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.Read Full Post | Make a Comment ( 52 so far )
‘Optimal Fetal Positioning‘ (OFP) is a theory developed by a midwife, Jean Sutton, and Pauline Scott, an antenatal teacher, who found that the mother’s position and movement could influence the way her baby lay in the womb in the final weeks of pregnancy. Many difficult labors result from ‘malpresentation’, where the baby’s position makes it hard for the head to move through the pelvis, so changing the way the baby lies could make birth easier for mother and child.
This is near and dear to my heart and something that I tend to go into depth with my clients on. It is SO SO SO very important and it is rarely discussed in prenatal visits with OBs. It’s not really something discussed at prenatal visits with OBs amd I’m assuming that it’s because positioning doesn’t really matter when the baby can be cut out if it’s a problem. Midwives and my homebirth OB in Korea as well as other natural minded OBs tend to spend more time on this. Anyway, it’s near and dear to my heart because I had a difficult position with my first baby, face first. Face first and face up or occiput posterior, OP, are two different presentations. Face first is rare, one in 500 at most. It is a position that is refrequently sectioned because the labor is very slow but it is vaginally deliverable in some situations. It is very uncommon and there are reported cases of broken necks and facial paralysis but I think that is generally due to pitocin augmentation causing much stronger contractions that the face first baby can handle. I planned a natural birth and after three days of contractions, meconium and fetal distress was sectioned (for failure to progress) only to find a face first presentation that ultimately resulted in an inverted T incision (which I will discuss in depth in another post).
The first picture is a face first presentation. The second is the optimal occiput anterior presentation.
I am also including the chart below that shows the presentation view from the outlet. My son was Face First, LMT, left mentum transverse. This is considered to be a physically impossible presentation for vaginal delivery and the occurrence is extremely rare.
I spent a TON of time talking and reading and researching what happened, what caused this and how it could have been prevented and there are many things that I did wrong. I have healed from all of this and am completely capable of talking about it as I think that everyone should know how they can affect their labor, by the way. My situation was a series of events. First, poor diet in early pregnancy led to early swelling. Pitting edema at fifteen weeks usually raises red flags and of course I was told to sit with my feet elevated above my hips as much as possible, which of course I did (I mean who doesn’t want to be lazy when pregnant???). I continued with my poor diet and now lack of exercise throughout the pregnancy and managed to gain 60lbs. Sitting in a reclined position is the worst thing you can do in pregnancy because it causes the pelvis floor to tighten and the uterus to tilt so the baby has to find a comfortable position somehow and mine settled ROT (right occiput transverse, right side of my stomach, back of the head towards my back and sideways, you would see the babes profile). This apparently is the best position for a baby to flip OP (occiput posterior, face up) during labor. Instead of doing that, mine just stuck his face in my pelvis. This causes a hyperextended neck and really, faces don’t dilate cervixes.
There are a number of things that I could have done differently but I’ll get to that in a bit. First I want to discuss what the optimal position is. Then I’ll tell you how to get there.
The ‘occiput anterior‘ position is ideal for birth – it means that the baby is lined up so as to fit through your pelvis as easily as possible. The baby is head down, facing your back, with his back on one side of the front of your tummy. In this position, the baby’s head is easily ‘flexed’, ie his chin tucked onto his chest, so that the smallest part of his head will be applied to the cervix first. The diameter of his head which has to fit through the pelvis is approximately 9.5 cm, and the circumference approximately 27.5cm. The position is usually ‘Left Occiput Anterior’ or LOA – occasionally the baby may be Right Occiput Anterior or ROA.
SO, how to achieve optimal fetal positioning? Very simply actually. First, posture. Gail Tully and Jean Sutton say no furniture! Sit indian style in the floor, this helps open your pelvis and release your pelvic floor. Use a birth ball for better posture. “Rest Smart” Nap or sleep in positions that let your baby’s back settle in your “hammock.”
To help facilitate good positioning, pelvic tilts should be done daily and several times a day. Walking and prenatal yoga also help with positioning by moving your hips and pelvis, stretching things out and encouraging the baby to engage in an occiput anterior position. Remember though, HEAD DOWN IS NOT ENOUGH! Babies can be head down but OP (face up) or asynclitic which can cause really long hard back labors. Read here to learn more.
So you may need to figure out what position your baby is in to begin with. Belly Mapping can help with that. By feeling where the baby is, where you feel movement, where the heart beat is, the shape of moms tummy, we can figure out how the baby is positioned. It isn’t hard to do at all. Once you learn the postition, you can then focus on improving it or changing it completely. Sometimes we know before labor even starts that the baby is OP and can get the baby to rotate. There are also ways to get a breech baby to turn.
Every pregnant woman should know this information. It is so vital in ensuring that you have the best labor and delivery possible. Sometimes breech babies won’t turn and sometimes OP babies stay OP but by learning OFP techniques you are at least giving yourself a chance to make a difference.
If you are pregnant here’s a list to help with positioning:
Pelvic tilts 20 each 3x per day
Sit indian style
Do not recline
Use a birth ball
Take at least a 20 minute walk every day
Learn what position your baby is in now
Learn what to do to improve the position
Learn what to do to keep the baby in that position
Get help if you are unsure
Get help if the baby won’t move
EDIT: Here is some information sent to me by Ann Tumblin concerning OP babies and epidural use.
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.
EDIT: 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.Read Full Post | Make a Comment ( 48 so far )