OP (Sunny Side Up), Cervical Swelling and Slow Dilation…These are a few of the issues my last client had. With her permission, I want to talk about her birth. It’s actually a pretty amazing story. In addition to what I mentioned, she also had a 9lb baby with a very large head and managed to get out with only a 2nd degree tear.
So this client had been complaining of back pain for a couple of weeks. She works at a desk so I was worried that her posturing may have aided in her baby positioning himself OP (occiput posterior) or what some people call sunny side up or face up. When a baby is OP, the back of the head, which is the largest and hardest part of the head, digs into the moms back in utero. This sometimes causes chronic back pain. Some moms never feel any back pain at all when their baby is OP. I had talked with her about this and suggested that she do pelvic rocks daily and spend as much time as possible in the open knee chest position. Open knee chest is when mom puts her head and breasts on the floor and sticks her butt up in the air with her knees about hip width apart. Sounds easy but when you are very pregnant it is quite difficult. I also suggested that she sit on a birth ball that was inflated enough so that her thighs where parallel to the floor in the hopes of relaxing her pelvic floor and encouraging baby to turn. She is quite tall and I don’t think she found the ball very comfortable. I also told her no reclining on the couch. I feel as if I should have done more to encourage her to encourage the baby to turn but her back pain came and went and she didn’t feel fluttering indicating hands in the pelvic area and I couldn’t see her tummy (She was two hours away from me) to see if she had the dip in the stomach that OP babies often make. I guess I didn’t want to freak her out with all the optimal fetal positioning techniques when in reality babies that are OP before labor almost always turn before labor or in labor.
This is a baby that is occiput anterior, the optimal fetal position for easier birth…
This is a picture of an occiput posterior baby. Notice how the back of the head is in the mother’s back…
This woman, who we will call Alyssa, began her labor at 4am the morning that she was 41 weeks and 3 days pregnant. At around 5am or so she began to have leaking that she believed was her water. I joined her at 9:30am. The time line for her birth m my arrival goes as follows…
9:30am: I arrive
Contractions about five minutes apart, less than one minute long
You were breathing through them very well
10:00-10:30am: We walked, contractions started getting longer and more intense
10:30-11:30am: Complaining of back pain, we do pelvic tilts and open knee chest, I worry baby is OP
Breathing well through contractions but growing more intense with each one
You rest in bed for a few contractions
11:30am: Contractions are very intense. Still around 4-5 minutes apart, a minute long.
You are ready to go to the hospital
12:00pm: We arrive at hospital. Staff is busy. We walk for half an hour and take it one contraction at a time. Back pain is intensifying and you are feeling a lot of pelvic pressure
1:00pm: You are admitted. You are 4cm and 100 effaced and your water is leaking. Baby is at a +1 station. You are monitored for half an hour and the baby looks great. You continue working through each contraction one at a time.
1:45pm: You are taken off the monitor and get into your labor room. Labor is very intense and you labor standing while leaning on the bed for an hour.
3:00pm: Labor is so intense and contractions are coming every three minutes for about a minute and a half. You have a lot of pelvic and rectal pressure. You are a bit shaky and very hot. We put ice cold towels on you.
Because labor is so intense, the nurse figures you must be very progressed and asks if you want to be checked.
You are 8cm dilated. You are having urges to push.
4:30pm: Contractions continue at 3 minutes apart and about 2 minutes long. Your back pain is much worse as is the rectal pressure. We try many positions to help complete your cervix. A check shows that you are stlil 8cm. Midwife breaks your water and your cervix closes to a 5 or 6 and the baby retreats back to a zero station. We talk about the baby possibly being OP but she cannot confirm with exam. We spend the next hour trying to get the baby to turn.
5:30pm: The nurse checks and says you are 9cm with a lip. We spend half an hour getting you in positions to aid dilation.
6:00pm: Labor has become unbearable and you are having urges to push, your back pain is very intense. Midwife checks you and you are 6cm and your cervix is swollen. She again is almost certain the baby is OP. She offers and epidural and you accept. You also have a shot of Nubain to hold you over until the epidural is placed.
7:00pm: Epidural is in place. You feel pain on one side for an hour or so.
8:30ishpm: You are 10cm
9:30ishpm: You begin pushing. The baby is at a +2/3 station when you being. After an hour is becomes clear that the baby is OP. It is also clear that he has a very large head. You push for another hour holding the squat bar and/or sheet tied to it while his head molds.
11:30pm: Baby is coming down but getting hung up on the pelvic bone. You push flat on your back with your knees pulled far back and apart. He is able to descend past the pubic bone and begins to crown. The doctor uses baby shampoo as lube and supports your perineum as you push the final few pushes before he is born.
12:00am. Baby is born!!!! He comes out crying and looking around and after being checked out for a
few minutes is brought to you for skin to skin contact. You try to nurse immediately but he was interested just yet.
12:20am: Less than half an hour after being born, your baby is successfully nursing!!!
12:30am: The doctor is finished tending to you and leaves. You and dad bond with your baby.
1:30am: I leave
So the time line is a synopsis and not the birth story with all the details. What I’d like to include in that is that as her back pain intensified and the midwife agreed with me that the baby was probably OP, we began to get Alyssa into every position we could to get the baby to turn. The bed was broken down with the squat bar attached because when she was 8cm we tried to get her to sit on the bed with her legs on the lower portion with her upper body on the bar in a semi squat position in order to put pressure on the cervix to complete it. She didn’t like it because she had so much rectal pressure, so we took the bar off but left the bed broken down. Once the OP presentation because very obvious, we had her lower body on the bottom part of the bed with her upper body on the middle so that she was basically on her hands and knees. We tried to apply counter pressure but Alyssa didn’t like it. She had not wanted very much massage or touch so we didn’t not try to relieve her back pain that way. She mostly responded to cold on her lower back.
Another point I’d like to talk about is that she was at 8cm for more than two hours before the midwife broke her water. She had been in active labor for about 13 hours at that point and was ready for things to move along. By this point her labor had become all but unbearable. I believe that the baby’s OP presentation was making labor much much more painful. She was already beginning to lose control during and even between contractions and I think that even though AROM (artificial rupture of membranes) was not part of her birth plan, it really did sound like the best idea at the time. Of course, once it was done and the midwife felt her cervix close and the baby retract, she had this “OH SH!T” look on her face. And also of course, once it was done the contractions became even more intense.
I am not sure if the midwife breaking the water at 8cm is what caused the chain of events that followed. If it would have broken on it’s own, the same thing could have happen. I had it happen with another OP baby client. Her bag ruptured spontaneously at 8cm and her cervix went back down to 7cm and the baby retracted from +1 to -1/0 station. I also think that after having been at 8cm for two hours with transition strength contractions after having labored all day, that Alyssa was running out of both steam and motivation, understandably.
The former OP client I mentioned who went from 8cm to 7cm took SIX FULL HOURS to get from 8cm to complete. She had no option for an epidural as she was in a Korean hospital that did not offer them outside of business hours. The doctor was also performing c section so she didn’t have anyone offering to end the labor for her and her cervix wasn’t swelling either. She managed and made it through it but it was incredibly difficult. I have no doubt that in that scenario that Alyssa could have continued her labor without an epidural.
What made Alyssa’s labor even more difficult was to spend two hours at 8cm with pushing urges, eventually get told she was 9cm and still have pushing urges and then learn that she was 6cm with a swollen cervix. I think that hearing this was incredibly difficult for her. Maybe there were too many vaginal exams, maybe she didn’t have to know all of that was going on with her cervix but the fact is, she was pushing involuntarily even at only 6cm.
I have read that premature pushing does not always make a cervix swell and that her swelling was probably more the result of fetal positioning. It could also be a combination of the two, it’s hard to say. At any rate, with the intensity of pain she was feeling the midwife thought it best that Alyssa get an epidural to relax enough to be able to dilate. I was incredibly worried about this because it would be hard to get the baby to rotate with the epidural but I really do believe that at this point it was necessary. Her cervix wasn’t going to get a break and she was in too much pain to be able to invert her with open knee chest to pack the baby out of the pelvis some.
The midwife was right, the epidural helped and she dilated quickly. As the time line mentions, she pushed for nearly two and a half hours. The head was large and had a lot of molding at birth. He did get hung up under the pubic bone but the McRoberts maneuver, flat on back, knees far apart and up as possible dislodged him and within a few pushes he was out.
The most amazing part of this birth is that mom had only a second degree tear. OP babies are often associated with a higher incident of third and forth degree perineal tears and considering the size of this baby as well, I think this mom was incredibly lucky. I think that the fact that Alyssa had a successful vaginal delivery is a little bit of a miracle. We had THE BEST nurse on staff that day who helped me encourage Alyssa to move through her labor before she got the epidural. We had her doing a lot of things she didn’t want to do but she trusted us and we helped her and she did it. All of these things helped, I really believe this. They helped her baby move down so that when she did get the epidural, labor continued to progress. The support continued after the epidural in that we continued to help her move to help the baby move down. The woman used a squat bar to push with an epidural, THAT is a feat in and of itself. It took three of us (nurse, dad, me) to support her through it but she totally did it.
Here are some facts that I found regarding OP babies…
- The incidence of persistent occiput posterior babies at delivery is about 5.5% overall
- With a persistent posterior, both first and second stages are prolonged (Ponkey et al). However, longer second stages do not in themselves cause worse maternal or neonatal outcomes; in one study, as long as the fetus was stable, the second stage could continue without harm to mother or baby (Kuo et al).
- The likelihood of cesarean section or instrumental delivery (forceps or vacuum extractor) is greater when there is a persistent posterior position; in fact, the 5.5% of persistent posteriors account for 12% of all cesarean deliveries performed for dystocia (Fitzpatrick et al).
- Persistent posterior positions are associated with an increased incidence of premature rupture of the membranes, oxytocin induction and augmentation, epidural analgesia, chorioamnionitis, , episiotomies, severe perineal lacerations, vaginal lacerations, excessive blood loss, and postpartum infection (Pearl et al, Ponkey et al).
- Worse, there is a sevenfold increase in the incidence of anal sphincter injury, that is, third- or fourth-degree perineal lacerations (Fitzpatrick et al). Babies delivered from the posterior position were more likely to have Erb’s Palsy and facial nerve palsy than those delivered from the anterior position (Pearl et al)
- Occiput posterior babies often times cause a premature urge to push (pushing before 10 cm dilated)
- Occiput posterior babies can cause cervical swelling due to the hardest part of the head bearing down unevenly on the cervix. Cervical swelling can cause a stall in dilation or not allow the baby to descend enough to be pushed out despite the mother’s best efforts.
This study also explains the implications of epidurals with OP babies…
Epidural Analgesia Linked to Increased Risk of Occiput- Posterior Babies
Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005). Changes in fetal position during labor and their association with epidural analgesia. Obstetrics & Gynecology, 105 (5, Part 1), 974-982. [Abstract]
Summary: This prospective cohort study used periodic ultrasound examinations during labor to evaluate changes in fetal position and their relationship with epidural analgesia. The researchers sought to determine whether epidural analgesia is responsible for higher rates of fetal malposition (occiput-posterior (OP) or occiput transverse (OT)) or whether women experiencing labor with a malpositioned baby have more painful labors and are therefore more likely to request epidural pain relief. A total of 1562 nulliparous, low-risk pregnant women were enrolled in the study.The researchers found that the position of the baby (occiput anterior (OA), OP or OT) at the time of enrollment (in the early part of active labor) predicted position at birth poorly. For instance, of the women with an OP baby at birth, only 31% had a baby in the OP position at the initial ultrasound scan. Similarly, sonograms done later in labor were also poor predictors of position at birth. The data demonstrated that changes in fetal position were common during labor, with 36% of participants having an OP baby at the time of at least one scan. More than one-half of the women who gave birth to a baby in the OP position never had an OP baby at any ultrasound assessment in labor. Overall, 79.8% of babies were born in the OA position, 8.1% were OT, and 12.2% were OP at birth.
Epidural analgesia was strongly associated with delivery from the OP position: 12.9% of women with epidurals gave birth to babies in the OP position versus 3.3% of women without epidurals (relative risk 4.0, 95% CI 1.5-10.5). Transverse position was not related to epidural use. In a statistical model that controlled for various medical and obstetric factors that could affect outcomes, epidural use was still associated with a 4-fold increase in the risk of OP birth.
The data suggest that the association between epidurals and OP babies is not because women in labor with an OP baby are more likely to request an epidural. Women who received epidurals were no more likely to have OP babies at prior to or at the time that the epidural was administered. Furthermore, women with OP babies in labor or at birth reported the same degree of pain as those with OA or OT babies and were no more likely to report “back labor,” which is commonly thought to be related to the OP position. Finally, women with OP or OT babies at birth were much more likely that those with babies in the OA position to give birth by cesarean section, with 6.3% of OA babies born by c-section versus 64.7% of OP and 73.8% of OT babies (p<.001).
Significance for Normal Birth: Epidural use increases the risk of instrumental (forceps or vacuum) delivery in first-time mothers. Experts have proposed various reasons for this association, including diminished urge to push and changes in the tone of the pelvic floor muscles that inhibit proper rotation of the fetal head. Letting the epidural “wear off” has been thought to increase the likelihood of unassisted vaginal birth, however, this systematic review calls into question that common practice.
In normal birth, there are complex hormonal shifts that help labor progress and facilitate delivery. The laboring woman produces natural endorphins that help her manage the pain of labor. Her ability to move freely and assume a variety of positions while pushing work in concert with these hormonal changes. Epidural analgesia numbs the sensations of birth, and the production of natural endorphins ceases as a result of the disruption of the hormonal feedback system. When the epidural is discontinued, the woman’s pain returns but her natural endorphins may remain diminished and therefore her pain may be greater than if the epidural had not been given in the first place. Furthermore, when an epidural is administered, the woman is usually confined to bed and attached to fetal monitors and an intravenous line. The woman and provider may become accustomed to laboring in the bed attached to machines. When the epidural is discontinued the restrictions! on her movement may persist. Under these conditions, it is likely that the impact of an epidural on normal birth may outlast the epidural itself.
Ann Tumblin also sent me this regarding OP (face up) babies. It was done by Penny Simkin who is basically the mother of all doulas. It is very informative so if you have ever had an OP baby and are nervous about it a second time, I highly recommend you taking a look at it.
I believe that Alyssa’s birth outcome was the combination of her determination and trust that we were supporting her in every way we could and we were. I was sore the next morning which isn’t saying much compared to how she felt but more of a testament to the work I was doing. We were incredibly lucky to have the staff that we had and I also believe that if any piece of the puzzle had of been missing that her birth story would be very different. I think the point that I want to make about her birth is that if a mother is supported completely and if epidurals are not done too early that even very difficult births can have a great outcome. Mom is satisfied with her experience which is, other than healthy baby and mom, the best thing.
If you had an OP baby, please share your experience with us.Read Full Post | Make a Comment ( 34 so far )
This is an email response to the question:
If I had an episiotomy during my first delivery, will it increase the risk of tearing next time? Does perineal massage help?
First, here is some statistical information on tears…
How common are tears/episiotomies?
Most women who have a vaginal birth have either a tear or a cut. A few women have both.
We don’t know exactly how many women have a tear in the perineum during childbirth. Doctors and midwives don’t always record small tears. Experts think that at least a third of women in the United States have a tear large enough to need stitches.
In one study from the United Kingdom, more than 8 in 10 women had a tear or cut during a vaginal birth.And about 7 in 10 needed stitches.
Bad tears, which go all the way from the vagina to the anal opening (third-degree or fourth-degree tears), happen less often. But we don’t know exactly how many women in the United States have a bad tear. In one study from Canada, about 7 in 100 women who give birth had a bad tear.
Your chance of having a cut (episiotomy) depends on where you live. In the United States, about a quarter of women have a cut. In some eastern European countries, nearly all women have a cut during delivery.
Sources for the information on this page:
- Graves EJ, Kozak LJ.National hospital discharge survey: annual summary, 1996.Vital Health Statistics. 1999; 13: i-iv, 1-46.
- Audit Commission.First class delivery: improving maternity services in England and Wales.London: Audit Commission Publications, 1997.
- McCandlish R, Bowler U, van Asten H, et al.A randomised controlled trial of care of the perineum during second stage of normal labour.British Journal of Obstetrics and Gynaecology. 1998; 105: 1262-1272.
- Sultan AH, Kamm MA, Hudson CN.Anal sphincter disruption during vaginal delivery.New England Journal of Medicine. 1993; 329: 1905-1911.
- Wagner M.Pursuing the birth machine: the search for appropriate technology.In: Wagner M. Pursuing the birth machine: the search for appropriate technology. Ace Graphics, Camperdown, Australia; 1994.
- DeFrances CJ, Hall MJ, Podgornik MN2003 National Hospital Discharge Survey. Advance Data from Vital and Health statistics No 359Advance Data from Vital and Health Statistics 2005.This information was last updated on Nov 07, 2008
I have had this question a few times because most of my doula clients are second timers. While I have not found any hard studies on this topic (I am sure there have been some but I can’t find any), it has been suggested that up to 50% of women with an episiotomy scar will have a 2nd degree tear in subsequent births. That’s a big number but there is a lot of explanation that needs to go with that.
It is also important to understand that a vaginal tear is generally better than having an episiotomy. Tears typically do not tear as deep and far as a cut will and episiotomies actually increase the risk for a third or fourth degree tear. This is because once the cut is done the head emerging can cause the cut to tear farther back and deeper into the muscle. Tears will usually heal faster too. (this was not in the original email).
The scar tissue is a weakened area so it is more likely to give way but there is no guarantee that it will tear in a subsequent delivery. It’s not that the scar prevents vaginal stretching, it’s that the scar itself is weak and not as pliable as vaginal tissue. I had a client who had a huge episiotomy her first birth, it require 50 stitches and took months to heal. She had a surface tear her second birth and only needed 3 stitches. Many docs and mw’s wouldn’t have even stitched what she had. She said that within three days she felt completely normal and fine.
Also, 2nd degree tears are really not that bad. They will usually heal on their own without stitches but most OBs and hospital MW will stitch them. Homebirthers tend to opt out of 2nd degree stitching (because it is invasive and interferes with bonding) and they do fine. A 2nd degree tear doesn’t tear into the perineal muscle, it’s more is a skin tear. Of my 3 clients that had 2nd degree tears, two felt fine in less than a week and one was fine after less than two weeks. My point to all of that is that you would much rather tear a 2nd degree tear than to have an episiotomy so don’t let that scare you. Another thing worth mentioning is that none of them felt the tear as it happened and none of them had any kind of drugs during labor.
When you crown unmedicated, you feel the ring of fire for a few minutes, then the area goes numb because the nerves have so much pressure from the baby’s head. It’s natures own anesthetic and it’s also natures way of helping you not to tear. When a woman is left to push as her body tells her (rather than a nurse or doc coaching her) then she will instinctively not bear down when crowning because it burns. This allows the vaginal tissue to stretch as opposed to being push on as hard as possible and forcing the baby’s head out to quickly. This is why it is so very important to instinctively push rather than have cheering leading and counting pushing. Of course, it’s pretty much necessary when you have an epidural because you can’t really feel what your body is doing but when you are unmedicated you know exactly what’s happening. It’s also hard to get staff to let mom push instinctively. Most are so used to coaching epiduralized moms that they do not even realize that an unmedicated mom in an upright position needs absolutely no help.
This is also why it’s so important not to push on your back in the bed because then you aren’t giving the staff free access to everything. In addition to keeping people off your vagina, horizontal pushing also helps you stretch better because of gravity (increased blood flow to the area helps stretching plus it brings baby down with less effort). A squat position (like using a squat bar on the bed) also helps you to stretch better just by way of positioning. It just opens everything up. This is REALLY hard to achieve in a hospital birth most of the time. You will have to be firm and aggressive to make it happen and you will also have to be strong enough to initiate it during labor. Really you should hire a doula but you knew I would say that before you even emailed me;)
That said, there are a few women who require an episiotomy and I say require very lightly, I don’t really think there is any reason to give one other than a SERIOUS decel in the fetal heart tones that requires immediate delivery but that is very rare. It unfortunately is way over used as a reason. There is a difference in a decel and a very serious decel . When this happens to an unmedicated mom, a pressure episiotomy is done but can only be done that way after the ring of fire is no longer felt, meaning the nerves are numb and mom won’t feel pain from the cut. It sounds horrifying and it is but like I said, there is no cutting pain. If the nerves are not numb then a local anesthetic can be given if there is time. Again, these are very rare circumstances and there are ways to prevent this from happening.
The debate is out on perineal massage. Some people swear by it others say it doesn’t work. Don’t allow anyone to do it during pushing though, as it does increase the risk of tearing. If you think about it, it makes sense, someone else is touching you and they cannot feel what they are doing, only you can. You would touch more gently or firmly because you know what is happening. The best thing anyone else can do is to use warm compresses and perineal support which is still easily done if mom is upright. I recommend that moms support their own perineum because again, you are the one that is feeling what is happening and know how much or little pressure you need.
As for perineal massage during pregnancy, even if there is no solid evidence that it works, it can’t hurt and if nothing else it teaches you to relax your bottom. If your partner can do it for you it will teach you how to let the muscles go. For instance, he would use a finger on each side at the bottom of your vagina (while you are sitting up against the headboard or wall, oh and use lube). Then he would gently sweep the fingers out in opposite directions and kind of down and while he is doing that you just completely relax and concentrate on letting the muscles loose. Here is a link
But if your partner were doing it he would use his index fingers instead of thumbs.
I definitely would not use the same care provider that did your episiotomy the first time even if you like them. The thing is that even if you tell them you do not want it under any circumstance and that you would rather tear, those that use it, almost always use it and if they say “we only do it if it’s necessary” then you can count on having one. If you truly want to avoid another one and you truly want to reduce the risk of tearing, then you will need a provider that is more hands off and who will encourage you to get off your back and who is pro-natural birth. Most of them will SAY they are though so that’s the tricky part. This again is where I say hire a doula because doulas usually know the scoop on the different providers in the area. They see these docs and mws in action and know how they really are.
I am not trying to freak you out or be anti doc or negative it’s just that I have seen it happen. I have seen docs tell clients they are pro VBAC and want them to have the birth they want then threaten them with statistics that are not true or try to force a repeat c section on them. I have seen them tell clients that they support upright non coached pushing but in labor force them on their backs and start counting to 10. I think a lot of times they just tell mom what ever she wants to hear to get her to be quiet then when it comes down to the birth, they do whatever they want. Yes they do know best when there is a real emergency and either mom or baby is in trouble. hand down. But when it comes to unmedicated birth and leaving the body to do what it is supposed to do, they are not because the majority of American women get epidurals and that changes things. I would suggest finding that provider who supports your wishes and believes in your body so that you do not have to fight for what you are entitled to. If you are set on keeping the provider (if it’s the same one) then definitely hire a doula so you don’t have to fight alone. (sorry for the little speech:)
SO in short, you do have a risks but you have lots of options and you can set yourself up for the least risk of tearing.
EDIT: I am adding THIS LINK for more information on the history of episiotomies and their use today. This is a great read. Here is the intro…
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The following piece was submitted by Rita Ledbetter, CNM ~ she is my midwife and works in the Medical Arts office in Moline. I asked her if she’d be willing to share her knowledge on the subject of episiotomy ~ to cut or not to cut when delivering. I am very appreciative that she took the time to write and submit this article so that expectant mothers can be more informed when developing their birth plans!
Hi -this is Abby’s midwife Rita. She asked me to write a little about episiotomy – the cut made at the opening of the vagina (perineum) when a baby is being born. Routine episiotomy is no longer recommended but still occasionally is needed.
Birthing babies is not new and tearing or lacerations of the opening of the vagina have always been part of the process of birth. Some women had tears, some did not. In olden times it was common to allow as many cobwebs as possible to grow in the home as a woman prepared for childbirth. If a tear happened during childbirth the sticky cobwebs were packed into the tear and the woman was kept in bed for 10 days or so with her legs closed to allow her bottom to heal…..Go HERE to read more