Aloha ladies. I am really stumped on something, and would love some input. My most recent mom was a really healthy, fit woman with no complications. They wanted a natural birth, and the plan was to stay home as long as possible before heading to hospital when contractions were about 3 minutes apart and strong. They texted me around 6pm to say that she was having contrx about 6 minutes apart, lasting one minute and pretty light. At around 8:30 they called me to come, and when I arrived 30 minutes later mom was laboring in the tub. The problem was that her contractions were already only 2 1/2 minutes apart, lasting for a minute and a half or longer. She was handling them okay, but definitely in "serious" mode and moaning very loudly.

In my experience as a doula and childbirth educator (along with pretty much any textbook you can find), women do not get to this duration and frequency of contrx until they are into late active labor or moving into transition. I personally didn't feel like she was "there" yet because it was her first baby and she hadn't been in labor very long, but you never know. According to the plan they came up with, what their doctor requested, and after observing her physical and emotional signs, I suggested to head out to the hospital.

After a horrible 30-minute ride to the hospital, mom was checked and found to be only 2cm!! At this point the contractions were still coming every 2 to 2 1/2 minutes and never completely letting up. It was very much like transition contractions. I watched this beautiful, strong woman just fall apart from the pain and lack of relief in between contractions. She was shaking, sweating, and heaving into a bucket. Her husband and I helped her make it through this for another 6 hours until she was begging for an epidural at 6cm.

I'm sorry for the long story, but this is one of the first births where I felt helpless in some ways. I tried every comfort measure and position that she would allow, but the pain was just too much for her. Have any of you ever seen anything like this? It was almost as if her body was over-producing oxytocin or something. It just didn't make sense. Thanks in advance for your input.

How long was it after the epidural until she was complete?

I've seen this happen with primips before with relatively short labors with malpositioned babies. In fact I had one last week where STRONG contractions were q2 from 11pm until 7am when she had the baby. I had checked her earlier in the day because of 3 days of latent labor so I knew she went in to it at 1cm. I think she was 5cm around 3am, the only other time I checked her. Anyway, her baby was small and seriously acynclytic and at one point posterior. The only way this mom was able to cope was with the help of a very, very hands-on doula.

yes I see this alot! and I am a firm believer in the spinning babies concepts and techniques. the big tip off of a malpositioned baby is the crazy pain of early labor. she could have benefitted from some body balancing techniques like an inversion and side lying releases. there are many other things you can do offered by gail tully on her spinning babies website.

I wish women were more educated about the fetal position and its importance during labor. Women would benefit from this knowledge and have more tools in their bag to help them handle labor.

I also think Jean Sutton has a great book that would be good to give to your clients on optimal fetal positioning. the book is very easy to read and short. nothing overwhelming. you can find the book on jeans website called. www.optimal-foetal-positioning.co.nz .

i hope you find it as amazing as i did. i am a fanatic about optimal fetal positioning now, more so than i am about providing comfort measures. i have realized that you can do all the comfort measures in the world but it won't change an OP or asynclitic baby. and once you have corrected a malposition, labor is faster and less painful. thats when the comfort measures can begin.

I often have to tell my moms that i don't recommend an epidural if I see a bad labor pattern because I need to get her to do certain things to get her baby to turn. they are usually receptive and try everything they can to help the baby turn. after we are successful they may decide not to get the epidural becuase it is no longer as intense. or if they do at least i know that they shouldn't run into problems later when delivering the baby.

Another possibility would be cervical scar tissue. This can result from a LEEP procedures, a cervical biopsy, or a D&C. Honestly, when I see this type of labor pattern with a malpositioned baby, the mom looks/acts pretty normal in between. If she looked and acted like she was in transition and was only 2cm, I would lean toward cervical scar tissue instead.

The ladies I have seen this painful early labor did not have a history of any of those procedures. If this lady did have a history of it I could understand that, but since there was no mention of it I just think immediately of something not balanced or too tight holding up progression.

I see so many ladies come in for early labor in terrible pain only to be told they are not in active labor. I can only imagine what goes through their mind at that point. Many we will morphine rest then send home and they end up coming back in no different shape... which is why I have turned to other alternatives so these women can go home with something to work with other than tylenol or ambien. Most of the women that come to us do not have a doula or never heard of one. They have no idea about optimal fetal positioning and have had no prenatal birth preparation classes. Some thought they would like to give a natural birth a try, but after 3 days or so of intense laboring with barely any progress they give up and want inductions and epidurals to make it all end. This is why i am so big on educating them when and where ever I can.

My first client had this exact labor pattern when I got to her home. I was almost convinced she was gonna be one of those quick births. Instead she was only 2cm when we got to the birthing center and she delivered 35 hours later... Now I assume the issue was a slight malposition, the midwife said at some point that the baby is a little asynclitic. I also had the same problem with both of my long labors.

The question is - how do you make a difference between a possible fast labor or a suspected malposition? If your client has this kind of transition-like labor at home how do you make the decision to stay and try techniques for malposition or to head to the hospital suspecting a fast labor? I assume it will come with experience...

Start with balancing, you can follow the protocol Gail has on her spinning babies site or do your own thing, but here is her protocol for all

Rebozo sifting
Forward Leaning Inversion
Rest smart (honestly not sure for how long)
Myofascial release (abdominal release)
Abdominal tuck
Side lying release

try to nap, maybe a shower, have something to eat like oatmeal. Keep the environment beneficial for labor

Can do the miles circuit and if she notices that her lunges feel better on one side then do more lunges on that side.

Great circles on the birth ball or standing to encourage chin tuck and engagement

There really are alot of things you can try. Long start/stop, very intense early labor is a sign of malposition. Jean Sutton has some good books on Optimal fetal positioning, one for professionals one for parents that are pretty good. helps you understand what is going on in there. Also lots of information on spinningbabies.com on this subject. Gail has a chart on her spinning babies website comparing OA labor patterns to OP patterns.

women can play an important role in positioning their babies if they are educated on the subject. so teach your moms about posture and balance.

She was complete about 4 hours after receiving the epidural. I thought of the cervical scar tissue also, but mom said she never had any procedures that would cause that.

Thanks for all of the comments and suggestions ladies. I agree that it was probably malposition, and it was a struggle because she didn't want anyone touching her and her body's reaction to the pain caused her to literally shut down. She wouldn't listen to me, her husband, the nurses, no one. She was gagging and choking and shaking through the contrx - it was terrible.

I definitely think my inexperience with this type of situation made it difficult to tell if they should go to the hospital or not. I don't know the right answer to that one because there are first-time moms who go fast. You just never know.

Was she admitted @ 2cm?
Also how was her delivery? How long did she push for? Did she need any assistance such as a vacuum or forceps?

Another thing I was thinking about was her state of balance and how relaxed her pelvic floor muscle and pelvic ligaments were. Also how tight was her psoas muscle or any other muscle relating to the pelvis and birth? Sometimes these muscles and ligaments can be so tight that labor and dilation can't progress no matter how much she is trying to breath or relax. This is where the forward leaning inversion, rebozo, shake the apple tree, side lying release, sacrotuberous release, sacral or abdominal release may help. All of these techniques physically work on softening and relaxing the muscles and ligaments of the pelvis/perineum.

If she got her epidural and progressed normally and quickly without any problems during the pushing stage, she may have just been so tight that progressing would have been very slow and painful without the help of the techniques I listed above or an epidural.

I sometimes almost forget the 1st principle of spinning babies of balance is not always for the malpositioned baby- many women are very tight and even twisty "down there" where they need these balancing techniques before, and during labor to help the body be able to progress smoothly even if there is no malposition.

There's a physical therapist in my community that works with pregnant women to relieve pelvic pain. She has a way of testing for resistance in the pelvic floor, relieving what can be achieved before labor and then has a way of testing what positions for labor and pushing put the least amount of resistance on mom's pelvic floor. For some women walking really isn't good, for others their body doesn't like squatting, for some semi sitting to push really IS the best position. I think there's a whole lot of un-tapped potential and room for research and study with what she's doing. There aren't many physical therapists that address the female pelvis at all beyond medication.

Wow, that sounds like great stuff! Wish there were more of them out there... Gee even wish that would have been something mandatory for an OB doc to learn hahahaha!

Did mom have a history of sexual abuse?

I had a client that cervical adhesions with her first baby....she labored through hard labor and only was a 2 after hours. The nurse was an experienced nurse and mentioned that she wondered if there were some adhesions and when they broke, she would go faster. She ended up going from a 2 -10 in an hour after over 12 hours, if I remember right of laboring at 2 cm. and had a very small little boy that was not malpositioned. Her next labors were very quick.

But, most of the time when I have seen it, the baby is sitting wrong....if it is going on and on, transition like...
My own first labor started out in transition, I think (I have a high pain tolerance), I may have slept through the first part as I woke up when my water broke. I had him about 7.5 hours later. I don't know what I was dilated, as I did not have a midwife (not something I recommend ever!!!)