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. 



3 comments:

Emilie Bourdet said...

Hello Spinning baby!
I am 32 weeks pregnant with my first baby and I am also training to become a doula.
I have a question about squatting. In your dvd 'daily essentials' you have some yoga postures that involve squatting(with the knees higher than the hips) on a block. I have been reading 'let birth be born again' by Jean Sutton and she strongly says that deep quat(where knees are higher than hips) is a 'no-no in late pregnancy and labour as it reduces space in pelvis, make the upright baby even more so. So I am a bit confused with those different informations about squatting when knees are higher than hips. Could you please explain the differences if there are any!

Thanks for the great tips and your commitment!
much love,
Emilie

Spinning Babies Lady said...

Hi, Emilie! Squatting with feet flat and knees over the ankles a bit everyday leads to a more mobile pelvis.
Jean Sutton talks about not squatting when your baby is trying to engage. But squatting everyday a bit in pregnancy at other times can be beneficial. Does this help?
Calf stretches are a good subsitute if your OP baby is grinding his or her little head on your pubic bone.
Calf stretches also prepare us for squatting and make the hamstrings longer.

lapaupachica said...

hello. :)
I am around 41 weeks and my baby hasn+t engaged. My midwife is tranquile about waiting but as a yoga teacher and first time to be mum I am freaking out. About squatting, should I avoid it? Only "high squats" or none? What would be the best sitting position for meconsidering I feel I might be throwing forward my baby's head if leaning forward and notletting it enter the pubic bone. Thanks a lot and sorry for my mistakes. I am not a native English speaker

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