Re: [ozmidwifery] Re: OP stats...interesting

[Marilyn Kleidon]

Hi Jo:   I never cease to be amazed at how this 1cm/hour or Freidman's Curve continues to be applied rigorously to women in labour. Coming from the homebirth environment to the hospital one, at least to my mind it is hurdle often before women. As a midwifery student this view of labour was presented to us as the statistical norm(for hospital birth) and as such had standard deviations on either side of it that were still normal and they were different for both multips and primips. Of course in a "slow" labour we have to always be looking out for a truly obstructed labour, maternal, and fetal exhaustion: that is where our skill comes in. Similarly we have to be mindful of truly preciptitous births as opposed to those that are just faster than the "norm".   Often in birth, complicated ones in particular, the true picture only presents itself with hindsight. It can be a delicate art discerning a stalled labour from a slow but progressing one. Similarly we have to resist the urge to normalise everything and accept the persistent OP (or the deep transverse) baby as one who wont come out vaginally and be thankful for the option of caesarean birth. Please note I said PERSISTENT< most of these babies will eventually turn and then descend and come out in 2 to 3 pushes: it often takes time, many PERSISTENT position changes, and much support. However some wont or can't turn: their alignment may be just mm out and while both mother and baby have muscle tone the baby remains "stuck". Surely we have all heard tales from the past of mothers who slipped into exhausted sleep in such labours, woke up and pushed out their baby. I don't know the statistics of morbidity/mortality of mother and baby in such births but can't imagine they are that good as we all know the risks of PPH, infection, etc.. in exhausted mothers and babies. This is why we have to watch and listen very carefully in such situations. Perhaps this is why we don't do this is busy hospital situations where 1:1 care cannot be guaranteed. Perhaps why such births have more successful outcomes in a homebirth/birthcentre environment where 1:1 care is guaranteed.   I do wonder about the effectiveness of the so called "walking epidural" in such slow/stalled labours. Where I practised homebirth in Seattle the slowly progressing, exhausting labour was the most frequent reason for hospital transfer and for most of these women an effective epidural and sometimes (but not always) a 'whiff' of syntocinon was all that was needed for the baby to descend and birth. We did have one baby that never descended past the pelvic brim and mum went to 41+ weeks then SROM, days of early painful labour (with antibiotics and careful monitoring), finally an epidural that never really worked (started with the walking epidural) and finally a c/s: baby was direct OP, only 3300g, mum was extremly fit and active. Another young woman's waters broke at work and she progressed (galloped) to fully dilated in 2 hours, we rushed to her home but finally transferred to the hospital after 2.5 hours of pushing and no descent. This mum refused an epidural or any pain relief, did receive synto for an hour or so, then agreed to a c/s rather than a mid-forceps: baby was too high for a vacumm. This mum again very fit, soccer player, baby just 2800g, persistent direct OP.   I do think that often either SROM/ARM are responsible for these babies getting "stuck", which is why I try to preserve membranes (ie I avoid ARM) especially if labour is sluggish. But often with OP babies the labour starts with a gush! WE often decry the "modern lifestyle" and the couch potato syndrome as reasons for the prevalence of this unfavourable position in babies. I must confess i have seen this more often in the very fit mother, primip, often an athlete, very firm abs. That I have also seen it in considerably less toned multips leads me to suspect it may be largely due to the internal shape of the maternal pelvis, which also leads me to believe that it is quite a normal presentation for many women and that with time and good management and support the baby will birth. What I have also observed (and experienced personally) is that our bodies learn, I truly believe our muscles remember, and unless mismanaged from outside, subsequent births will be easier: those deep internal muscles remeber what to do to give the baby a "passageway" and not an obstacle course to be born.   I can only think that the 1cm/hour rule is there to avoid obstetric disasters, we can only  replace it with true midwifery care.   in respect   marilyn   ps: I think walking epidurals are truly effective pain relief for the woman with a normally progressing labour, that is she would have the baby in a couple of hours of active labour with or without the epidural. I just don't think they are an effective "treatment" for stalled or potentially obstructed labours. I don't think there is any research on this.      From: Mary Murphy To: [EMAIL PROTECTED] Sent: Tuesday, April 13, 2004 9:30 PM Subject: [ozmidwifery] Re: OP stats...interesting Hi Jo,  The stats agree with my perception of the births I attend as a community midwife.  I try my damnest to get women to use good posture in pregnancy, using the Alexander method & Optimal Foetal Positioning as a guide.  It helps quite a bit, and also Bowen therapy & Chiropractic.  I have used Bowen in labour with success, however, there are some that just won't turn & they are usually the Epidural/NE C/S that I attend.  I wish there was an easy answer. MM