Doula Momma

C Section With an Inverted T Incision and Face Presentation

Posted on July 1, 2009. Filed under: Birth, Cesarean, Face First/Mentum Presentation, inverted t incision, Pregnancy, vbac | Tags: face first presentation, inverted t incision, landon study t incision, rupture risk inverted t incision, t incision c section, uterine rupture, vbac, vbac inverted t incision, vbac t incision |

I have procrastinated writing this post. It is the post that I most wanted to write from the moment I my cyber friend Pam dreamed up the idea of writing a blog. I have put it off because I needed to organize my thoughts and my statistics and references and people. Well, really not MY people but the people who are out there that are dealing with having an inverted t incision scar. I feel the pull to get it all down and typed out and saved somewhere that is easily accessible on the internet though so it’s time to stop procrastinating. I just want to make sure that if there is a woman out there googling ‘inverted t incision’ she finds the answers to some of her questions because there is not a lot of information out there. I feel that if I can at least put everything I know in one place maybe someone else will have an easier time than I did when I was trying to learn everything I could.

My quest for inverted t incision knowledge began with my own birth story. In short, we ended up with a cesarean after a very long natural labor that resulted in an inverted t incision because of my son’s face first presentation. So there is no confusion about what the face first presentation is as some people confuse it for ‘face up’ or OP (occiput posterior), I have included some pictures below.The first picture shows what a normal vertex occiput anterior baby looks like in utero. The second picture shows how the baby hyper extends it’s neck when presenting face first. The third shows the different ways the baby can present. My son was Left Mentum Transverse (LMT).

Here is an article written by a woman who delivered a face first presentation. I added it into my article because I am scared that one day the link will not work. The link is HERE. Below is the article…

Face Presentation is a relatively uncommon labor presentation (only about .4 percent of births) when the baby is head down but has its neck extended, as if looking down the birth canal, rather than with its chin tucked into it’s chest.  The chin or the nose presents first (very rarely the brow), not the top of the head.

Presentation refers to the part of the baby first entering the pelvic structure on it’s way out the vagina.  A vertex birth (head first) happens approximately 95 percent of the time.  The options (in order of occurance) are: Vertex, Breech, Shoulder, Face, Brow

Attitude is the relationship of the baby’s extremities -arms, legs and head – to his main body.  A fully flexed baby is compact and compared to poorly flexed or extended.   A fully flexed vertex presentation makes for the smallest diameter of the baby’s head exiting at all times.  If the baby’s head is only partly flexed, a larger diamer will have to come through the birth canal, making for a longer labor and more difficult exit.  (Trust me on this!)  If the baby’s head is Fully Extended, the baby is Presenting by Face.  This sounds very scary when described, as the head is bent backwards till it is resting on the back shoulders.  It appears like the baby is going to break it’s neck coming out!

Labor: The top of the baby’s head will be resting (uncomfortably!) on the mother’s backbone.  Labor will likely be slower since the face is not an ideal canidate to dilate the cervix.  Mom is probably going to be in a bit of extra pain.    In my case, once I past transition I had no urge to push since the head was not hitting the proper nerves.  (I don’t know if this is always the case or not)   I found this very disconserting since I knew from past experience I should be wanting to push.  The diamater of the head as it presents is about the same as a vertex birth (abt 9.5 cm).  However, while the presenting parts may be equal, for the face presenting baby – the full width of the head is to follow!    When a baby is vertex, the head bones actually mold together and overlap, making the head easier to push through and out of the birth canal.   Face presentations have no such luck.

Having an angel-faced baby is akin in size to a breech birth!!  However, as long as the baby is face up – chin facing the mom’s bellybutton – there is no danger.   With a breech birth, the danger is the head getting suck in the birth canal after the body has sucussfully exited, possibly with the cord pinched.  With a face first baby, the head comes out first – so there is no danger of asphyxiation.

Please note that angel-faced baby’s are routinely C-sectioned in hospitals.  Any baby that is sunny-side up “fits the requirement for a c-section”.   Moreover, since labor will be longer and mom will appear to be ‘hung up’ at stages – some will say there is a faliure to progress.  (Again, this is simply because the nose does a poor job of dilating the cervix.)  Please give labor a try – these babies can and do fit!  It’s worth the extra effort.

The Prognosis: Since Angel babies are born sunny-side up (face and throat facing upwards toward the ceiling) the baby needs to be suctioned at once, so no amnioatic fluid is asperiated into the lungs.  Since the baby is born with his neck pushing against the mother’s pubic bone, there is sometimes a fear that the child will suffer from breathing difficulties (edema around the throat), but this rarely happens.  Although the baby is terribly bruised during the labor (imagine using YOUR nose to force through the birth canal!) the prognosis for mommy and baby (assuming they have a caring provider that allows them to birth vaginally) is fine.  The face will be swollen for a day or so.  90 percent of angel-faced baby’s deliver vaginally!!!   Mine did!  At over 9 1/2 pounds too!  With a big ole face like a dinner plate!

If the chin is facing the Mom’s tailbone:  (Posterior)  Then the prognosis is not so good.  Even midwives agree that if you have a face presenting baby with a “mentum posterior”, vaginal delivery is almost impossible.   Often the chin will get hooked on the tailbone, and the baby is wedged in the no-mans land of the birth canal.   Happily of all face presentations, only about 30 percent are posterior and many of them rotate before they get stuck.

Vaginal Delivery: Remember, 90 percent of all face presentation babiess deliver vaginally!!  The reason for this is most face babies aren’t diagonosed until very late in the labor when it is already apparent that baby is coming down that birth canal, doctor training or no!  Be aware that if a hospital rountinly uses sonograms during labor, or if your doctor is doing frequent vaginal exams, they will discover your baby is facing the heavens and may request a preemptive c-section (because of the small danger a baby may asphyxiate on it’s own amniotic fluid.)  You need to decide what you feel the risks of this are.  I had my angel baby vaginally, natrually, and at home.  And it’s a decision I feel blessed I made.

Material gathered from:  Spiritual Midwifery, by Ina May Gaskin & Gentlebirth

Also some cool midwife books that I don’t own but that my midwife brought over the day after Stealth Baby’s birth to show head position, rotation and generally talk about what happened the night before while I was in labor land.

Most face first presentations are delivered vaginally as they aren’t diagnosed until the baby is descending. In order for a baby to deliver face first, it would need to be mentum (chin) anterior. Face first labors tend to be much more painful for the mom and much slower since faces don’t dilated the cervix very well. Only 0.4% of babies will present face first. In my situation, the doctor didn’t catch that my son was face first and she even tickled his head to stimulate his heart. She must have felt his cheek or forehead. Often times doctors will realize the presentation when they check and the baby sucks their finger. Sometimes the mouth is mistaken for the anus and the baby is misdiagnosed as being breech. The causes of face first presentations can be a weak abdominal wall and the pelvic shape. Other times it’s an OP (occiput posterior) baby who just happens to stick their face in the pelvis at some point during labor.

It has been said that the problem with the face first presentation isn’t really the face but what follows. In our case, my son had a 14.5 inch head that had the face engaged the pelvis would have had to pass through the pelvis unmolded. I am sure that wouldn’t have happened. I do not really believe that women can grow babies they can’t birth but in a situation where a rather large head must birth unmolded, it makes me wonder. Regardless, because his face presented transversely, he was unable to engage past a -3 station anyway. This article discusses face first presentations in more depth.

My face first presentation was diagnosed once the c section began. He was wedged in such a way that he couldn’t go forward and pulling him back out was very difficult as well. This resulted in the additional vertical cut into  the contractile portion of the uterus. Interestingly enough, as only 0.4% of babies present face first, only 0.4% of cesareans are inverted t incisions. They are typically saved as a last resort in emergency situations are extremely difficult deliveries that require more room to maneuver within the uterus.

When a cesarean delivery starts out with a horizontal bikini cut as mine did and then is given the additional vertical cut, usually the cut is small and stays in the lower segment of the uterus. These kind of scars are generally considered safe to VBAC although finding a provider may be difficult. My operative report does not indicate how long the vertical cut was, sometimes the doctor does include that information. Mine only says that it was cut into the contractile portion of the uterus. Sometimes the t extension does go into the fundus or the top of the uterus. This is more representative of  a classical incision and is considered riskier.

Because of the increased amount of scar tissue and a scar in the contractile muscles, the recommendation from ACOG is that women with inverted t incisions should not TOL (trial of labor) in future pregnancies. My doctor also told me that I should deliver at 36 weeks after an amniocentesis to check for lung maturity. While the third trimester risks of amniocentesis are low
, I have a big problem with purposefully delivering a preterm baby by elective cesarean. My son was born at 41 weeks and 1 day. He was 8lbs and 5 oz. He was healthy other than the birth trauma and breathing issues related to our cesarean. He obviously needed to gestate that long. At 36 weeks, he would have been 5 weeks and a day early. He definitely would not have been ready to be born.

This early delivery recommendation stems from the increased risk of uterine rupture. There is an increased risk but it may not be as high as some doctors make it out to be. The rupture rate for a low horizontal cut (bikini) is about .5% and I have heard doctors say there is a 15% chance of rupture for an inverted t incision (offering no info to back up that claim and not responding when I challenged it). I have read online where doctors say 4-9% but with no references or studies proving that range.

Ann Frye says “.As far as the type of incision goes, the mother who has a low transverse uterine incision is at the lowest risk for scar-related problems such as dehiscence and rupture. Those with classical or T-shaped incisions are at more risk for rupture, which tends to be more traumatic than the usually benign scar disruptions which occur in women with low transverse incisions. While some types of incisions pose more risk, the highest risk is still probably around 5% (some scars are more rare and limited data is available. From looking at the existing data, 5% seems to me a generous estimate of risk for all types of Cesarean scars, with the order of risk as follows: low transverse [0.5% Haq, 1988; to 2% Clark, 1988], low vertical [1.3% Enkin, 1989], classical and inverted T [probably about the same for both: 2.2% to 4%, depending on the study], upright T and J-incision [probably somewhat higher, but no specific data is available].). Women with an upright T, J-shaped, or classical incision or those who have experienced previous uterine rupture may want to birth in the hospital, although finding a practitioner that will assist them to have a VBAC will be more difficult. However, in these cases scar disruption is **most likely** [emphasis the author’s] to occur during pregnancy with accompanying fetal distress and possible death, or not at all. ” The references are vague here as well.

The Landon Study (2004) found that the rate of rupture for inverted t incisions is 1.9%. I tend to trust this study more than anything a doctor tells me or any other study. The reason is because it seems to be the largest one I can find. Most women with inverted t’s do have repeat cesareans so there are not many large studies. This particular study included a total of 17,898 women who had TOL after cesarean. Of these, 14,483 had a prior low transverse incision (bikini cut) and the rupture rate was 0.07%. Of the total 17,898 women who had TOL, 105 had inverted t incisions, j or classical incisions. Two of these women ruptured equaling a 1.9% rupture rate for inverted t, j and classical incisions combined. All of them either showed up late in labor or simply refused repeat cesareans. The outcomes for these two women and their babies were not included in the study.

For me personally,I am comfortable with TOL after inverted t in a supportive environment with fetal monitoring. If I have a successful VBAC, I am comfortable home birthing the next one. I have found a doctor that will TOL with me. His only requirements are venous access (hep lock but I don’t have to have the IV if I don’t want it) and continual electronic fetal monitoring. I can live with both under the circumstances. I will have no time constraints on my labor, limited staff interruption, the use of a tub and wireless portable monitoring, a doula, my Bradley Method trained husband and the comfort of knowing if my uterus blows that my doctor is there waiting in the hallway. There is a 0.095% chance of the baby dying in the event of a uterine rupture. Outcomes are greatly improved when the cesarean can be performed within 20 minutes of the suspected rupture. For me, I can VBAC comfortable knowing these percentages. I think that the option to VBAC for moms with inverted t incisions should be based on the mothers comfort level and knowledge. I hope that this post can help moms make a more educated decision. I will add new information as I learn it.

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