Ok ladies - your turn! I'm looking for ideas to help in trying to rotate a baby from a deep transverse arrest.
It seems to me that, when combined with a dense epidural, even with left and right lateral position changes, these babies in LOT or ROT positioning do not want to budge.
I had a woman who was stalled at 7-8 cms/-1 station for hours - no epidural, small amount of pitocin augmentation, remained mobile - who finally consented to an epidural so we could titrate the pitocin higher to bring the baby down. This was baby #1 for her.
Finally, after many more hours and left and right lateral position changes Q 30 minutes, she got to complete dilation, but remained at zero station. Baby felt to be LOT position to me. By Leopold's, I estimated a 9+ lb baby. No matter what I did, this baby did not descend.
Any thoughts, ideas, suggestions from other nurses, midwives and doulas? Like I said above, she remained mobile for many hours, and when she received an epidural, I changed her from far left to far right lateral Q 30 minutes. Maternal pushing, after laboring down, did nothing to move this baby any further.
15 comments:
no personal experience, but have heard from doulas about good results when mum rests on hands and knees while partner/nurse/doula strokes the belly in the desired direction of movement for the baby. Said to work well before or during labour!
We have what we call the 'Go back to your room and come out when you are ready to play nice' position. Essentially we place the patient in trendelenberg and position them on their far right (sometimes using the stirup to place their leg up a bit) for ~30-45minutes, then rotate to the far left for the same amount of time. We keep them trendelenberg for an hour or 2, then we position normally and hope that baby has rotated correctly. Good luck!
What about a Rebozo? Do any of your doulas use these tools? In my doula workshop, a doula demonstrated how to use a rebozo to change the position of baby. http://www.birthingnaturally.net/cn/tool/rebozo.html
There is also a Rebozo DVD, I think it's called "The Rebozo Way." I'd recommend checking this out!
http://www.spinningbabies.com/techniques/activities-for-fetal-positioning/roll-over
The position in the middle of the page, on her side is my magic position for reducing anterior lips and rotating OP babies. Two tips that differentiate from right/left lateral.
1. make sure arms are on opposite sides of the body--I really think this puts more pressure on the tummy, which encourages the baby to rotate/descend.
2. Make sure the top leg is bent as high as you can make it---I find this one particularly difficult to trace FHTs in if the leg is too bent.
Our epidurals too are often low dose enough to do hands and knees for awhile as well, but I usually just rotate them back and forth.
I was also going to recommend using a rebozo. I was taught to use one during my doula training and found it to be useful when trying to reposition babes. :)
Lunges! Check out Gail Tully's Spinning babies site. Attended her workshop in January. Highly recommend it! Also check out Penny Simkin book on preventing dystocia.
Here are my ideas:
1. If it's early labor and baby is still pretty high up, have her do an open knee chest position for 45 min.and see if you can get the baby to back out and rotate, maybe with sifting or hands and knees after that time is up. It's deathly uncomfortable for mother, but better than a stuck baby.
2. I would try a 'texas roll'/exaggerated Sims with mom's upper leg cranked just as high up as you can get it, then try that on the other side after 30 min.
3. It's also worth it to try some pretty vigorous sifting with a rebozo, or use the bedsheet to do the sifting -- nurse/doula grab one side, partner grabs the other, and they sift mom back and forth (think of almost 'sloshing' the baby around - it's pretty energetic sifting). You can do it with an epidural in place. One of my doula colleagues swears by this for rotating OP babies.
I asked about ROT positioning at a Midwifery Today conference since I had just experienced an ROT labor. That's where I first heard the acronym of ROT=ROTten.
One of the suggestions I got was an inversion to try to lift the baby out of the pelvis. The way I was taught it was "boobs on the floor" - like, she really has to get her front as low as possible in comparison with her hips.
I wish I felt more confident with a rebozo. It looks so easy when I see it demonstrated, but then when it comes time for hands-on I hesitate. Does anyone have any tips for getting more comfortable with using it?
For my OP baby (#6 for me) they had me do something similar to that roll over. Hands and knees, left side, back (with knees to chest), right side, then leaning over the back of the bed with it in the upright position (me on my knees at that point upright), and then back to hands and knees. Moved a persistent OP that was high and floating. Did this during the pushing phase, and in ten minutes baby turned and came out in her full bag of waters.
Blessings!
Dawn
This is what happened to me. Stalled at 6cm for hours, finally consented to AROM "to strengthen the ctx". And then immediately thereafter (24 hours into labor) asked for epidural. Pitocin drip. Got to complete. Pushed for an hour - oh, her head is sideways! Oh dear. Tried a couple times to push her back up and rotate. Didn't work. Sectioned.
I didn't have a doula and my midwife was a giant disappointment - she didn't even show up until I was already on the epidural (yes, 24 hours into labor.) Will always wonder if I'd had some more experienced help...
Naolí Vinaver has some interesting workshops and videos about how to help baby turn.
My first thought was lunges and other asymmetric positions. If mom has an epidural and can't do this, then try to replicate the position as best you can while she is on her side. The trick is to get the pelvis asymmetrical. That can give baby more room to turn where it needs it most.
If you are trained in it, manually disengaging the baby so it has more room to finish its rotation can sometimes work. Gotta make sure the cord doesn't prolapse, of course, but disengaging the baby (via knee-chest position, trendelenburg, or manual disengagement) can sometimes work.
It's really optimal not to have AROM in these situations if possible, so baby still has that cushion to help him turn. Sometimes if that's gone, it's really hard to help them turn and a c/s become inevitable.
When a woman has a situation like this, I sometimes suggest that the woman see a really good pregnancy-trained chiropractor to see if there is any pelvic misalignment/tightness that can lead to malpositions such as this. I've seen this make a real difference for a lot of women....not a cure-all but it CAN help.
But yeah, a transverse arrest is not an easy situation. Sometimes they'll spontaneously resolve with movement/change of position, but not always.
May I ask a question? Shouldn't the baby's position be checked before AROM, augmentation, etc so that these interventions don't make the baby's turning even less likely? Or would it be too hard to tell at that point?
since there are some epidural comments, check out this post about birth centers at www.rnperspective.com
Walcher's Position can bring a baby down. I've seen this work amazingly well. If it doesn't work before water is broken, try again after. I usually do pelvic floor release first (also on Spinning Babies)
http://www.spinningbabies.com/techniques/activities-for-fetal-positioning/walchers-trochanter-roll
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