question for midwives: compound presentations

[vizbizz]

If you are faced with a compound hand and vertex presentation, what do you do?

Do you tell the mother, and discuss options with her?

What can be done to prevent severe tearing?

vizzbizz.....not a midwife......but my friend delivered her 3rd baby @ home - compound hand & vertex presentation......had a tear..but did not require stitches.....

would it not also depend on the speed of the delivery ....i don;t know if this would become apparent until crowning anyway...at which point , i don;t know what you could do except control the speed of the delivery - by panting, midwife controlling descent too , holding the hand back....and supporting the perineum....or have an episiotomy??

has this happened to you before?

will await with interest!

I would be bloody angry if I wasn't fully informed about a complication of pregnancy.

highlander- it is often not apparent until the baby is actually being born! if it is discovered during the first stage,,then i believe a doctor would be called in ...but if it happens in the second stage...not a whole lot to be done, i believe..........

but i will stand absolutely corrected if i am wrong! which i might well be!! as i said., not a midwife....

In my (extremely limited) experience, compound presentations are rarely apparent until the last minute, as baby is actually delivering. I guess I would try to limit damage to the perineum by controlling the delivery and let the perineum stretch as much as possible (but would try and do that anyway ) Might be more hands-on than normal. I don't know about 'holding the hand back', probably wouldn't be possible in many cases.

Ds was a compound presentation and I 'only' had a 2nd degree tear. I have delivered a couple of compounds and have never had worse than a 2nd degree - and whilst obviously not ideal, that's not regarded as 'severe tearing'.

Of course you would always inform the mother and talk through the delivery but as I said it often is only apparent after the fact, iyswim...

If in 1st stage call a doctor in

In 2nd stage, I really think it would depend on my gut instinct. Trying to hold the hand back could cause more problems. Just try and make sure that the head is birthed nice and slowly and that the woman is in the best position possible to maximise pelvic capacity.

vizbizz..this happened to you ?

yep, this happened to me. there was no mention of it until the baby was delivered! I am still pretty ticked off about it. From what hubby tells me, the midwife didn't support the perineum, and there was no mention of episiotomy either. I wonder if the tearing may not have gone so far if it was done.

I ended up with a third degree tear, and quite a bit of internal tearing too. it's been almost 9 months, and I am still pretty sore, though ultrasound therapy seems to be helping there.

It was a long labour - 26 hours. I have been told this can mean worse tearing as all the tissues become more fragile.....but i can't help but think "what if?"

that's horrid......especially if you are still sore months later......can you go over the delivery with the hospital..get hold of your notes....not good to still be feeling 'what if' after birth...is always good to get 'closure ' ( hate that word, but it says what it needs to!) on an experience that has traumatised you.....i am sorry you had a bad experience...

unfortunately the notes don't say much. I have been thinking about calling the midwife, but have reservations about it.

Have ended up with PTSD, and am working through that. My physio, and one specialist think the long term pain may be nerve damage, but they aren't really sure.

I have done some reading, and it seems some experts think you should be able to tell in advance of second stage - signs like prolonged labour with slow progression, severe pain in pelvis or back, a long time to feel the urge to push etc. They are somewhat vague identifiers, but I guess to an experienced professional the combination may suggest the problem?

I had really scary pain in my tail bone area (thanks to little elbow poking it) and so had a last minute epidural - which meant I really wasn't in the ideal position to prevent tearing....but there also wasn't any instruction to take it easy on birthing the head. I was told to push as much as I could every step of the way.

I'd love to experience a "normal" delivery, but after all this I am going c-section next time (major surgery is a scary option, but not as scary as the thought of going through months of this again). In all honesty I thought the labour and delivery were ok, but months of never ending pain have been a nightmare. I know the chances are probably small of this happening again, but I am just not willing to take that chance.

I have had a few compound deliveries, one severe needing an emergency section baby had his hand right over his head, and the others were the type where as the head was crowning there was a little hand there as well, personally I guard the perineum and encourage mum to pant not push to try to prevent tearing,and I tell her what is happening this is not always easy to do I have never had to do an epis with one, any tear imo is not nice but I have not yet had a severe tear they have all been 2nd degree, sometimes though despite the best will in the world nasty tearing cannot be prevented.

It's happened to me the last three times and all the babies have had massive heads .

As people have said it's not apparant until the baby is actually emerging. I've had two superman poses and one with baby's fist pushed right into her check and elbow jutting out to the side!!.

I had second degree tears with all but they never caused me any probs afterwards and the last one didn't even need stiching. Perhaps this next baby will come out with both arms in front like a diver

I think it's quite a common thing to happen and my midwives barely mentioned it, they certainly never saw it as a cause for alarm. I guess it really depends on the position of the baby and the presenting parts. Some are much easier to birth than others.

vizz...why reservations about speaking with midwife? if you have PTSD , then you must have had a really bad time.... if it helps, i had one crap birth ending in emergency c.s followed by an easy VBAC...like you , i yearned for a nomal delivery....

did spend the majority of my 2nd pregnancy dreading this would happen again..but spent the whole time researching VBAC and making sure it was damn well going to happen!

I had had years of PND after my first birth. and none this time..but i had gone through everything and been able to get 'closure' (sorry, again!) on my first birth.

it might be worth working through everything again to make sure that you have a full understanding of things and can rebuild..

hope you get through this.....

vizbizz

write a letter to your hospital and say that you would like to have a meeting to discuss the delivery. The midwife who cared for you can be asked to attend but it is not under any obligation to do this but hopefully she will, you can have a meeting with the hospital to go through your notes, and discuss what happened and you can ask any questions you have.

Its not very good that this was not done after the delivery or the next day

I'm in NZ, and the midwife I had was independent, and not a part of the hospital. The follow ups I had were through the hospital, and they were worse than useless. I penned a complaint, but didn't get any real answers (just lots of faff that sounded like answers, but really just skirted the issues).

I eventually went to a private (and expensive!) specialist to get a decent assessment and physio. As I said, the problem wasn't the delivery, it was the pain and poor support afterward. I didn't know you could hurt so badly for so long after. I thought the delivery and week or two after would be the worst. I couldn't have been more wrong.

I just can't face trying it normally and risking it again. It's been too long.

Epsitomies do not prevent tearing though... there are women who have BOTH.... and if you cut you can tear further too ! It's why episio are not routinely done.
If you cut a piece of paper or fabric you will see that it is actually weaker that if you had left it whole and so will tear faster and more so than if un-touched. Do you see what I mean ?
And internal damage is hard (impossible?) to prevent.
I have supported mums (I am a doula) with not a perrineum tear AT ALL... but quite bad vaginal grazing.

I hope you cna work through your PTSD.... that's horrid and hopefully with time you will heal... hugs to you!

In my experience (m/w for 10+ years) compound presentations are not unusual. If the birth was on dry land (ie not a water birth) then I may be maore tempted to brace the forearm gently against the face whilst birth of babies head occured, as I feel that a lot of the trauma is caused by the quick release of the arm and the elbow flipping out across the perineum, however it's very difficult to say as you just tend to judge what to do when the situation is occuring, some perineums look like they are stretching beautifully, other look like there may be a need to support that arm. There is no good evidence to support "supporting the perinuem" makes a difference to outcome, look for the HOOP trial, sorry I can't post a link as they never work! As most of the women I care for now labour in water I have seen much less perineal trauma and do believe this is due to the relaxing effect of the warm water on the perineum. As for the length of labour 24 hours is not a hugely long time, it would be more relevant if your babies head had been very low in the vagina ot on the perineum for a length of time. I have also recently read rave reviews for a product called the epi-no (I thnk) which is a perineal muscle trainer and has reduced the ammount of perineal trauma in studies, hopwever these have been on small number so far. I thought that the Independent Midwives in NZ had their own complaints system, is this the one you have been through? I fully agree that the correct follow uo and support is so important after a 3rd degree, I hope things start to improve for you soon.

Thanks to all for your support and answers.

I was soooo looking forward to being a mum, but it's been a nightmare year. It helps to get any support. Thanks

..always support here when you need it!!