Failure to progress--the most commonly cited reason for a cesarean--often really
means a care provider is admitting frustration and impatience with a woman's labor.
This is especially true if the woman is not laboring according to Friedman's Curve.
Of course, labor should progress reasonably. But there are more landmarks of progress
than cervical dilation. For instance, when a baby has a fifteen and a half inch
head, a mother will certainly need more time for molding to occur, and forcing
a more rapid delivery will only cause harm to mom and baby.
Cephalhematoma, excessive caput formation, and bruising might well be expected
from forcing this larger baby through the pelvis. Some decelerations of heart
tones would probably occur as well, from head compression. The mom will suffer
from tearing and bruising of tissues that would have sufficiently stretched, given
enough time. Progress may be marked by further descent, more effacement, and softening
of the cervix, or by noticing that the mother has become more able to deal with
her environment and her contractions, allowing further progress to take place.
There may be psychological reasons for slowed progress as well as physiological.
- Valerie El Halta, "Preventing Prolonged Labor," Midwifery Today issue 46
Caldeyro-Barcia R. The influence of maternal position on time of spontaneous
rupture of the membranes, progress of labor and fetal head compression. Birth
Low-risk women in spontaneous labor with intact membranes were randomly assigned
to recumbency during first-stage labor (N=225) or to do as they please (N=145).
Only 5% chose to lie down. Women were matched with respect to parity and maternal
weight and height, as well as infant birth weight, length, loops of umbilical
cord [around the neck or body?], and circumference of head, abdomen and chest.
No woman had pain relief medication or oxytocin.
Contractions became stronger but less frequent as a woman went from supine
to lying on her left side. Contractions were stronger and equally frequent when
she went from supine to standing. (Gravity alone adds 35 mm Hg to contraction
pressure.) For primigravidas, active first-stage labor (4-5 cm dilation to 10
cm) was shortened by a median length of 78 minutes (36%). The additional pressure
on the fetal head when the mother stood did not increase the incidence of fetal
head molding, caput succedaneum [a pressure-caused swelling on the fetal head],
or heart rate decelerations. "Thus, in upright positions, labor is effectively
shortened.... The upright positions are reported to be associated with less pain
during labor and are preferred by women when they are given their choice of position
- Henci Goer, Obstetric Myths Versus Research Realities, Bergin & Garvey 1995
[After attending fifty hours of homebirth labor], one of the last tricks I tried,
and it seemed an appropriate time, was the "hospital threat." I knew
that both mommy and baby were fine. I explained that it was time for her to finish
her work. We were all here for her. Then I gave her a deadline. I told her that
I wanted her to be completely opened by 7 a.m., or I was going to take her to
the hospital. She and her husband both cried at the prospect but seemed to gain
determination. We put her to bed with her husband, then went into the adjoining
room to quietly wait and rest. Our doula stayed awake and talked to the mom, giving
her lots of support. At 6 a.m., the woman said she had to push. [At sixty hours
since labor began] the little one made his appearance. He had a nuchal cord, which
we unwrapped; his shoulders were pretty tight. We flipped the mama over on her
hands and knees, used the Wood's Corkscrew, and out he tumbled. He was a little
floppy so I gave him about four puffs of oxygen. He breathed and cried and wanted
his mommy. He weighed 9 pounds and his mother had no tear.
- Cynthai Luxford, LDM-CPM, from "The Longest Labor," The
Birthkit No. 21
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Question of the Week
Q: As a care provider for women during their childbearing
years, it is also essential to be able to have competent information I can give
to the women whom I continue to care for beyond the birthing times of their lives.
What are the signs and symptoms of breast cancer? How does the percentage of women
who breastfeed to those who don't correlate with cancerous tumors in women's breasts?
Can you recommend any books that are informative, honest and coming from a natural
- Amanda Moore, midwifery student
Send your responses to:
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Question of the Week Responses
Q: 1. What is the longest you have waited for a placenta
after the birth of the baby? What was the outcome?
2. What is the longest you have seen from full dilation to the beginning of
pushing - or to the birth of a baby? What were the outcomes?
- Nancy Wainer
A: The longest wait from full dilation to birth was sixteen hours. Another
mom took twelve hours. They labored up to transition and then shut down, maybe
because they were tired, but I believe there were a lot of emotional factors involved
(including issues of sexual abuse). The longest one, after only occasional contractions
and intense discussion, decided to try a push. She immediately got the urge to
push and the baby was born in five minutes. Fetal heart tones were stable throughout
for both of these moms. If they had not been, I would not have been willing to
wait those lengths of time.
A: The midwife I work for waited almost two hours for a placenta. This
woman labored verrrrry slowly. She was 8 cm for almost a whole day! Outcome? Healthy
water-born baby boy, happy mama!
At the first homebirth I attended, mom was fully dilated at 5 a.m. on Saturday
and gave birth 3 p.m. Sunday! Mom insisted on staying home if baby was fine (she
was). Mom would get the urge to push, push for two hours, cry her eyes out and
go to sleep. She would wake up, shower, eat and then the urge would begin again
and we started the sequence all over! Outcome? Very large healthy baby girl (born
at home) and a mom who crowed, "I did it!"
- DeeDee Farris-Folkerts, CD
A: After the birth of my last baby, the cord pulsated for one full hour.
After it stopped, we cut the cord, and I pushed the placenta out, with a contraction,
less than fiveminutes later. The placenta looked just fine. How unusual is this?
- J E A Herendeen
A: The longest I waited for a placenta was two hours. We tried nursing
baby, a shower, rest, and finally lying on her stomach. Everything was fine. There
was extra bleeding and mom was weak at one point, which is when we just tried
- Carrie, lay midwife
A: This may be an obvious question, but it springs to mind since it wasn't
specified as being one of the "several things" tried: Did she simply
try pushing despite not feeling any urge?
Surprisingly, I never felt any urge to push during my second birth but pushed
anyway because following a vaginal exam I was found to be complete. Fifty minutes
later, our baby was born. I often wonder if I would have waited, instead of pushing
simply because I was fully dilated, if the urge would have come. We had variable
decels, during pushing, and I also wonder if that is because I pushed without
feeling the urge. Baby was a little gurgly at birth and had an oxygen mask and
a little oxygen blown over her face for a few seconds to help her pink up more
quickly (Apgars were 7 & 9). Her heart rate was fine immediately after the
- Leslie Ashton
A: Placenta: Two cases, one for two hours, no signs of shock, and checking
constantly; outcome good. The other four hours, no signs of concealed hemorrhage
or shock, good outcome. Both were rare cases in my practice. After that, waiting
one hour, fifteeen minutes has been the longest and with a good outcome.
Waiting for the pushing reflex: Ten cm dilated doesn't mean second stage will
be two hours. After 10 cm other normal events of birth can happen that have nothing
to do with CPD or arrests. Many times it's 10 cm and baby still needs rotation
before the pushing reflex appears. Contractions keep coming, softer and more irregular
than when she was reaching 10 cm. These babies are usually -1, -2. Some mothers
can sleep. But baby/mom are doing work that is sensitive. I think arrest happens
when a woman is given Pitocin and the head starts hitting the pelvic bones with
little chance to accommodate; it's worse with an epidural.
The birth I waited the longest for was when the baby was transverse going OA.
It was approximately nine hours until consecutive and strong pushing reflex started
(yes sporadic softer pushing happened before, which helped accommodate). Baby
and mom were perfect--drinking, tired but strong. Another significant was four
hours, between 10 cm and pushing, baby was way high,-3 ROP. With a little help,
the pushing reflex started and the baby was born very fast after accommodation
to OA. If it's not a face presentation (I don't do those births) or OP that may
need special help, I feel perfectly secure. Nature is kindly working as it should
when 10 cm are reached, baby is high, and rotation is still going on (normal,
normal, normal)--and membranes, when baby is still rotating, should not be touched.
- Debbie Díaz
A: I had a mother who had prolonged ROM with spontaneous onset of labor
with a normal progression of active labor, completely dilated at 5 a.m. NO urge
to push until midwife gave encouragement to go with a slight urge that developed
around 9:30 a.m. Was crowning beginning at 11 am, going fifty cents worth-plus
at 1 p.m. with no further progress at 2 p.m., therefore chose transport to hospital.
When arrived at hospital, head had retracted to a +2 station and hospital used
Pitocin as contractions were 4-7 minutes apart (and had been most of pushing);
ended up with vacumn delivery. Also upon arrival at hospital, copious amount port
wine colored bloody show (had been no bloody show for whole labor), which was
ignored by hospital staff. The baby was born covered with port wine colored blood
and with the placenta. Physician felt there may have been an abruption. Baby had
hypotension, hypovolemia, and a low hematocrit.
I have felt since this birth that the baby was on a short cord, as it needed
time to start labor after SROM, needed time to descend, which created the long
second stage. But as a midwife I had never seen crowning that did not progress,
therefore, we chose the transport. The parents were given choices regarding the
transport as I told them I did not have experience with crowning such as this,
and that we could stay at home and things might be OK or not OK or we could go
to the hospital and things might be OK or not OK. The client chose to transport.
I can't wait for science to begin to document more of the relationship between
the baby and the mother in labor variations. We certainly see them and want to
believe there is a purpose.
- Debra, midwife of 25 years
A: Twenty years ago I was working in a small mission hospital in Zambia.
A grand multip was almost fully dilated and having good contractions--and I was
tired and wanted to go to bed. It was about 10 at night. Everything appeared absolutely
normal to me so I swallowed my principles and ruptured her membranes. There was
a usual amount of clear liquor. The contractions stopped completely. The almost
fully dilated cervix shrank back to 6 or 7 cm and I was left waiting. Over an
hour later the woman went to sleep. I hopped onto the other labour bed and we
both slept all night. In the morning the contractions started again and she had
a normal vaginal delivery.
Re: volunteers in hospitals [Issues 3:37]: Soothing, gentle, reassuring touch
and massage is usually welcomed by laboring women and postpartum moms. A small
well-constructed study has shown that simple massage techniques performed by partners
decreases labor times, interventions, and complications. It also reduces stress
and women's perception of pain. I'd put your volunteers to work doing that. Some
basic safety precautions would have to be conveyed and simple techniques taught,
but only a few hours of orientation and training would get them going.
- Carole Osborne-Sheets
I am a doula with a hospital birthing client who has a partially covering placenta.
She is at 26 weeks and there has not been any sign of movement from her first
ultrasound that revealed the placenta's location. What facts can I offer her?
Are there any ways to encourage it to move?
- Stephanie Medearis, CD, CBE, midwife's assistant
Colorado Springs, CO
It has been my experience, both in my own practice and in reports from other
perinatal massage therapists, that often techniques that involve static pressure
and gentle movements performed by a knowledgeable therapist are more effective,
in most cases, than stroking, kneading, and superficial touch, although those
types of massage techniques are often soothing and reassuring.
- Carole Osborne-Sheets
Re: the news item about glocuse levels [Issue 3:41]: Even at the highest glucose
levels, this "difference" in weight is inconsequential. A quarter of
a pound (200 gm) is not likely to be a significant factor in birth. I'm concerned
that people might glance at this type of study and draw conclusions that are taken
out of context or out of proportion.
- Gail Hart
I have only used the RAMP method [Issue 3:41] one time and not prior to anticipated
shoulder dystocia but after initial rotation attempts and posterior arm did not
work for me. I used my hand as a ramp and it did work very well. A practitioner
should be skilled at every method to relieve shoulder dystocia. We all have a
favorite method that we use consistently and successfully. However, be prepared
to switch if one method does not work.
- Anne Katz Jacobson, CNM
Does anyone know the effect of hemochromotosis (genetic iron overload) on pregnancy/delivery/baby?
Because this disease affects the liver, eventually causing cirrhosis, and toxemia
has been linked to poor liver health, I wonder if there is a connection between
hemochromotosis and toxemia. Have any studies been done on it?
- Paula Wilson
I challenge anyone to find reputable research demonstrating a link between BTL
(Bilateral Tubal Ligation) and early menopause [Issue 3:42]. Many women ascribe
all sorts of gynecologic difficulties to BTL, but study after study has failed
to show any connection between BTL and reduced libido, pelvic pain, irregular
bleeding, or early menopause. I assume the writer would have experienced early
menopause no matter what method of contraception she chose.
- Samantha McCormick, CNM
I am a board-certified lactation consultant and I understand difficulties with
breastfeeding very well [Issue 3:40 & 41]. Sometimes consultants forget it's
not always getting the baby directly to the breast that counts but the overall
experience. I do have an answer to your concerns and would love to correspond
with you. "Anon.," please e-mail and I will offer you my opinions about
what you can do with your forthcoming child.
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