a question for midwives/doulas

[vizbizz]

my ds is now 16 months old, but as I am working through PTSD, I am finding it important to find out a few things.

Ds was a compound presentation, and as far as I know the attending midwife had no idea he was until she saw his hand alongside his head. Even then, she didn't do anything apart from tell me to keep pushing with every contraction I had.

I am wondering if any of you have missed something like this in your experiences, or is it something you usually pick up on earlier in labour? WHO guidelines suggest that unless a baby is very small, a compound presentation is better delivered by CS if other methods of repositioning don't work. In my case a CS would have been infinitely better, as I am still in pain thanks to nerve damage. Can anyone share their experience as primary caregiver in similar situations?

Sorry you are still having a hard time, but good you are working through it..seeking answers about birth trauma is so importnat IMHO......from my limited experience, have never heard of compound deliveries being delivered by c.s ..simply for that reason., unless other aspects the presentation of the baby was making vaginal delivery impossible..??......a friend recently delviered at home, compound presentation, not diagnosed until baby born , virtually !! she had a second degree tear, but it healed without stitching....some schools of thought talk about guarding the perineum, others don;t....do you have a reference for the WHO guidelines..purely for my own interest am interested to learn more about this

Sorry to hear about the PTSD.

As for the compound presentation, in my experience, its reasonably common to have a hand up by the head, possibly 10-20%, and in most cases, its impossible to tell until the head is being delivered, so I don't think its a case of the midwife 'missing' something.

Once the head is delivered and the hand becomes visible at the side of the head, there is no real maneuver which will get rid of the hand, and sometimes having the hand there will result in more of a tear. If the compound presentation is felt early in labour, for instance if the hand is on the top of the head, rather than at the side, then this is much less common, and I think this is what the WHO site is referring to, and it may be an option to have a c/section then. However, I have found that if you squeeze the fingers (gently!) or tickle the hand, the baby often moves its hand away. Its not something that we would recommend having a c/section for in the unit I work in, as the section still carries the usual risks, while if you can get the hand to move, you should still be able to birth normally.

Obviously in your case, and with hindsight, it might have been better to have had a c/section, but it doesn't sound like there is anything the midwife could have done differently. As midwives, we all groan when we see a hand coming out with the head!

Good luck with the counselling.

the WHO guidelines were on a WHO website, I can't remember the URL. A couple of specialists I have seen all agreed that a CS could have been a better option. One in particular said that there were a number of indicators that should have alerted the midwife that things were not as they should be, and if she had investigated she might have been able to determine the malposition earlier. very slow progression, extreme lower back pain (thanks to baby's elbow in spine), lack of urge to push etc. By the time I said "I need to push" Her response was "it's about time"

Also, I phoned the midwife a few months ago. And raised that idea with her. Her response was "isn't hindsight a wonderful thing?" Yep, but it wasn't as though things were happening so quickly that there wasn't much time to check things out. In an emergency I appreciate that there isn't always time to consider all options, and you do what must be done as quickly as possible. The entire labour I was only progressing at a bit less than 1/2cm per hour. She told me that at one stage she considered suggesting a transfer to the hospital (I laboured in a birthing hospital), but didn't say anything! Later when I asked for a transfer so I could have an epidural, she resisted the idea until I insisted (an insistence I am truly grateful for now!). When I asked her why she didn't speak up, she said that I had seemed "intent" on a natural birth. My birthing plan was VERY easy. I let her know I would much prefer a natural birth, but if she had any concerns to let me know and we'd decide from there. Surely if a midwife has concerns about transferring a woman to hospital that should be voiced? A midwife of her experience would not consider a transfer lightly.

I know that even with the best care a compound presentation can still have this result, but I can't help but feel I didn't get best care. I certainly didn't on follow up, but that is a different kettle of fish again.

vizbizz, I had to respond! the exact same thing happened to me one year ago and I have spent ages thinking about how it could have been managed/averted. I have done loads of research etc and yes, if a compound presentation is obvious then there are certain tricks which can move babs hand back to where it should be. I can only speak for myself, but there were a lot of things I had to come to terms with in my baby's birth and this was one of them. I actually still think the midwife should have picked up on it, as after doing all the research I have discovered I displayed all the classic signs of compound presentataion - waters broke early (first baby), slow dilation despite 80% effacement on admission, severe back pain and to top it all off a delightful haematoma upon birth. So I understand exactly where you're coming from and yes, in early labour it could/should have been picked up on. I'm an avid reader of this site and this is the first thread I've felt the need to register and respond to so that will hopefully convey how strongly I feel about this. If it's any consolation, the research I turned up mostly recommended an episiotomy to facilitate delivery. But my point always had been during delivery that my midwife should have picked up on what was going on. Sorry if longwinded. Am talking to pschyotherapist/friend in informal manner about what happened and thinking of talking to someone "properly" if that helps.

hi Oscy,

Thanks so much for your reply, and no it wasn't long-winded. I think I have done the same as you in reading and researching about it all. I think an episiotomy would have made it even worse TBH. I tore very badly, and when they were trying to stitch me up the stitches were tearing out as they did them! The tissues were so fragile that they had to overlap a lot to make it all stay in place.

I am getting psych help with CBT/EMDR. I had to see 3 services before someone actually thought my symptoms were severe enough to do something about them! The first 2 conceeded that I has PTSD symptoms, but didn't do anything about it. The therapy is hard, but I hope it will help me come to terms with it all. I wish you luck also, it's a hard thing to come to terms with sometimes.

best of luck with the counselling, I haven't followed any up for me yet but think I will. Re: episiotomy, I was told I was going to tear into back passage (sorry if tmi) and "buttonholing" was obvious on my perineum, so not sure if I was better without cut or with. I'd love to have that opinion reveiwed by another midwife, if anyone would like to respond!
Either way, I tore anyway, then had haematoma the other side which was drained and sutured so have ended up with loads of scar tissue. nice to know I'm not alone! thanks for posting your experience vizzbizz, it's not easy thinking about it all over again.

HI Oscy, if you are still finding it hard to think about it all counselling is probably a good idea. As I said, it is really hard but I hope it will help. I am still in the early days, but already some improvement on some issues.

I didn't tear into back passage, though the anal sphincter muscle was torn quite a bit. I have a big bundle of scar tissue also, so it could be that it's not a damaged nerve but one trapped in the scarring. Even if that was the case, I was told the nerve is probably damaged by now anyway.

In all honesty it wouldn't have been as bad if I had healed as I was told to expect. The ongoing pain has really had a lot of consequences, and I think without that I would have found it easier to deal with the birth issues.

vizbizz, you didn't have an easy time of it, sorry to hear the pain is still such an issue, that would definitely hinder the emotional healing for sure. Hopefully some resolution will be on the horizon for both of us.

I have been a midwife for ten years and once or twice I have felt a hand in front of the head on a vaginal examination, the one time I can remember particularly the woman had a cs for other reasons but it was not recommended specifically due to the hand. It is more common for the hand to be beside the head and there is no way that you would know about it until the baby is coming out. It happened to my sister with her first and she had had a quick labour with no problems. She did have a bad tear but luckily it healed well and she went on to have two more normal deliveries without any tearing. Unfortunately many first time mums have a lot of backache and long slow labours this is not always a sign of problems. I personally would discuss transfer possiblities with a woman who was labouring slowly early on to prepare her that it might need to happen but of course you just never know when things are going to speed up. I can understand your feelings towards your midwife, as a midwife myself I do look at situations sometimes and think was there something else I could have done that would have helped or something else I should have avoided doing. I am a bit too conscientious and do sometimes lose some sleep over labour care, something which I am enjoying having a break from on maternity leave. I think that like many things it is a very inexact science and there are many different opinions as to what is right and what is wrong. In your case a cs would have been better but for many women that would not be the case and you have to remember that if we did lots more unnecessary caesarians more women would have bladder problems, infections and long term abdominal pain

Before this I was very adamant that CS was something that I would consider a last resort. Now it is the only way I would consider having another, providing the pain goes away before I am too old to consider it. I find the thought of such major surgery frightening. I have heard of women who have gone on to deliver again with no tearing (even feeling better after they re-tear and have it repaired better), but also of those who have made their problems worse by tearing again. There are also so many publications that discuss 3rd or 4th degree tear on the first delivery and the increased risks of incontinence etc after a another vaginal delivery. But then in my opinion nothing is worse risking this experience again.

I heard so many positive/empowering/whatever stories about childbirth before my experience. It usually goes well but if anything happens, I was told, you'll be cared for. All of it was a load of crap TBH. I was given no choices, no information, and what I would consider very lacking care afterward.

I find it distressing/annoying that every midwife I have spoken with says it's so hard to tell if a baby is compound, yet most specialists say the indicators are there if you read it properly. So what am I supposed to think? As nonscary says, it's an inexact science, but it's funny how noone tells you that until it all turns into a mess.

So how do I trust anyone again? This is the hardest thing for me to deal with now. I would like another child, but not at this cost. I hear so many people say anything is worth it, but I don't agree. Sometimes the cost is too high.

Sorry, I am rambling now. And as you can tell I am still very bitter that this was such a negative experience on so many levels. I hope that psych can help because if they can't, I won't have another baby and it's yet another thing I have lost.

oscy, you said you did lots of research on this. Do you have any sites or publications that would be good to look at?

I think that you should go to your GP and insist on a referral to the obstetric clinic where you could discuss it with someone who has a copy of your notes. Ensure that they write in your notes that you could have an elective section with a subsequent pregnancy so that if you do decide to go ahead you can do it with peace of mind that you will be able to have a cs. Although a planned cs is not ideal in many situations as you have said in yours it would be infinitely better.

I have already spoken to 3 specialists (one was rude and totally lacking in empathy). I have let them know I want a CS, and they have agreed that it's a reasonable request considering circumstances.

It may all be a moot point anyway. As I said, it all depends on the pain. I can't so much as use a tampon, or even use ordinary toilet paper, there is no way I could carry a baby on that pelvic floor.

vizbizz, I empathise completely with what you are going through. I have access to full text medical journals through work and have a background in research which is how i got my information, here are some links: www.fleshandbones.com/readingroom/pdf/580.pdf and also www.jmwh.com/home is a good resource. Also www.emedicine.com/med/topic3275.htm . I hope this helps you. This is not the total of what I found by any means but is a start. From what I recall, csection is not really an automatic option for this type of presentation, the gist seemed to be either catch it very early and push hand back (as I think mintpurple was saying) or else an episiotomy upon delivery. The haematoma I had was just bad luck i think. Babs sleeps with his left hand wrapped around his head to this day! Having read about it thoroughly, I really think with hindsight, that 1) I had an inexperienced midwife (I don't think this just because of this issue, but LOTS of others) and 2) baby had hand at side of head as opposed to top of head, which is probably easier to catch.
I understand what mintpurple and nonscareymidwife have said and while not wanting to hijack thread I just want to say you sound like lovely compassionate midwives that I wish I had met during my own labour. There is no substitute for knowledge and experience in the midwifery profession, and hopefully next time I have the privilege to have a baby I will meet your doppelgangers in my country. Vizbizz, don't give up hope of a vaginal delivery, speak to whoever you have to and work through it to your satisfaction.

sorry Vizbizz, reread your post and see you are determined to have cs, follow whatever path will let you resolve this with least amount of pain and most resolution.

Thanks oscy. I also have research experience. I am a med lab scientist. But I can't access a lot of the papers from home and don't have much chance to get to a library. I already had one of those, but the other 2 are also good. I wish my other computer hadn't crashed, I had some good stuff there.

Episiotomy really isn't something I want to consider next time either, as so many of the more recent papers seem to suggest that a significant number of women who have them tear badly and end up with 3rd and 4th degree tears anyway - so more injury for nothing. I guess I am just not willing to risk this again, even if the odds are small.

It seems to me another vaginal delivery would be very dicey. The specialists tell me that surgery could cause more problems that it solves (more scar tissue etc), so I figure more tearing with another delivery would also have big possibility of the same. It doesn't make sense to me when they say another delivery is fine, but surgery now isn't.

I guess part of my issues are, as I said, that you get all this positive empowering stuff before the birth how you'll be informed and have choices etc. yet I wasn't even told there was a problem until it was all over.

I agree with you that the midwives here sound more compassionate, though the one I had is certainly experienced. I have to admit my confidence in the medical system is badly shaken after this last year and more (though working in a lab made me somewhat sceptical to begin with).

Just want to say thanks to all of you for chatting with me. I am just trying to get through this, and sorry if I sound so negative and bitter. It's been horrible regretting his birth, and hating being a mother when before I couldn't wait to be one. Nothing can give me this time back, and the memories of his early days will always be horrible ones for me.

I just want to move forward and stop regretting the decision to have him. I am terrified of having another experience like this one: bad birth, bad information and follow up, no help, support or understanding from the medical profession until much, much later than it could have been. So many treatments I finally got could have made so much difference if they were timely rather than so badly delayed. Having worked in the industry I know how bad the funding problems are, and just don't know how to trust the system again.

Again,m thanks for your concern and support.

Vizzbizz - are you still around? I would really like to message you privately as I’ve come across a few things you’ve posted on mumsnet when I’ve been searching for help on my problems.

It’s like you’ve written my own birth story and experience! I’m
18 months pp gave birth June 17 and I’m in so much pain daily! Would love to
Hear from you!!

nonscareymidwife In your case a cs would have been better but for many women that would not be the case and you have to remember that if we did lots more unnecessary caesarians more women would have bladder problems, infections and long term abdominal pain

Why on earth would a c section cause bladder problems??
This is my whole point as to why we can't trust midwives!
I have never heard of a section causing bladder problems.
More likely with a normal delivery, surely?
At the end of the day, hospital staff are always going to cover their backs and close ranks. They will NEVER admit liability and quite frankly don't care once you're out of the door. So long as their 'statistics' look good they don't give a flying fig.
Harsh but true.

Why on earth would a c section cause bladder problems??

I know this is an old thread but just wanted to say that bladder injury is one of the risks routinely warned about before a CS - it's due to the surgeon accidentally cutting the bladder during the procedure because of how close to the uterus it is. But vaginal birth can also cause bladder problems, just in a different way.