As a midwife, what do you do when...

[QueenOfThePride]

the baby is in the birth canal and goes into distress?

[pamamidwife]

During pushing? I suppose it would depend on the degree of distress and where we were at, how fast this woman pushes out babies, what it would mean to transport and have a distressed baby born in a car or ambulance, etc.

Many babies do reasonably well with low heart tones in pushing. Babies that are unmedicated do the best and have the greatest reserves. If a woman needs to get her baby out, an unmedicated, aware mother is able to facilitate positions that can best help her baby be born. If progress is slow and recovery after pushes (because recovery is what matters here, not the heart rate during pushing) is getting slower or deeper in counts, then I'd consider transport.

It's very individual. I've had situatioins with really low heart tones during pushing and right before pushing. In the latter, right before pushing were some late decels, but the mom was near complete and had fast second stages. I think it was about 20 minutes before baby was born, but baby was fine. She lived way out in the country and any ambulance that came was likely to be volunteer, so it was all a call based on many factors.

[QueenOfThePride]

I was wondering more about any manual stretching of the perineum? Is it really necessary? Does it really make the baby come out faster?

[pamamidwife]

no - in fact, when another person applies intense pressure to the perineum, it causes women to tense up and hold in their breath.

with a woman who is aware, looking at her in the eyes and saying, "your baby needs to be born NOW" is all it takes. she will get that baby out.

[MsBlack]

ITA w/Pam.

[QueenOfThePride]

Originally Posted by pamamidwife

no - in fact, when another person applies intense pressure to the perineum, it causes women to tense up and hold in their breath.

with a woman who is aware, looking at her in the eyes and saying, "your baby needs to be born NOW" is all it takes. she will get that baby out.

Thank you.



So instead of telling me what was going on, my midwife stretched me open and proceeded to push my tissues back over the baby's head like a sweater as he was crowning. Despite me screaming, "STOP IT!!!" Then tore me with his shoulders.

[momileigh]

So, how about fundal pressure?

:

Not promoting it, but I do need opinions/information.

[momileigh]

Ooh, Queen, I'm sorry... I hate it when midwives do things to you instead of working with you...

[pamamidwife]

I've heard that fundal pressure works in some instances, I'm not sure about something like this. The last thing I'd want is to cause the anterior shoulder to become impacted behind the pubic bone because of that pressure, you know?

[babycatcher01]

To me fundal pressure is a no no. I have read were there may be a time for it, but to me seems like you could do more harm then good. If you find a reason to do it you need to know exactly how to do it. Even in an emergence situation letting the mother do what she can to ei positioning, letting her using her body to it fullest potential and letting her take charge and focus on getting the baby out.

[blissful_maia]

Originally Posted by pamamidwife

with a woman who is aware, looking at her in the eyes and saying, "your baby needs to be born NOW" is all it takes. she will get that baby out.

:

It also depends what you mean by distress. I wouldn't worry about early decels, with full recovery in between, during pushing. Lates, or variables, depends. Also depends how imminent the birth is.

[BirthFree]

Originally Posted by pamamidwife

no - in fact, when another person applies intense pressure to the perineum, it causes women to tense up and hold in their breath.

with a woman who is aware, looking at her in the eyes and saying, "your baby needs to be born NOW" is all it takes. she will get that baby out.

Both of your replies were wonderful, thank you.

[momileigh]

How would fundal pressure cause an impacted shoulder? (You *never* do f.p. once the head is out.)

And as far as more harm than good, can you elaborate? I can't find any info on the risks of f.p. and I'm unlikely to hear any cons where I train

[pamamidwife]

Fundal pressure forces a baby straight down in an unnatural way...it creates strain on the lower uterine segment as well, possibly increasing the risk of uterine rupture. I know there are many cultures that do this routinely in second stage, but I can't see any reason why we would need to do that.

Babies rotate and corkscrew through the pelvis in second stage - they don't just barrel through straight down. The muscle fibers of the uterus facilitate this rotation. Pushing on the fundus could easily affect this rotation and inhibit the baby turning properly. I honestly believe that this can increase the risk of an impacted shoulder. Does that make sense?

You're training in the US and you are learning that fundal pressure has no negatives? Is it routinely practiced? I'm curious about this because I just don't see the need for it. If women are upright, why would we have to 'assist' them in birth like that??

Here's more info for you: http://www.childbirthconnection.org/...e.asp?ck=10204

[momileigh]

Thanks for the link. Although anyone who causes a tear using f.p. is obviously not being very careful. We would never use f.p. once the head was crowning.

And yes, what you're saying about the rotation does make sense, although I think the baby corkscrews whether you use f.p. or not. (Maybe not always.)

Not exactly routine, but when FHTs are down and progress is slow, it is quite common.

Of course, we never try any positions during second stage beyond supported sitting and McRoberts, which drives me nuts.

[homemademomma]

Originally Posted by blissful_maia

:

It also depends what you mean by distress. I wouldn't worry about early decels, with full recovery in between, during pushing. Lates, or variables, depends. Also depends how imminent the birth is.

well, early decels aren't distress. they are normal. it may seem like semantics but many people get freaked hearing decels in pushing and i think it is important to note the difference.

[mothercat]

Early decels with 2nd stage labor is a physiologic response to head compression, especially in a rapid descent. I think there is a study by Roberts from the late 70's, early 80's which showed that if the baby recovers well after the contraction it can tolerate decels for about 30 minutes.

I did my one and only episiotomy early this year for a baby that kept dropping to the 80's and the recovery kept getting slower after each contraction. We were about 25 minutes into pushing with the decels and mom had the tightest peri/vaginal opening I had ever seen. I explained to mom what I felt I needed to do and she agreed (my other choice was a rapid transport). Baby came out with the next push and needed a bit of help to get started.

I agree that inexperience or unfamiliarity can make for a panicky situation. If the midwife thinks that the baby is in so much distress that it needs out NOW, then she should transport or be prepared to do a full on resuscitation. She probably won't need the whole scenario, but she had better know how to do it and be prepared to call transport if the baby isn't coming around quickly.

On another note, situations such as these can leave the mom feeling quite traumatized. I have a list of birth trauma resources on my web site, but it would violate the MDC UA to link directly to that. I have written to MDC admin. and will be starting a thread in Birth and Beyond with that list that will be stickied so it will be easier to find. HTH.

[blissful_maia]

Originally Posted by homemademomma

well, early decels aren't distress. they are normal. it may seem like semantics but many people get freaked hearing decels in pushing and i think it is important to note the difference.

Yes, I know this, of course. But I think that "distress" is such a both over- and mis-used term. Non-reassuring heart tones seems more appropriate and less "diagnostic" since 9.5 times out of 10 a pink, vigorous babe is born.

[QueenOfThePride]

Originally Posted by blissful_maia

Yes, I know this, of course. But I think that "distress" is such a both over- and mis-used term. Non-reassuring heart tones seems more appropriate and less "diagnostic" since 9.5 times out of 10 a pink, vigorous babe is born.

My baby's heart tones were 60-70 with no recovery. But he came out screaming with excellent Apgars.

[blissful_maia]

Originally Posted by QueenOfThePride

My baby's heart tones were 60-70 with no recovery. But he came out screaming with excellent Apgars.

This is what I mean. He may have appeared to be in "distress", but you can't make that diagnosis until you see a compromised baby after birth (cord gases, etc).

At what point in the 2nd stage did this happen?