Sunday, July 26, 2015

Engaging Baby in Labor


Engagement of the baby into the pelvic inlet (brim) is important because to fit through the pelvis, baby has to get into the pelvis first. Engagement is when the widest part of baby's head enters the true brim of the pelvis.


Figure 1. Diagram depicting the fetal head immediately prior to engagement. The straight black arrow depicts the scanning plane at the level of the pelvic inlet, utilized to depict the presence or absence of engagement of the fetal head, with the transabdominal transducer placed in a transverse fashion above the maternal symphysis pubis opposite the maternal sacral promontory. The curved black arrows depict various possible scanning planes, which may assist in depicting the fetal biparietal diameter either below or above the pelvic inlet (engaged or not engaged). The dashed lines indicate the scanning planes utilized in obtaining Figures 2a and 2b. Note the fetal head is in the left occiput transverse (LOT) position, correlating with Figure 2. (Modified from Norwitz et al.2). http://onlinelibrary.wiley.com/doi/10.1002/uog.102/full


Yes, but if baby doesn't engage at 38-42 weeks, won't baby engage in labor?


Many do.
One study, back in 1999, showed that only 14% of first time mothers went on to cesarean, but in that setting the cesarean rate was normally far lower. My, how times have changed.
Non engagement of the baby is one "flag" that tells us to pay attention to body balance and fetal position. After adding balance, many babies rotate and engage with labor contractions. Labor really is useful!

How can I tell if my baby is engaged?


Tips to tell if baby is engaged. Is baby in ideal starting position which support easier engagement
(but doesn't guarantee it, obviously).
Does baby overlap the pubic bone in early labor or active labor? Is baby Occiput Posterior or Left Occiput Transverse?

How can I help baby to get engaged?

Things that help fetal flexion increase engagement.

Adding body balancing will help a long, free stride, walk in soft soled shoes engage baby.
Some people walk the stairs, sideways, holding the railing, up and down one side and then the other. Go both directions on both sides, to get the best pelvic movement.

Deb Lawrence's Dip the Hip (Figure 8s) or otherwise, releasing the lower back muscles and ligaments to the pelvic crests at the back of the pelvis.

Contractions have not started yet, and/or

Membranes released (water broke) but no contractions yet


Circles on a firm birthing ball. Not so much the up and down bouncing... if the baby's head is on the pubic bone, that is going to be tough on the baby. But flowing circles and figure 8s will also loosen up those pelvic attachments just mentioned and help your little egg drop into the cup of your pelvis.

Psoas Muscle Release (or resolve short psoas issues at www.coreawareness.com)



Will Breaking the Water help baby engage?

Yikes! Please no! Well, in some cases this may work really well. In many cases, its nearly the same as signing the cesarean permission form. That's said pointedly. Add balance and then movement first if you can.

Adding body balance may help baby engage, because engagement is as nature intends, and adding balance returns your innate design closer to that which nature intended for you.


With contractions to help baby engage

Now we're talking. The first task of contractions (other than the practice contractions of pregnancy) is to engage baby. Some babies must be rotated first, and we hope the first baby, or VBAC baby, enters the pelvis from mother's left side. But flexion, chin tucking, is the most important indicator of vaginal birth. I believe that entering the pelvis from the left gives the first baby the most opportunity to tuck their chin.

There are techniques on Spinning Babies that have anecdotal claim of helping engagement.

The circles on the ball may be effective in engagement.

The next three techniques only work with contractions! They do not work in pregnancy.

Posterior pelvic tilt. Flatten your lower back so that your arm can't fit in the space where your lower back curves if you flatten it against the wall. This would only be effective with contractions!

One favorite of mine is Janie King's Abdominal Lift described in her book, "Back Labor No More." I add a posterior pelvic tilt to the "belly lift" and find even greater success for babies that are still high once labor is active.

Walcher's "Open The Brim" is specific to engaging babies at the inlet and has been studied. This is a common technique in Germany and other places in Europe. Its intense and often successful.




References for Engagement



Caughey, Aaron B., et al. "Safe prevention of the primary cesarean delivery." American journal of obstetrics and gynecology 210.3 (2014): 179-193. (...it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught.)


Debby A1, et al. Clinical significance of the floating fetal head in nulliparous women in labor. 2003 Jan;48(1):37-40.  (A persistently floating head with advanced cervical dilation (7 cm) should prompt consideration of cesarean section since little is to be gained by waiting. ) [OMG, Walchers!]

Ghi, T., et al. "Sonographic pattern of fetal head descent: relationship with duration of active second stage of labor and occiput position at delivery." Ultrasound in Obstetrics & Gynecology 44.1 (2014): 82-89.  (13.5% of babies were posterior with a 50% cesarean rate. Posterior babies came down through the pelvis better if flexed as told by observed Angle of Progression.)

Haberman, S., et al. "OP22. 08: To evaluate the value of the determination of occipito posterior position before head engagement and risk of persistent OP and Cesarean section." Ultrasound in Obstetrics & Gynecology 38.S1 (2011): 121-121.  (Before engagement, 76 (43%) fetuses were in occiput posterior position (OP), but 67 (88%) of them rotated to occiput anterior (OA) during labour. Eleven (6%) fetuses were delivered in OP, and 9 of them were in OP before engagement (P < 0.001). 22.4% of cases in the OP group underwent Cesarean section compared to 12.7% of controls (P < 0.001).

Kelly, Georgina, et al. "Women's Perceptions of Contributory Factors for Not Achieving a Vaginal Birth After Cesarean (VBAC)." International Journal of Childbirth 3.2 (2013): 106-116.

Khurshid, Nadia, and Farhan Sadiq. Management of Primigravida with Unengaged Head at Term Placenta 4.2 (2012): 4.
 (The incidence of high head in primigravidas at term was 22%.The most common cause was deflexed head, next was cephalopelvic disproportion. In 40% no cause found. Vaginal delivery occurred in 67% of cases, 33% of cases had caesarean section. No interference i.e., ventouse or forceps required in 60% of cases. In 64% cases labour lasted more than 12 hrs.)

Shaikh, Farhana, Shabnam Shaikh, and Najma Shaikh. "Outcome of primigravida with high head at term." JPMA. The Journal of the Pakistan Medical Association 64.9 (2014): 1012-1014. (The most common identified cause of non-engaged head was deflexed head in 28(28%), while no cause was found in 45(45%) women. Further, 45(45%) women presented with spontaneous labour, while labour had to be induced with prostaglandin in the rest. Vaginal delivery occurred in 59(59%) cases and caesarean section was performed in 41(41%). The duration of labour was <12 32="" cases.="" hours="" in="" p="">

Verhoeven, Corine JM, et al. "Does ultrasonographic foetal head position prior to induction of labour predict the outcome of delivery?." European Journal of Obstetrics & Gynecology and Reprod Biology (2012).

Best outcomes for first time mothers with unengaged babies were found in this 1999 study: 

Roshanfekr, Daniel, et al. "Station at onset of active labor in nulliparous patients and risk of cesarean delivery." Obstetrics & Gynecology 93.3 (1999): 329-331.iology (2012).

Best outcomes for first time mothers with unengaged babies were found in this 1999 study: 

Roshanfekr, Daniel, et al. "Station at onset of active labor in nulliparous patients and risk of cesarean delivery." Obstetrics & Gynecology 93.3 (1999): 329-331.
The rate of cesarean was still dramatically higher for the unengaged, but wasn't near 50% higher as in four other studies. In fact it was 19%, less than 1 in 5. Today 1 in 3 of all women deliver by cesarean section. So I'm not sure what we can derive from this fact. 



Friday, July 24, 2015

Unraveling the mystery of non-engagement

Dear Gail, "I loved your new video on exercises for optimal fetal positioning!

I finally got my second baby into the right position but alas, he did not engage and I did not go into labour which resulted in an elective section at 42 weeks.

I had a previous cesarean when my waters broke without contractions. My first baby didn't engage despite being induced.  I'm now wondering if there is something wrong with my hips?  Do you have any idea on why neither of my babies engaged?"
[Slight editorial changes were made here to help you understand the email better.]
This baby is well engaged and fitting through the inlet and midpelvis.

Lack of engagement in the pelvic brim (inlet). One parietal eminence remains outside the pelvic brim.
Baby stays high, -3 Station or higher.
From Smellie.


Gail responded:
"Congratulations on new motherhood again. Congratulations on your new baby!
I'm so impressed with how much you did to achieve a natural birth and try to wait for labor. I may be able to shed some light on the mystery or, I may not...let's try.


When baby is in an optimal position and doesn't engage I wonder about
  • Misalignment of the pelvis (SI and symphysis joints, rotation of sacrum on vertical axis)
  • A reduced diameter of the pelvic inlet from nutritional or sunlight deficiencies growing up
  • Psoas tightness (see www.coreawareness.com)
  • Scoliosis
  • Something to do with the baby and cord: short or wrapped cord, or baby's arm in the way
  • Dates are incorrect and baby is 2-4 weeks early
  • An overall small pelvis. When an ideally positioned baby, Flexed and Left Occiput Anterior or Left Occiput Transverse doesn't fit the bones, then we have a true Cephalo Pelvic Disporportion, or CPD, which means baby's head really is too big for the pelvis.

To guide our train of thought, I want to acknowledge that you've had two babies that did not engage. That makes the question of correct dates, a short or wrapped cord, or compound presentation (hand or arm coming with the head) unlikely. 

My questions to help detect some more clues: 

Do you know of any spinal or pelvic misalignments or differences to the average in your situation?
Did either baby have any molding on the head? Molding would typically only be seen after many hours of very strong and frequent uterine contractions. Actually, many babies that haven't engaged even with strong, frequent contractions show no molding of the head. But its a clue that may help if it is present.

Sometimes if a woman's outlet is quite wide, the inlet is narrowed, by a torque that closes the brim and opens the outlet. Think of a clothes pin and as you open the clothes pin the top of the sticks get closer together. This can be corrected if it is the case. A spasm in the ligaments is the cause. The right kind of body work is necessary.
How would you know if you have a wide outlet? 

The lines represent (from the top) the pelvic inlet, the midpelvis, and the outlet diameters.

A posterior baby remains on the pubic bone and not engaged.
Doing your own Pelvimetry to figure out if pelvic shape is a contributor.
Pelvimetry means measuring the pelvis. We can do a simple approach to get a general idea of pelvic shape. The following is a just for fun self test. The test is not detailed enough to be definitive. See an experienced midwife, obstetrician, or labor and delivery nurse for verification of your pelvic size and shape. MRI measurements may help, but really, labor decides if the pelvis is big enough.

 Let's talk about three places in the pelvis for a self-check. 
  1. The sitz bones
  2. The pubic arch
  3. The front to back distance between bones (not the padding around the bones, so to speak)
  4. The side to side distance between hip bones.  
Remember, Measurements can't usually tell you if you can fit a baby through the pelvis. Once the baby is engaged, then the size of the pelvis becomes less important than the mobility of the pelvis!!

I include this because many women ask, not because I think that the answers tell whether or not you can have a baby through your pelvis. This is a guide, a beginning. The land is not the journey, however. Let's start the self test. 

Lie down, wearing thin stretch pants or undies to do these first two checks. Stand for the last check.

1. )  The Sitz bones, or Ischial Tuberosities, make up the side limits of the outlet. 
If the outlet is pulled wide by ligaments and chronic muscle tension (you don't have to feel tense emotionally for this to have happened over the years), it may be that the inlet is pulled narrow.
To find out see if your own fist fits easily between your sitz bones (externally!).


Image from http://library.jefferson.edu/Collections/DVDs/obgyn101/Text/Abnormal%20L&D/fetopelvic_disproportion.htm
You can lay on your side and use your own fist from behind you. Or, ask your mate. 


Find your top sitz bone beneath the padding of the upper buttocks.
Feel for the edge of the lower sitz bones, its a bit of a reach.

Closing your hand, place your fist between the tuberosities and choose the best description: 
A. You can feel both sitz bones at once on the edges of your fist, or a slight tilt brings you in touch with the second sitz bone.
B. You can easily feel space around your fist in addition before your sitz bones are touched by your fist. Roomy.


Now,
2.)  Feel for your pubic arch.

Pubic arch in red
Laying on your back with knees bent, wrap your fingers around your pubic arch. Its like a kid grabbing themselves to avoid peeing their pants. You don't have to smash your fingers into your urethra, be kind. The measuring place is between the top and the sitz bones at the bottom of the pubic arch.

A. Is there room for three fingers or 1 and a bit more?
B. Or is the arch very wide, even four of your own fingers fit across?
This second check verifies the first check.


Now stand,
3. )  Approximate the depth of your inlet. 
Have a helper measure the visual distance between your pubic bone and top of your sacrum.
They kneel next to you and by just eyeing the distance, not wrapping the measuring tape,
they hold one end to the front and one end horizontally to the back. This is very simplistic.
A. My distance is about 9 inches 
B. My distance is about 7 inches
This is a rather subjective measurement. If you have a girlfriend about your size, you can measure each other and compare. 
By far, most people measure 9 inches or a little more. Remember, you aren't measuring fat or clothes,  find the bones and approximate. A measurement of about 7 inches, more or less, might mean the front to back distance is a short distance. See more in pelvic shape.

An alternate way of assessing if one has a Platypelloid Pelvis
4.)  Approximate distance between hips
Stand and measure the distance from hip to hip (ASIS). Use a tape measure or ruler.

Image from http://www.activeortho.com/store/how_to_measure_si_belt.html
I also like the Serola Sacroiliac belt http://www.serola.net/serola-sacroiliac-belt

Your hip to hip bone measurement is
A. 11-13 inches
B. 15-17 inches between boney hips.
The fourth measurement verifies the 3rd. 


Outcomes of Your Pelvimetry

If you answer B to these questions, you are likely to have a small inlet.
If you answer A to these questions, you might still have a small inlet or not, its not conclusive.
You can also ask an experienced (years and years of) midwife or Labor and Delivery Nurse to do your pelvimetry for you. But they will not necessary know that an extra wide outlet may mean an extra constricted inlet. We can't feel the inlet for one thing. 

Not many birth care providers understand how one change in a pelvis causes another. They would think wide outlet means a big inlet, too. This would make some people shrug or say its not a pelvic issue.

And of course, sometimes that is correct, when the overall pelvis is large. That's not our assumption for this situation. We may be seeking clues here for pelvic torsion, I believe, or cephalo pelvic disproportion. Let's rule out Pelvic Shape first. 


Pelvic Shape and Engagement

Another possibility to lack of engagement is an triangular shaped pelvis, called the Android pelvis, which can make engagement an issue.
In that case, you find close tuberosities (Sitz bones) and a very narrow pubic arch of only 1.5 or maybe 2 fingers across. 

Not engaging from a posterior position is common for this pelvic shape. Helping baby be in an ideal LOA position usually brings about engagement and labor progress. It is not uncommon for birth providers not to know how to help engage baby in an android pelvis. Walking the halls is unlikely to engage  or rotate a posterior baby in this pelvis.

Another possibility to lack of engagement is an narrow front-to-back pelvic diameter, called the Platypelloid pelvis, which can make engagement an agony when baby starts posterior. Helping this baby into a Left Occiput Transverse position is the only way for baby to engage. That will immediately relieve the brim pain and labor will likely stop so the uterus can rest and then after a meal, labor will resume and bring the baby in 6-8 hours. If the uterus doesn't need a rest (maybe because baby started LOT then labor may be 24 hours or less in this pelvis, a second baby may come in 6-8 hours total if starting LOT.)

When pelvic shape is the issue, we see that skills in supporting a labor with a pelvis that is not round is of key importance. Skills to support labor are slipping away from the world. Spinning Babies is determined to bring them back!

Here is an introduction to engaging baby in labor: http://spinningbabies.com/start/in-labor/engaging-baby-in-labor/
And
Here are tips for helping baby engage in pregnancy: http://spinningbabies.com/start/in-pregnancy/38-weeks-is-baby-engaged-yet/

I hope some of this is helpful. Most of what you read here will not be useful to you, so I include this hoping that you find some clue to help you decide what to do for a future pregnancy or put a new story for your past experience.

Finding a way to make sense of something unexpected that didn't fit our expectations is really a first and major step in healing.


Soon, I heard back:

"This is amazing!  Thank you Gail!!
I'm so thankful for your response as the midwives and doctors I have asked have not been helpful.
Yes, you can absolutely use my question in your blog.  My first baby was [Occiput Posterior]  which is why I believe the waters broke early - well it was actually on my due date but I always presumed he just wasn't ready to come but if it is a case of there being something wrong with my hips then it could be that he just couldn't engage...
My mother was told she had "tilted hips" which resulted in 3 c-sections for here so perhaps there is hereditary here!
I had been preparing for a VBAC for over a year!  I never thought I'd end up with an elective but just bring supported by the hospital staff to go right up to 40+16 was healing for me, I felt like I gave it my best shot but I am just so curious as to why I didn't go into labour!... "

Gail ponders,
Well, now we have another clue. I wonder what "tilted hips" means? Could simply be a steep inlet which often needs a vertical position, like standing up and leaning forward, to help baby engage. It could also mean the hips are rotated in such a way that the baby needed mother to add body balancing to help baby find the space to enter the pelvis. 

"Let's make room for the baby" is not imploring a magical increase in hip size! It means aligning the hip joints and so the muscles within the hips. It means lengthening and releasing muscles and ligaments to help the pelvic bones be more aligned and more mobile -just as nature intended!

A chiropractor or osteopath has skills for pelvic alignment. And some have the extra training for myofascial release of pregnant women, such as taught by Dr. Carol Phillips, DC, in Annapolis, Maryland (www.dynamicbodybalancing.com). Explore the possibilities of professional help. 



Why a baby didn't engage is a common question. 
We have some techniques that may help reduce the higher percentage of babies born by cesarean when they are unable to engage in labor, but we may not be able to help every mother and baby with engagement. Next blog, Engaging Baby in Labor. See the references there.



Changing the Earth by supporting Birth

Mothers bring forth life; medical corporations do not. Birth can be simple, powerful and loving. Fetal positioning, natural birthing and practical help for normal birth.