January 24, 2001
Volume 3, Issue 4
Midwifery Today E-News
“Transverse Lie”
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THIS WEEK'S ISSUE

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Quote of the Week:

"...licensing diminishes accountability to people in favor of accountability to a licensing board."

- Fremont Women's Clinic collective,1977


The Art of Midwifery

Transverse lie is common up to 26 weeks....if the baby remains transverse after 27 weeks and is high in the uterus, listen carefully around the lower portion of the abdomen for placental sounds...to rule out placental praevia.

- Elizabeth Davis, Heart and Hands, 1997, Celestial Arts

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News Flashes

A Finnish study of the long-term effects of cesarean section looked at the occurrence and outcome of the first pregnancy and first birth subsequent to cesarean section for 16,938 women. There was decreased fertility among the women who had cesareans, as well as increased spontaneous abortion. Induced abortion was increased only among women whose only previous delivery was the cesarean. There were also modestly increased numbers of ectopic pregnancies, and seriously increased numbers of abruptio placenta and placenta previa.

- Amer J of OB and Gyn, 1996, vol. 174, No. 5, 1569-74


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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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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??

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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

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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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