Q: I recently attended a birth as a doula. After labouring
for 8 hrs. my client was almost fully dilated except she had
an anterior lip. When the doctor did a vag exam, she was
able to pull back the lip while the mom pushed with a
contraction and ultimately pushed the lip out of the way.
However, two hours later with strong effective pushing, the
lip was still there. The doc was frustrated and couldn't
figure out why the lip wasn't cooperating. An epidural was
done to hopefully relax the mom and take care of the lip.
After half an hour, this goal was reached. The mom continued
to push when coached to do so because of course now she
couldn't feel any sensations to bear down spontaneously.
My questions are:
1) What else could have been done other than an epidural to
resolve the lip dilemma?
2) Once the lip had disappeared, could the epidural be
turned off or at least the amount of the drug reduced so the
mom could regain some feeling to be able to push more
effectively?
A: An anterior cervical lip occurs when the presenting part
is not positioned correctly upon the cervix, causing unequal
pressure that results in unequal dilation. Think of a square
peg trying to come through a round hole. If there is unequal
pressure, and the fetal head is not given enough time to
accommodate (mold), then the narrowest diameter of the fetal
head cannot come through the widest diameter of the inlet.
In my experience, if a cervical lip is developing, you are
dealing with an abnormal presentation--either an asynclitism
(where the head is tilted out of the midline) or an
extension of the head which must be corrected in order to
facilitate the descent.
The temptation is to treat the symptom--the lip--by pushing
it back out of the way, without considering why it is there
in the first place (the malpresentation) and correcting
that. If you allow the fetal head to back off the cervix,
even just a bit, it will often allow the baby to tuck its
chin and approach the pelvis at a better angle.
As a doula, coach, or midwife, you have two choices. You can
change the head directly by applying pressure to it, which
is not comfortable for either the mom or the baby, OR you
can encourage the baby to back off the cervix by changing
the mother's position. I have had great success with
encouraging the mom to try two contractions on her left
side, two contractions on her right side, two contractions
on her hands and knees, and two in a knee-chest position.
Have her epty her bladder first (she can use all the room
she can get!), have her blow through the contractions, and
refrain from pushing. These positions will usually make it
easier to do that anyway. I rarely have to go through more
than two cycles of the eight contractions before the lip
disappears and descent takes place. If you detect an
asynclitic presentation, have the mom pull up on her top leg
as she is side lying, which will open that side of the
pelvis a tad more (sort of a half McRoberts position).
Remember, you are trying to allow the baby a little room to
back off the cervix so it can reposition its head correctly.
Even if the mom has an epidural, she can be rolled from side
to side, the upper leg adducted to facilitate the flexion.
In this particular situation, an upright sitting position is
not as helpful, and in fact the 45 degree angle pushing
position which is de rigeur in the hospital actually
compounds the situation because the pushing urge becomes so
strong, and the angle so acute, that the baby has no room to
back up and cannot reposition itself. Remember that the
uterus is extremely competent at working the head down into
the pelvis at the appropriate speed and angle if given the
opportunity to do so.
-Vicki L. Taylor, L.M., C.P.M.
Pensacola, FL
====
A: The most probable reason for the persistent anterior lip
under the scenario you describe is a large head that needs
to mold.
If hands and knees or side-lying with the top leg all the
way over onto the bed things doesn't work, eventually I try
an epidural as a last resort just in case the woman is
unconsciously holding back. Of course the epidural could
have been turned off for pushing and then re-dosed for a
cesarean birth if it became necessary. But if it's any
consolation, it may have turned out the same if it truly was
CPD. I hope the client knows what a good job she did!
-Cynthia Flynn, CNM, PhD
====
A: As I read the account of the labor with the lip that
would not be reduced, I wondered if the birth would end up
being a c-section. I'm sure that many will recommend an
all-fours position or knee chest or upright postures, birth
balls etc. as postural ways to help reduce the lip. These
sometimes work. I've heard of putting ice on thick swollen
lips, but have not tried it myself. I imagine there are
herbal preparations that are used too. However, my own
experience is that those persistent lips are an ominous
sign--they just hang on and slip back over the head, despite
efforts that seem to result in their disappearance. Often, a
persistent OP is involved (all the more reason to read
Optimal Foetal Positioning by Sutton and Scott), sometimes
CPD, as in this case, where baby just didn't descend. I
imagine that the epidural gave the mother a chance to rest
and regain some strength for the push ahead.
I don't know of any physiologic reason why having an
epidural would cause the lip to go away. Does mother's lack
of relaxation cause a lip? Letting epidurals wear off after
pain relief is achieved is a problematic situation, I think,
particularly if the mother does not want to reexperience the
pain. It almost seems unethical to provide relief and then
to say, "Now we're going to withdraw it." Most mothers who
receive epidural here seem to push quite effectively if
allowed to await the urge to push as the baby descends.
-Karen Pettigrew CNM
South Dakota
====
A: Perhaps my question is part of the answer; What POSITION
was the mother assuming during most of the second
stage--squatting (upright), Fowler's or side lying?
-J.B.
====
A: ...rushing 2nd stage by attempting to "resolve" the lip
may in turn cause the baby to be pushed down too soon in an
unfavorable position for vaginal delivery. I don't practice
the "you're complete, now push" management of 2nd stage. I
think this sets up the problem described above. From what
I've seen so far, if the mom is going to push the baby out,
no lip of cervix is going to keep her from doing that. I
feel a stubborn anterior lip is more a symptom of other
problems than THE problem. Positional changes (hands and
knees) and putting her in water may allow enough relaxation
to enable the baby to BACK UP and get in a flexed position.
-Kelley Hewitt, LM
====
Reprinted from Midwifery Today E-News (Vol 2 Issue 23 June 9, 2000)
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