Comments on: Tight shoulders http://www.bellytales.com/2007/02/04/big-baby-no-problem/ The Diary of a New Midwife Tue, 06 Jan 2009 03:03:44 +0000 http://wordpress.org/?v=2.7 hourly 1 By: The Student http://www.bellytales.com/2007/02/04/big-baby-no-problem/comment-page-1/#comment-5638 The Student Fri, 16 Feb 2007 23:56:28 +0000 http://www.studentmidwife.org/2007/02/04/big-baby-no-problem/#comment-5638 Hi, Nurse2: I have very rarely seen hands and knees used in the hospital, I think in part because 1) many of the women delivering have epidurals and it's very difficult and cumbersome for them to move into hands and knees and then support that position and 2) many of the providers delivering women today have only done so from lithotomy, semi-fowlers or side-lying positions, and just don't know how to use the hands and knees position, especially since all of the normal mechanisms of labor are upside down in that position. Hands and knees (the Gaskin Maneuver) is one of the BEST maneuvers for shoulder dystocia, and if the baby's shoulders had actually been stuck, I think it would have been one of the first things we tried (but they weren't stuck; the shoulders were fine, and no additional maneuvers were needed to deliver this baby). However, I haven't heard of the Gaskin Maneuver being used to help prevent a laceration in a woman delivering a large baby, although I can see how that could work really really well. Next time we have a large baby (and maybe a woman without an epidural?), I will suggest using hands and knees and see how it goes. I have never yet caught a baby from hands and knees position, but I would love to!! Hi, Nurse2:

I have very rarely seen hands and knees used in the hospital, I think in part because 1) many of the women delivering have epidurals and it’s very difficult and cumbersome for them to move into hands and knees and then support that position and 2) many of the providers delivering women today have only done so from lithotomy, semi-fowlers or side-lying positions, and just don’t know how to use the hands and knees position, especially since all of the normal mechanisms of labor are upside down in that position. Hands and knees (the Gaskin Maneuver) is one of the BEST maneuvers for shoulder dystocia, and if the baby’s shoulders had actually been stuck, I think it would have been one of the first things we tried (but they weren’t stuck; the shoulders were fine, and no additional maneuvers were needed to deliver this baby). However, I haven’t heard of the Gaskin Maneuver being used to help prevent a laceration in a woman delivering a large baby, although I can see how that could work really really well. Next time we have a large baby (and maybe a woman without an epidural?), I will suggest using hands and knees and see how it goes. I have never yet caught a baby from hands and knees position, but I would love to!!

]]> By: nurse2 http://www.bellytales.com/2007/02/04/big-baby-no-problem/comment-page-1/#comment-5634 nurse2 Fri, 16 Feb 2007 21:11:19 +0000 http://www.studentmidwife.org/2007/02/04/big-baby-no-problem/#comment-5634 I have a question . . . for big babies, do you ever try having mom get into the hands and knees position? Or would it have been impossible because she had the epidural? That is a big thing I am always thinking about . . . working as a doula, I have seen the OB or midwife in a hospital go nuts if a woman w/ an epidural got into the hands and knees position, even if the epidural was "turned down" at the beginning of the 2nd stage. I have seen HUGE babies (11lbs) born over intact perineums w/ mom in hands and knees, moms also LOVE this position, even moms who did have the epidural (if they can support their weight, they can assume the position). Sometimes lacerations are impossible to avoid but I think this position really helps . . . gives you some extra room and some extra time. I have a question . . . for big babies, do you ever try having mom get into the hands and knees position? Or would it have been impossible because she had the epidural? That is a big thing I am always thinking about . . . working as a doula, I have seen the OB or midwife in a hospital go nuts if a woman w/ an epidural got into the hands and knees position, even if the epidural was “turned down” at the beginning of the 2nd stage. I have seen HUGE babies (11lbs) born over intact perineums w/ mom in hands and knees, moms also LOVE this position, even moms who did have the epidural (if they can support their weight, they can assume the position). Sometimes lacerations are impossible to avoid but I think this position really helps . . . gives you some extra room and some extra time.

]]> By: The Student http://www.bellytales.com/2007/02/04/big-baby-no-problem/comment-page-1/#comment-5470 The Student Wed, 07 Feb 2007 21:15:45 +0000 http://www.studentmidwife.org/2007/02/04/big-baby-no-problem/#comment-5470 I think the ticking clock stems from a lot of different pressures. For one thing, although many studies have demonstrated that the Friedman curve is obsolete (and even Friedman himself has stated that he never intended his study to be used as a guideline for management), the textbooks still define primary dysfunctional active labor as a failure to dilate at a rate of 1.2 cm per hour in primips and 1.5 cm/ hour in multips. And even if you're not actually clocking a woman's progress by the hour, I think that this concept is drilled pretty steadily into a doctor's head during his/her residency, so it's always there on some level, on a back burner. Plus there's the ruptured membranes clock, which is sort of an unspoken rule that once a woman's water is broken, she has roughly 24 hours to deliver, or else face a cesarean. This is supposedly to reduce the risk of chorioamnionitis (infection of the membranes, placenta and eventually baby) which can occur once the sterile membranes are ruptured and exposed to ascending bacteria from the vagina...but again, research has shown that the single greatest risk factor in chorio is repeat vaginal exams, which happen so frequently because impatient doctors are always sticking their fingers in to see if progress is being made. And while I do think many doctors have a woman's best interest at heart, there are always a few (more than a few) who don't. I have honestly seen cesareans performed becasue doctors didn't want to wait around for a slow labor to prgress, or wanted to get to their clinic hours on time, or leave for the weekend. When a woman is admitted to labor and delivery in active labor, there's the sense that something has to happen within about 12 hours. Either she is making progress, or she needs pitocin. If she has pitocin and is not making progress, she needs an intrauterine pressure catheter to make sure her contractions are adquate. If her contractions are adequate and she's still not making progress, it's either primary dysfunctional labor or secondary arrest of dilatation, and if it continues for 2-4 hours, she becomes a candidate for cesarean. The hospital just isn't a very patient place. That's why one of the best pieces of advice you can give to laboring women in low risk pregnancies is to STAY HOME for as long as possible. You have more opportunities to truly rest and relax at home, even with contractions, more oppotunities to walk or dance or jiggle or assume whatever position feels good, more opportunities to eat and drink...if you've planned a hospital birth, home is just a much better place to be during the early and early active stages of labor. I think the ticking clock stems from a lot of different pressures. For one thing, although many studies have demonstrated that the Friedman curve is obsolete (and even Friedman himself has stated that he never intended his study to be used as a guideline for management), the textbooks still define primary dysfunctional active labor as a failure to dilate at a rate of 1.2 cm per hour in primips and 1.5 cm/ hour in multips. And even if you’re not actually clocking a woman’s progress by the hour, I think that this concept is drilled pretty steadily into a doctor’s head during his/her residency, so it’s always there on some level, on a back burner. Plus there’s the ruptured membranes clock, which is sort of an unspoken rule that once a woman’s water is broken, she has roughly 24 hours to deliver, or else face a cesarean. This is supposedly to reduce the risk of chorioamnionitis (infection of the membranes, placenta and eventually baby) which can occur once the sterile membranes are ruptured and exposed to ascending bacteria from the vagina…but again, research has shown that the single greatest risk factor in chorio is repeat vaginal exams, which happen so frequently because impatient doctors are always sticking their fingers in to see if progress is being made.

And while I do think many doctors have a woman’s best interest at heart, there are always a few (more than a few) who don’t. I have honestly seen cesareans performed becasue doctors didn’t want to wait around for a slow labor to prgress, or wanted to get to their clinic hours on time, or leave for the weekend. When a woman is admitted to labor and delivery in active labor, there’s the sense that something has to happen within about 12 hours. Either she is making progress, or she needs pitocin. If she has pitocin and is not making progress, she needs an intrauterine pressure catheter to make sure her contractions are adquate. If her contractions are adequate and she’s still not making progress, it’s either primary dysfunctional labor or secondary arrest of dilatation, and if it continues for 2-4 hours, she becomes a candidate for cesarean.

The hospital just isn’t a very patient place. That’s why one of the best pieces of advice you can give to laboring women in low risk pregnancies is to STAY HOME for as long as possible. You have more opportunities to truly rest and relax at home, even with contractions, more oppotunities to walk or dance or jiggle or assume whatever position feels good, more opportunities to eat and drink…if you’ve planned a hospital birth, home is just a much better place to be during the early and early active stages of labor.

]]> By: wanderglow http://www.bellytales.com/2007/02/04/big-baby-no-problem/comment-page-1/#comment-5374 wanderglow Mon, 05 Feb 2007 05:52:23 +0000 http://www.studentmidwife.org/2007/02/04/big-baby-no-problem/#comment-5374 Congratulations! Great story. I've read about the "ticking clock" in several hospital birth stories. I understand that in hospitals they often prefer if mom dialates about 1 cm an hour. What is the reason for this? Is it to get moms in and out quicker (a profit thing), or is it a supposed sign of an "abnormal" labor and they want to progress things along quicker for the sake of mom/baby? Or is it because they are afraid of being sued? Any other reasons? I truly believe that OBs, etc. who have the power in hospitals have the best interests of moms in mind...it is hard to understand the choices they sometimes make and I like to think (hope?) there is another side to the story that is just as compelling as the midwifery model. Sounds like you were able to get mom a vaginal delivery when many other providers would have went for the cesarean (or at the very least the pitocin)...great job! Congratulations! Great story.

I’ve read about the “ticking clock” in several hospital birth stories. I understand that in hospitals they often prefer if mom dialates about 1 cm an hour. What is the reason for this? Is it to get moms in and out quicker (a profit thing), or is it a supposed sign of an “abnormal” labor and they want to progress things along quicker for the sake of mom/baby? Or is it because they are afraid of being sued? Any other reasons? I truly believe that OBs, etc. who have the power in hospitals have the best interests of moms in mind…it is hard to understand the choices they sometimes make and I like to think (hope?) there is another side to the story that is just as compelling as the midwifery model.

Sounds like you were able to get mom a vaginal delivery when many other providers would have went for the cesarean (or at the very least the pitocin)…great job!

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