Compound or nuchal arm occurs so frequently that it is considered
fairly normal. Yet, when all other causes for hang-ups of labor have
been eliminated, compound or nuchal arm is likely the cause. When suspected,
the baby's elbow or hand may often be palpated just above the symphysis.
The attendant may actually be able to cause the baby's hand or arm to
retract by gently and firmly putting pressure against it externally
and moving it away. This is much easier to accomplish if the mother
is submerged in water.
Upon vaginal examination, I have found the hand at the side
of the head or even over the head, and have been able to cause it to
withdraw by simply poking at the fingers. The problem may not be discovered
until the mother is approaching second stage, and is one reason for
her not feeling a pushing urge. She may say that she has supra-pubic
pain while pushing. While you are certain that she is not completely
dilated, or has a cervical lip, it will be the baby's elbow making pushing
painful. Have the mother put counter-pressure against the area while
she bears down. She will know just how much pressure to use as it is
difficult for the attendant to gauge. When the baby delivers, check
for a hand. If it is there, grasp it firmly, pulling it straight out
while pressing firmly against the mother's perineum. This will facilitate
delivery, while avoiding severe labial and vaginal tears.
E-News asked readers what they do about compound presentation.
Here is one reader's response:
I've seen a number of babies born vaginally with compound
presentations. On a personal note, both of my boys presented hand first.
With my older son, a cesarean birth was discussed with me by my attending
physician when he found the hand presenting. I talked him into patiently
waiting to see what transpired. I gave birth to my son vaginally four
hours later. With my youngest son, my physician found it very early
and patiently watched as I progressed quite normally and gave birth
to him vaginally as well. Both sons, now six years old and 3 1/2 months
old, prefer to sleep with one of their hands alongside their head!
Recently, a friend was having her third baby. Her baby had
been footling breech and was turned externally. She was delighted to
be having a chance at a vaginal birth and was induced after the version.
She ended up having a cesarean birth following two vaginal births because
of a compound presentation. She was progressing quite normally and the
fetus was healthy. Now she is having to cope with that loss. Why did
this happen? Perhaps I am being harsh and do not know all of the circumstances
but her baby was born around 4 pm. Is this a clear case of 9-5 obstetrics?
What do you do with a compound presentation? Watch patiently.
As long as the fetus and mother are healthy, why do anything else?
- Maurenne Griese, RNC, BSN, CCE, CBE
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Midwifery Today's Online Forum
I am an intern midwife in the slum area of the Philippines. I am dealing
with my first low blood pressure woman, rather malnourished as our patients
normally are. Her hematocrit is 32, she is due in a few days. Does anyone
have a suggestion on how to improve a low blood pressure in such a short
time? I am worried that if she hemorrhages, she would not have high enough
blood pressure. What is your experience on this?
To share your thoughts and experience, go to Midwifery Today's Forums.
Question of the Week
Q: I was very ill with Grave's Disease (hyperthyroidism
) after my third pregnancy, took an anti-thyroid drug for a year, and
have been in remission ever since. I had three wonderful homebirths, but
wonder if for future pregnancies I would need to be monitored by a doctor
and if I am likely to have thyroid trouble during the pregnancy.
Send your responses to:
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Coming E-News Themes
1. An E-News reader submitted the following description of her concern
for hospital-birthing women. Please share your thoughts on this issue,
and let's get some problem-solving dialogue going:
I AM A MIDWIFE WHO ATTENDS TO THE NEEDS OF WOMEN BIRTHING IN THE HOSPITAL.
I find that many "modern" (i.e. dot.com) American women and
a large percentage of my Chinese immigrant women have difficulty recognizing
and validating their strength and power in the process. I think the midwives
who attend the [Midwifery Today Eugene] conference probably identify the
same problem, especially those whose clients have the good fortune of
being cared for by midwives by virtue of showing up at a clinic that midwives
attend and having no knowledge of the issues of philosophy, etc.
I would find it useful and interesting to include "ways to inspire
confidence and a sense of the inherent power and brilliance" of women
into the section on women who care for women in the hospital. I work hard
at this endeavor every day, but because our presence is diluted by all
the non-midwives who work in the "institutions," I find it draining.
Your conferences are restorative and invigorating. However, I also feel
a sense of disappointment or frustration because I don't attend homebirths
and the most glorious stories usually are from homebirths. I fully support
homebirth and would love to see a movement to take normal birth out of the hospital and into the home. There are women who don't have a home
suitable for homebirth--they live in what the Chinese call "pigeon
houses" where many families share a common bathroom and kitchen,
are often alone and unsupported. I hope there will always be midwives
willing to attend these women in the hospital.
There is a strong need to remind midwives why they are midwives and
ways of bringing those midwives back to the fold.
2. ASYNCLITISM: What do you do when the baby's head is not deeply engaged
in the pelvis, but is tilted up toward the pubic bone or tilted toward
the mother's sacrum?
Send your responses to:
Know a strong woman? Helping empower one? If you haven't already done
so, please forward this issue of Midwifery Today E-News to one or two
of your friends or business associates. Thanks so much!
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to email@example.com or fax (212) 226-7026.
Question of the Quarter for Midwifery Today Magazine
Issue No. 57 (Theme: Cesarean Prevention/VBAC)
How do you prevent cesareans?
Deadline: Dec. 15, 2000
Send your response to firstname.lastname@example.org
It was interesting to see the questions from Australia concerning
third stage [Issue 2:47]. We've just had an interesting third stage where
the woman was hemorrhaging, Pitocin was given to facilitate delivery of the placenta, and a manual removal was attempted in the end. The cervix
had closed already and only one or two fingers could be admitted. The
patient was transported (to a local government hospital here in the Philippines)
and a complete hysterectomy was performed. She had a history of retained
placenta with previous pregnancies. The doctors berated us for giving
Pit before the placenta was out. So the question ensued as to whether
or not it was OK to give oxytocic drugs while the placenta is still inside,
in the event that it does cause the cervix to close sooner than normal.
I realize this was an unusual happening with the retained half of a placenta
in this case, but I'm curious also to hear about others' experiences with
I've personally been on a quest to stop meddling with things during third
stage, knowing it increases the risk of hemorrhage and we have enough
of that to deal with since we are working with high-risk and sometimes
malnourished mothers. I'm enjoying facilitating placental delivery instead
of taking the easy road and just pulling it out. It works wonders to have
the mom in an upright position. Being flat on your back makes it all the
harder to allow the placenta to deliver spontaneously. My last two patients
just got a funny look on their face minutes after delivery and plopped
out their placentas without a word from me as to what to do. They were
both on the birth stool, holding their babies and bonding. Most of the
time we just wait, monitoring the mother's vitals, watching for signs
of separation, and when we see that, encouraging the mother to push it
out on her own. We like to initiate breastfeeding during this time to
cause the uterus to contract, especially if it's taking a while. I feel
we get too impatient at times, wanting to finish things up, poking at
the uterus to see if it's firm, checking to see if it's rising, fiddling
with the cord, or tugging on it to see if the placenta is there. Most
of these things are fine and even necessary to monitor what's happening,
but gentleness is the key.
Re the cultural hand-washing ritual [Issue 2:45]: We need to remember
that bonding and attachment are not just physical phenomena, they are
also emotional and cultural. I don't believe we can or should try to create
"one way" to have a baby or to bond or to raise children, all
of which are somewhat culturally, ethically, or religiously guided. We
can strive for the safety of women and children in all aspects of their
lives but if, for instance, there is a cultural dictate to wash the baby's
hands, the dictate may be more important than the amniotic fluid that
remains there. In my experience the entire birthing environment takes
on the smell of mother and baby--does this mean the baby is confused?
I'd rather think that the baby feels safe surrounded by so much familiarity.
Let's give ourselves a little slack in how we live. Let's celebrate diversity.
I am currently taking fertility drugs (Clomid) after everything natural
failed. Is it still possible to have a homebirth or would it be considered
a high-risk birth?
- Tendai Phiri
Reply to: email@example.com
I recommend that the woman concerned about gestational diabetes [Issue
2:48] check out the Brewer diet taught in Bradley Childbirth classes.
I credit not having GD a second time to a high protein, well balanced
diet, NOT weight control. Superior diet is the key! I gained the same
amount of weight both times, yet my second son was 1 lb. 10 oz. larger
than his brother (with whom I had gestational diabetes)! You can find
Brewer's web page at Blue Ribbon Baby, and purchase a copy of his book:
- Amy V Haas, BCCE
Thank you, Terra, for your excellent commentary related to MANA [Issue
2:45]. I saw the trend they were following over a year ago and elected
not to renew my membership. If it were not for the awesome efforts of
those midwives who never did become "certified," we would not
be where we are today! I know that as an illegal midwife and nurse-practitioner,
a university education is not what makes an excellent nurse or midwife.
There is so much more to it than title, certification, etc. I worked alongside
lousy nurses who had BSN/MSN after their names--they knew the paperwork
inside and out, but had no love/bedside manner for their poor patients.
So, as always, we all fight one another and get nowhere. Look at the medical
doctors, who regardless of differences still hold together and have one
of the biggest, most effective voices in the world. I am so sad to even
admit that I know some of you who fight so hard against anyone who doesn't
adopt your beliefs.
Re a letter describing dystocia [Issue 2:43] in which after 13 minutes
the baby's head was pushed back and a c-section was performed: never in
my life have I heard that somebody waited for 13 minutes before doing
a c-section! And secondly, regarding the statement that the baby survived
because the cord was not cut, the cord is cut after the baby is born,
so there was nothing special about the fact that the cord wasn't cut,
because the baby wasn't born yet.
- O.S. midwife
I just had my third child. My first was nine days early, 6 lbs. 8 oz
via c-section due to being stuck; second was on his due date, 7 lbs. 12.8
oz, VBAC; third was one week overdue, 8 lbs. 6.2 oz, VBAC but stuck. We
managed to get him out vaginally. My midwife and the attending physician
suggested I should never attempt to give birth to another large baby.
My question is, HOW does one grow a smaller baby? Does it have to do with
being overweight? The foods one eats? The week overdue? I do not believe
in using epidurals so I labor drug-free. I would prefer my next birth
goes natural and not be forced into induction or scheduled c-section.
As I was carefully taught (by some of the best midwives on the planet)
occasionally it makes sense to break the water [Issue 2:48]. I was taught,
as well, that it is important to know the head position of the baby before
taking this step and to combine what you have learned with your intuition,
skill, and heart whenever making decisions with the mom-to-be.
I have had three situations in the recent past in which breaking the
bag seemed to be--and was--the "right" thing to do. The first
was a woman who was at 7-8 cm for several hours. She was tired and the
bag of water was bulging in front of the baby's head. We tried a few things
but decided to release the bag. (I should state here that my mothers eat
extraordinarily well and grow "bags of steel" that often do
not break until pushing!) As soon as I did, the baby came down and she
dilated steadily to ten and had the baby. She was very grateful for this
intercession (as opposed to intervention, a la Valerie El Halta, one of
my mentor midwives).
In another situation, a wonderful, intuitive and feisty mom ordered me
at 9 cm to break the bag. She had had her first bag released at this point
in her labor and the baby had come soon after. I was reluctant to break
it, and discouraged her, at which point she said " I want you to
break it now! If you don't I'll reach in myself and snag the thing on
my own!" I released the bag and within a few minutes, she began pushing
and had a large and beautiful baby.
The third situation was a woman with polyhydramnios. I was encouraged
by several midwives with far more experience than myself to release the
water gradually while exerting gentle but steady pressure downward externally
on the baby's body and head, rather than to wait for it to release on
its own. The woman was at 7 cm and had been there for a while. With the
head now well applied, she circled (my hypnobirthing term for dilated)
to 10 cm within the next hour and had her baby.
So even at my age, I am learning!
- Nancy Wainer
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