Wednesday, October 21, 2009

Advice and information needed

I've received several requests for information and resources about VBAC, VBAMC, twins, Bandl's Ring, and shoulder dystocia. I can't personally respond to all of these requests but I didn't want to just let them go unanswered. So I'm asking for your help! Several of the questions are fairly brief and it's hard to answer them without more specifics and background information. Nevertheless, let's see what we can do when we all put our heads together.

Request #1:
I have a friend that I'm trying to help. She is due in December with her third child. She's had 2 prior c-sections and is coming to find out that she does not want a third. I have some questions about what resources I should help her with and what she should look for in hospital policy.

Request #2: 
My best friend is having twins. She is currently 33 1/2 wks. Both babies are breech. Dr's of course want to section her bc of it. She is wanting true info on the safety of section versus breech birth. (I don't think there are any good studies on CS vs vaginal birth for breech twins. I mean, the Hannah Term Breech Trial was the biggest of its kind and that was only applicable for term, singleton breech babies.)

Request #3:
I have been curious about VBAMC for obvious reasons...Also, Rixa. Do you know where I might find info about Bandl's Ring? (if she is who I think she is, she's had 2 c-sections, and during the last one they discovered a Bandl's ring)

Request #4:
I have a question for you regarding shoulder dystocia. I have had 2 natural births, and both of them my daughters shoulders got stuck, it seemed they never rotated properly. The second time it happened I was in a hands and knees position though slightly upright leaning into an inclined bed. I was wondering if you could give me any information as to the best way to deal with this if it happens again (I'm pregnant with my 4th baby and a little worried about it happening again). Could it be that I am pushing to urgently and not giving the baby enough time to rotate before the shoulders pass? Thank you so much for your time!

Request #5:
I am interested in what the recent research shows about Pitocin administration and risk of uterine rupture in patients attempting a VBAC. For some reason, I thought that Pitocin was contraindicated for VBAC moms, but my OB tells me that she is comfortable administering Pitocin to augment (but not induce) labor. I'm not sure how I feel about this. I've done some of my own research, but find mostly mixed reviews. So, I thought I'd ask you since you are very familiar and up to date with obstetric research.

In case you were wondering about my background, I am expecting my 2nd child, in about 3 weeks. And I'm preparing and hoping for a VBAC. I had a c-section with my first for "failure to progress". It's a long story, so I'll try be concise: my water broke spontaneously 8 days before my due date; I waited for 12 hours for labor to start and had no contractions; was started on Pitocin-- labored on Pitocin for 12 hours and dilated to 1/2 centimeter; turned down the offer to do a c-section (since it had been 24 hours and they worry about infection risk), but I wanted to give labor a real chance; had Cervidil placed on my cervix and waited for 12 more hours-- no contractions; after 12 hours of Cervidil, I was dilated to 2.5 centimeters and "soft"; labored on Pitocin for 12 more hours and got to 5 centimeters when I stopped dilating. I never got an epidural and was up and moving during all the laboring; and by the time I got to that point, I was exhausted and it had been over 48 hours since my water broke, so I opted for a c-section. It was a tremendous disappointment and I felt like I never really got to do what I was preparing for. I still have no idea why my water broke, why my body didn't labor on its own, or why it didn't respond favorably to Pitocin. But, my doctor is very supportive of a VBAC. And I feel very lucky to be delivering at a hospital that does support VBACs.

Anyway, I guess the reason why I'm so worried about Pitocin is because I can't help but wonder what I'll do this time around if that situation happens again-- it's the only frame of reference that I have, you know? I've heard other doctors and other CNMs say that Pitocin can help VBAC moms, but I'm not necessarily interested in an opinion, I'd like to know what the research says. I am still just hoping and praying that I will go into labor on my own and that my water won't break until I'm far along, but I want to be prepared in case labor does slow down and/or stall. In fact, I just checked out some books on Acupressure because I've been told that it can help during labor. Do you have any other suggestions, I'd like to have more cards to play than just the Pitocin card.

I spoke with this last woman on the phone and gave several things to look into if this same situation arises, including nipple stimulation/breast pump, waiting a bit longer for labor to start on its own, asking her doctor about the possibility of low-dose pitocin, etc. We also talked about things that are theorized to make the amniotic sac stronger or prevent PROM. I wasn't able to find my files on UR rates and Pitocin administration during a VBAC, although I know that information is out there.


  1. I can't give you any scientific references right now (I do have them at my office, however), but I can give a personal reference.
    I delivered by 2nd via hospital VBAC. I did not go into labor, but broke my BOW first, with no labor. The midwives and OB's were very patient, I must say. I was eventually started on low dose pit (augmentation), and labor then progressed very quickly, and I had a successful VBAC. Pitocin can be your friend if used in the right way. Hope this helps.

  2. Sounds like each one of these ladies need a supportive homebirth midwife!

  3. Agree with Penny Lane, though they don't necessarily have to be home birth if a hospital (usually a research hospital) supports VBAC.

    For the shoulder dystocia I was told that once the head crowns you need to KEEP PUSHING!

  4. Just one small piece of information for request 2- I have a client who is expecting twins, and while reading about twin vaginal birth I came across the information that twins are not stable in the womb in any position except 2 heads down, so twin mom should not look to a c-section until she goes into labor at the very least- they may very well turn at the last minute.

  5. Home birth according to the nice British folks who have good luck with homebirth, is for low risk women. Twins? Not low risk. Can you labor and have 2 vag twins? yes. But you first have to ask your doc a few questions. Will the Doc do an external rotation on twin number 2? Will Doc do a breech delivery on twin number 2? If so, you have a good chance of having both vag. If not you could have a vag baby number 1 and stat c-section number 2. Which would suck and be dangerous for baby number 2. This is NOT the areana for a homebirth midwife.

    Bandles ring according to my OB friends is caused by prolonged labor. However, it does not always occure the second time. So it is possible to try a vbac (in hospital please!).

    Pitocin can be used to augment a vbac. That is acceptable. That means you are already in labor and not progressing much so they start a small amount to help along your labor.

    Congratulations in advance. I hope you all have lovely births.

  6. There are heaps of resources available on the internet, I suggest pointing these women to them rather than tailoring individual responses, which as you say is difficult to give without knowing the specific circumstances. The info is out there in fairly accessible forms so I'm sure they can get their head around it.

    Fab Homebirth resource and access to loads of research on different subjects including VBAC

    RCOG guideline on VBAC (includes research on oxytocin

    I also agree that they need to talk to a well informed midwife!!

  7. On the shoulder dystocia question, I felt like I had to respond. I've had 3 dystocias and 1 birth without a dystocia. The only birth without a dystocia was before I injured my sacrum during a fall, and it remained severely rotated for the duration of that pregnancy.

    I have been in physical therapy for the last several months to address the pelvic instability that we think may be playing a role in my dystocias. My shoulder dystocias are far from typical, with the longest pushing phase I've had being 20 minutes even with babies up to 11 lbs and shoulders up to 17 1/2 inches around. I have no molding on the heads of any of these babies even when head diameter has hit 15 inches, and labor is just sailing along until those shoulders get caught. To me, no molding and no difficulty achieving descent indicates no anatomical problem that would suggest a truly "tight fit."

    In my case, I think that the baby's descent plus my normally too loose ligaments are causing my sacrum to rotate slightly out of place, both keeping it from swinging back and decreasing the available space at my pelvic outlet. It was confirmed in physical therapy that I had a significant strength disparity such that the bones were not being supported evenly and could be getting pulled out of place.

    I would advise the woman asking questions about shoulder dystocia to stay with a care provider who can deal with shoulder dystocias well. Also, something that my midwife does is if she knows there is a risk of dystocia is to put pressure on one shoulder to help it move to a diagonal and hold it in the diagonal before the dystocia has the chance to really hit. If your dystocias are atypical, try to figure out what you think is going on and work with chiropractors and physical therapists to get as much pelvic stability as you can.

  8. Rixa - the women at ICAN usually have all this info to hand. I don't frequent the ICAN forums (on the website but I do read the ICAN yahoogroup. If these ladies join there and post their questions, they will get responses and be directed to research on the topic. They can try the ICAN forums, too.

  9. I was going to suggest ICAN too! It is a wonderful resource with amazing women to help support moms in their quest for a VBAC.

  10. is a good resource.
    Will you please publish the answers to those questions, too?!

  11. I, too, suggest ICAN. The Atlanta ICAN chapter has a very active and informative board - Even if you're not in the area, you can talk to women who've done lots of research, including one who has experienced Bandl's ring several times.

    Regarding shoulder distocia, here is what Ina May Gaskin posted in July here "I've only worked with women who were able to move and support their own weight. Step 1: get the mother to turn to hands and knees. Most will then have the urge to push. If not, I'll splint my first two fingers across the posterior armpit (it's usually the easier to get) and deliver the shoulder. If that's not possible, it may be possible to grasp one of the hands and deliver whichever shoulder it's attached to. The rest should be easy.
    Another variation is to have the mother take a "step" forward with first one knee, then the other to free an impacted shoulder.

    Ina May" There are more responses in the thread about positions to try, but the doctors seemed impressed with Ina May's "step" solution.

  12. New systematic review and meta-analysis on VBA2C from Sept. 2009 issue of BJOG:

    2004 NEJM Landon study on VBAC (risk of u/r w/ spontaneous labor - .4%, with a pitocin-induced labor - 1.1%, and with an augmented labor - .9%)

    In addition to the wonderful resources from ICAN, I think that these articles can offer some good starting-places for conducting research on VBAC and VBA2C.

  13. T%he Wonder of Birth is a blog that I have shared with several friends who want to VBAC because she has some great links to VBAC & VBAmC stories. Her post on VBAmC is a good place to start when looking for inspiration. Having never dealt with any of the issues posed in these questions I can't give any better advice than PP. Having had a friend fail at her VBAC attempt, I will say make sure you have the support of your spouse/significant other, that plays a huge role in a woman's success during birth (if you do not have the necessary support get a doula). Unfortunately it is often the case with VBACs or other challenges that a woman will need someone to advocate for her or remind her that she is making the right choice,lest she wind up at the mercy of medical system due to the fear mongering etc.

  14. Oh, I forgot one thing. Re the last question, did you suggest RRl to her? I drink a couple cups per day for the last 6 weeks & then once labor starts I will drink another cup or 2. It improves uterine tone & coordinates contractions for more effective labor. Also vit E improves oxygen absorption during labor & can help delay fatigue. There are other herbal remedies for starting/augmenting labor that might be preferable alternatives to pit.

  15. Here's a post I did some time ago that includes links to different articles, websites and research about VBAmC. She may find some of the information there helpful.


  16. Request #1 - For VBA2C, she has to be absolutely *certain* that her provider is insured to do VBA*M*Cs. Not because of risks, but because what she'll find is that very few docs are actually allowed (by their malpractice coverage) to attend those deliveries. Also, she needs to call the hospitals and talk to the administrators who can give her factual knowledge about the hospital's VBAC policies. So often, they say yes, yes, yes, only for you to reach 39 weeks, unable to switch providers with your respective insurance company, and they section you.

    This is the battle we're fighting in Eastern Idaho with combined communities of over 200,000 people. And because the docs can't even do it, they wouldn't allow the midwifery legislation to allow it, either. Lucky for us, we still have 9 more months until the law goes into effect.

    If your state is anything like ours, women have to be out of hospital to get what they want, which is great! But also, sad for those women who would feel safer in a hospital setting.

  17. I have tons of information about VBAMC on my main website. (I'm a VBA2C mama myself.)

    I have information about virtually all the studies about VBAMC there, and I have birth stories there of women who have had VBA2C through VBA7C. is the URL of my main website. Look in the VBAC part of the site. Also check out the recent BJOG review, at the link someone else posted already.

    As far as augmenting a VBAC goes, it does nearly always increase the risk of rupture over a completely spontaneous labor, but the difference does not always reach statistical significance in studies so hospitals see the practice as acceptable if you watch your pitocin dosage and monitor carefully.

    My personal opinion is that it sometimes can be useful if carefully and judiciously applied, but that a woman is usually better off NOT augmenting. Why increase the risk? Why not simply have more patience?

    If there is truly labor dystocia occurring, I'd rather see the common causes of it (like malpositions) addressed in other ways first (like repositioning mom, encouraging baby to turn if needed, etc.) before they resort to pit augmentation. However, there are times when it can be useful, especially if an epidural is on board. I just think many docs need to be less cavalier about using the risks of pit augmentation.

    ICAN is a great source of information for questions like these. Encourage folks to come to the ICAN forums and ask around.

  18. Uh, that should read, docs should be less cavalier about using pit augmentation. Sorry!

    As far as shoulder dystocia goes, I'm not sure I agree with the idea of keep pushing once the head crowns. Many think that's actually a cause of some shoulder dystocias.

    I've attended a number of talks at midwifery conferences about SD, and the idea is that once the baby's head crowns, there is often a pause while the baby's shoulders and body finish rotating. That's why you wait for the next CONTRACTION before pushing again.

    If you have the mom push before the next contraction, she may push baby before his shoulders have finished rotating and as a result they may get stuck on the pubic bone. Old midwifery and obstetrics textbooks apparently always used to teach waiting for the next contraction but it's gone out of fashion now.

    There are times when you don't wait, it's always a judgment call based on what's happening, but I've heard it emphasized by a number of midwife lecturers that usually you should WAIT for the next contraction so that baby can complete its cardinal moves and finish rotating out.

    I also agree with the person who suggested attention to pelvic alignment and instability issues. Working with a GOOD pregnancy chiropractor and physical therapist can really help maximize the space and alignment and make it easier for those shoulders to fit more easily.

    Mobility in labor and intuitive pushing positions are also critical. Many women find they want to arch their back right at the very end instead of curl forward, and this can help get baby's shoulders under the pubic bone as well. If allowed to follow the cues of their own body spontaneously, many will do some amazing things that help the baby get out more easily. There's a video called "Sophie's Birth" of NZ activist Pauline Scott which is a great example of this.

  19. I had never heard of bandl's ring, so of course I looked up what it was. This is supposed to happen when labor is obstructed, and the uterus is trying to push the baby out, and the lower part of the uterus starts to get really thin, prior to rupture.

    This woman may be one of the few that has something up with her pelvis (or just not being able to move to the best position for her births). I would recommend getting the Pink Kit, mapping her own pelvis, and finding out on her own what her pelvis is shaped like, and it's size. I'm not saying that she cannot have a vaginal birth, but that she may have some special considerations that she needs to figure out.

    The Pink Kit is great for figuring out just what works best for you. I discovered that I am was more open side lying than squatting, important info to have if you are trying to help get a larger baby out of a smaller pelvis.

  20. This comment has been removed by the author.

  21. Pinky, good advice about the twins. My friend has personal experience with a couple who went into labour at 35 weeks with their breech twins. They decided to stay home and proceed with an unassisted homebirth rather than go to hospital and likely have a c-section (Doctors all recommended scheduled c-section, no midwives would take them as clients because breech twins = high risk). One twin was born still, and the other was revived but died a couple of days later in hospital. I am pro-homebirth and pro-natural vaginal birth, but I just can't understand why this couple made the choices they did.

    (Edited post and deleted original.)

  22. I have a handout on Bandl's Ring that I'd be happy to share. Wrote it for a complications project.

  23. Re: shoulder dystocia. I agree with Well-Rounded Mama about waiting for the contraction!

    Whitney mentioned the Gaskin Maneuver, plus raising a leg to "step" forward. This lunge position works best if the mother steps forward with her leg on the same side of her body where the baby's back is located. Sometimes opening the oblique diameter of the pelvis in this fashion helps baby's shoulders to rotate.

  24. Pinky, I disagree that a VBAC needs to be done in a hospital. Many women have VBACs out of hospital, and they have straightforward births. In the hospital, a woman is in more danger of having augmentation and other complications. Why do something to make things stronger in a VBAC mama that could possibly risk a rupture?

    Re: request #1 I-CAN is the best resource for something like this. They can help find a care provider who can help with a VBAMC. They also have lists of questions that would be helpful in finding out what a providers’ true policies are.

    Re: request 2, I think the mom has to decide which risk she considers greater, the delivery of breech babies or a major surgery.

    Re: request #3 What about the Gaskin maneuver (turning the mom over to her hands and knees) in the event of a shoulder dystocia.

    Re: request #5 My understanding of Pitocin in the case of a VBAC mama is that it is contraindicated. My midwife suggested to me that we do nothing at all to try to start or augment labor because Pitocin can be very strong. I have no studies to support myself though.

    HOWEVER, labor does not always start with the rupture of membranes. This is controversial. Studies done in Europe suggest that when sterile technique is used, length of time with ruptured membranes does not increase infection. Something like 60% of moms start labor within 24-48 hours of water breaking. However, that leaves a large percentage of women who still have not gone into labor. My VBAC baby was born exactly 48 hours after my water broke. He was healthy and lovely. There was no augmentation or antibiotics. He had apgars of 10 and 10.

    It should not be considered a failure on the part of a women’s body when labor does not start after water breaking. A body knows how to get the baby out. The medical profession is just impatient.

  25. @ Abundant B'earth,

    I'd like to have a copy of the Bandl's Ring handout! I looked on your blog and didn't see anything; you can email me at kathy_petersen_283 at yahoo dot com.


  26. I want to really thank those who commented on this post. I have been looking everywhere for info on shoulder dystocia because my first child had a severe shoulder dystocia and I want to avoid it happening again (or have an idea of how to get them 'unstuck' with more ease this time). My first babe's shoulder was stuck before his head was fully out. The midwife had me chance position because he was 'turteling' while I was trying to push his head out. It was apparent to them his shoulder was stuck. Two midwives with over 500 births to their names said he was the worst shoulder dystocia either of them had seen. Like Jana I have an unusual joint structure, but mine is hypermobile and my tailbone had moved back greatly by early labor. But I expect my pelvic bones, which everyone assumed would easily move apart, didn't move as they hoped. I have been given several good ideas from these answers and I'm very pleased to find it.

  27. I had a Bandles ring with my second labour that was discovered during my second c-section. In my case planned UC turned transfer as I felt something was wrong, my baby was posterior, 3 days labour with broken waters, and stuck. My first c-section was due to an asynclitic baby and cascade of interventions. I went on to have a successful really boring complication free VBA2C 14 months after my second c-section. Nothing wrong with my pelvis at all, just a badly positioned baby at the time. Its was really hard to find much info on Bandles ring at all but would be interested in seeing that handout on Bandles ring though :)


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