teach my colleagues specific techniques (the Webster In-utero Constraint
Technique) that offer a specific chiropractic adjustment to the mother
and remove constraint to the uterus. The success rate for babies turning
to the vertex position is approx 90%.
Most women have a varying degree of imbalance in their pelvises, some
with enough stress to the muscles and ligaments to cause malpresentation.
The doctors I am instructing not only work with moms later in pregnancy
when there is a malpresentation, but are now caring for women throughout
pregnancy to balance pelvic muscles and ligaments early on so the uterus
is not constrained.
For additional information and/ or a referral for a DC trained in this
technique in your area you may call the International Chiropractic Pediatric
Association at 1 800 670 KIDS or go to
www.4icpa.org
I can be personally reached by email or phone: ohmdc@home.com
or 1 610 891-1190.
- Jeanne Ohm DC
Secretary of the International Chiropractic Pediatric Association
A: Use a pen to perform acupressure on the
outside lower corner of the little toe nail. Do both sides while "doing
the slant-board thing." Also start taking the homeopathic remedy
pulsatilla three times a day (three or four pellets under the tongue).
As soon as the baby turns head-down, STOP all treatments. Assure the baby
and yourself that head down is normal and that the baby will be "held"
close after he/she is out, that it is as "safe and loving" outside
as it is inside. Lastly, know that this will work, know that you can say
"NO" to a scheduled c-sec.
- Jennifer L. West, LM, CPM
Albuquerque Homebirth
A: Moxibustion done by a doctor of Chinese
medicine or someone licensed in acupuncture is effective (at least for
breech babies) around 80% of the time. I've not heard whether it will
turn a transverse, but it doesn't hurt to try.
- Sharon Thornton
A: Turning a baby with a short cord may meet
with little success, but a baby can't be born at all in a transverse lie,
so assistance in position change is required if she wishes to avoid a
c-section. Many doulas know a lot of baby-turning tricks, as do some of
those who practice acupuncture, acupressure and moxibustion. Secondly,
any chiropractor familiar with the Webster Technique will have a very
high success rate. Known for its success at turning breeches, the technique
optimizes the functioning of the uterus, which in turn helps babies assume
a better position for birth. Finally, and not least significantly, mom
should ask her baby what she (mom) needs to do in order for baby to turn
to a vertex position in time for birth. Baby may be holding back if mom
is holding back or is unresolved about something, so getting quiet and
asking baby what is needed, and trusting the answer that comes, may be
all that's required.
- Claire Winstone, M.A., R.C.C.
Vancouver, B.C., Canada
A: Have you considered an ultrasound to rule
out anomalies that might affect the baby's lie? Is this a first baby?
Sally Kane, CPM, LM
A: Why hasn't anyone suggested ECV (external
version) before doing a section? In experienced hands it has an impressive
success rate. If it were me, and maternal positioning had not helped,
my next choice would be to see an experienced OB or midwife and request
ECV, with the understanding that a section may still be needed.
- Jeanne Batacan
San Jose, CA
A: There is a very gentle way to encourage a baby
to turn to a vertex position: use a radio or tape player with earphones.
Put on some gentle soft music (classical or the like--do not use rock
music), then position the earphones low on the abdomen just above the
pubic bone. The baby will often move head down to listen to the music.
It works well most of the time.
Definitely do not schedule a c-section as babies often turn just before
or in the beginning of labor. The c-section choice is always there later
if truly necessary.
- Judy Jones, CPM
A: Have the mom walk on her hands at the pool
in the water.
- Mimi
Canmore
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Switchboard
More on perineal massage [Issue 3:3]: for more information,
search Medline
It's a search engine for the National Library of Medicine, which has information
on just about any (medical/health) topic.
Perineal massage in labor (especially aggressive, prolonged perineal
'ironing') *might* cause the tissue to be more susceptible to tears because
it might irritate the perineum. Perineal massage prenatally *might* help
prevent tearing in women with scar tissue on their perineum. Evening primrose
oil has been recommended as a massage oil to help elasticize scar tissue.
Perineal massage *might not* be 'necessary' in a physiologic sense (maybe
it doesn't actually stretch the tissue) but it could be helpful for some
women as a tool to prepare them for the way stretching sensations will
feel.
- Melissa Jones
====
More on essential oils:
The following list of essential oils, according to the IFA (The International
Federation of Aromatherapists), should NEVER be used [in pregnancy]: bitter
almond, boldo leaf, calamus, yellow camphor, horseradish, jaborandi leaf,
mugwort, mustard, pennyroyal, rue, sassafras, savin, southernwood, tansy,
thuja, wintergreen, wormseed, and wormwood.
Other essential oils promote menstrual flow and/or stimulate the uterus:
yarrow, fennel, nutmeg, aniseed, sage, palmarosa, clove bud, peppermint,
bay, and sweet thyme. There are many other "disputed" oils which
are potentially harmful, but there has never been enough documented evidence
to support or refute these claims.
I don't routinely recommend the use of essential oils during the first
trimester of pregnancy. If essential oils are used at all during pregnancy,
their strength should be reduced to no stronger than half that used for
a non-pregnant woman.
- Alison
====
I am a midwife in Israel. I also have a website in Hebrew about birth
called www.leida.co.il. One of our
ladies wrote a heart-wrenching story about how she has moved to Honduras
and is expecting twins and cannot find a doctor who will deliver them
vaginally, even if they are both head down. Her first birth was totally
natural, and she is heartbroken. She says there are no midwives there
who are willing to help, and the policies are all very interventive. She
would be most grateful if anyone knows of a midwife or natural-minded
obstetrician who will help her deliver her babies vaginally. If any of
you knows of such a person, or how to find one, please let me know via
email at: shemesha@inter.net.il
as soon as possible.
- lana Shemesh
====
More on home and hospital birth:
I have a hospital and homebirth practice. I work with traditional midwives
in my area and have found this to be a mutually satisfying relationship.
We are different, our clients are different. Much of the criticism about
the medical establishment, home vs hospital, CNM vs. traditional midwifery
excludes a significant variable: the clients. It is often like comparing
apples and oranges. Many of my hospital clients have incredible stressors,
years of poor nutrition, alcohol and tobacco abuse. These patients come
to birth with a totally different package than the clients seeking homebirth.
Their pregnancies, labors and births will be different than those of my
midwife colleagues. One cannot be as patient about postdates with someone
who has a pack of cigarettes a day habit. Bed rest, herbs and beautiful
thoughts will not keep a patient with HELP syndrome from thrombocytopenia,
endangering her life. I will be a more interventative with some of these
clients.
It is not that I have abandoned midwifery, I am dealing with the hand
I have been dealt with these particular women. So the next time we make
generalized statements about the management of certain women, make sure
you see the whole picture. There is room for all. There are many different
kinds of women, what they want, what they need, and there are many different
kinds of midwives. Our goal is finding the right fit. It is a mature,
brave gesture for one midwife to acknowledge she cannot be all to everyone
and help women find the right midwife.
- P.B.
====
Thanks to Anon. who recognizes that many hospital midwives not only battle
the system but the women themselves who are uninterested and resistant
to anything empowering [Issue 3:3]. We too have women begging for induction
prior to due dates and many are skeptical that they can birth without
epidurals, or at least some narcotic. The demand for ultrasound in this
population is high and no matter how much a midwife talks about the lack
of medical need for one, these ladies are insistent. I would love to know
where the women are who want a noninterventive pregnancy and birth. We
are also working with a very low socio-economic group who are not nurtured
and are not able to do so themselves. So we do the best we can by caring
and educating and rejoicing in that occasional young woman who, at the
end exclaims, "I did it!" Judge not--you don't always know what
we are working with.
- Elenie Smith, CNM
Alto Pass, IL
====
More on VBAC and cesarean incisions:
I spent time in a Bolivian maternity clinic operated by Canadian missionary
nurses. No doctor was available and the closest hospital was a rough 2-hour
drive away. To send the moms in there was as good as signing their death
certificate. Due to the combination of circumstances, few women were sent
in to the hospital. We usually didn't see these women until they came
to the clinic in late labor. At that time lower segment, transverse incisions
were never done. Classical incisions were the only form done in area hospitals.
We could not send someone in to the hospital just because they presented
in labor with a previous classical incision. So VBACs with classical incisions
were not uncommon and were taken in stride. In all the history of the
clinic, there had never been any kind of complication due to classical
incision! These moms labored and successfully gave birth as though there
had never even been an incision.
Another non-statistic: My aunt was a missionary midwife in Africa for
36 years. She retired in 1975 after nearly 12,000 births. She too worked
without a doctor or hospital closer than 100 miles away. Of course she
had never seen the lower segment, transverse incision. I asked her specifically
about the "dangers" of VBAC and she just chuckled and said a
VBAC was a very safe option. Of course in her experience, VBAC wasn't
considered an "option"--there was no other choice.
I am not advocating doing something simply because it has been done under
such circumstances. Wisdom is still in order. We do not have to set out
to prove our theories at the expense of a mom/baby. But judging by both
of the above situations, I would say VBAC with any kind of incision is
not only possible, but probably very safe and efficient. Of course in
neither of these situations did attendants do anything as foolish as inducing
labor in a VBAC mom, and there was little if any intervention of any sort
in either situation. Labor and birth just proceeded as simply, safely
and efficiently and as God planned that it should, and therefore it was
also successful.
- Elaine, midwife, CBE, doula
====
I had a c-sec with my first baby in 1993 (footling breech discovered
after my water broke). Since then, I've had three wonderful homebirths
and am planning another in August 2001. My c-sec led to an interest in
natural birth, becoming a doula and a childbirth educator. Recently, in
Washington state, and I'm assuming across the country, the birth community
has become very freaked out again about uterine rupture in VBAC women.
I am becoming nervous that if I have any more children, I will not be
able to find an attendant to support a homebirth or even a vaginal birth
because midwives are pulling out of doing VBACs. A woman in my area who
was not a VBAC ruptured, the baby died and mom barely survived. I've seen
a rupture at a birth I attended (lots of Pitocin). Also recently in our
area, two VBAC women in the hospital ruptured without augmentation.
I would like to see more information on any studies currently being done
with VBAC women, and basically any information I can find on VBAC and
homebirth. I'm not afraid to have a homebirth, but it saddens me that
women, even in the hospital, would again be convinced that a c-sec is
the "safer" option for themselves and their babies. I don't
believe that's true.
- Teresa
====
I truly look forward to each installment of the E-News as it maintains
sanity in the medical world in which I practice. I am blessed with the
opportunity to deliver my first grandchild in June, and am curious to
hear from other midwives who have had a similar opportunity. I feel confident
about working with my daughter, but am being exposed to much negativity
from my co-professionals, even the midwives. Help!
- Nona McNatt
====
I have recently been accepted into the nurse-midwifery specialty of the
Master of Science in Nursing program at Vanderbilt University's School
of Nursing. It is a specialized, accelerated program called the "bridge
program" because it allows students with bachelor's degrees to receive
their RN licensure after the first year and then join the rest of the
MSN students the second year in the specialty of their choice. My bachelor's
degree is in biology. I am currently researching financial aid options
and wonder if anyone has any advice or knows of any aid available to nurse-midwifery
graduate students. I am on my own with this (my mother does not approve
of my chosen career and refuses to help me) and I do not belong to a minority
group or any particular religious affiliation, so any scholarships from
those sources are unavailable to me. There are not any assistantships
or stipends available and federal aid is limited and will not be enough
to cover tuition. Any suggestions would be sincerely appreciated. I am
very passionate about this field and have wanted to be a CNM for so long
and don't want to lose this opportunity.
- Victoria Harris
Reply to: vicki_bella@yahoo.com
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