Friday, November 22, 2013

“My Baby Hasn’t Dropped Yet”!

You read about it, you wait for it to happen, and then it doesn’t!  Pregnant moms everywhere scour the internet wondering if they are going to have to be induced, or worse yet, have a cesarean. 

I get a sick feeling in the pit of my stomach when I hear how a poor mom is facing a cesarean based on the fact that her baby ‘hasn’t dropped yet’.  It’s happening so much, that it’s becoming  a common belief that this is where the evidence leads us. 

So, what does it mean when your baby ‘drops’?   When your baby drops, it means it has nestled down into your pelvis and become ‘engaged’.  When your doctor or midwife does a vaginal exam, they are not only checking for your dilation, and your effacement, they are also checking the station of your baby.  This tells them how high or low your baby is in relationship to your pelvis.  Your baby's station is measured in cm -above and below the ischial spines.  If your baby's head is even with the ischial spine, then it is considered to be "zero station", and also nicely "engaged".  Let's look at the following pictures:



My index finger is pointing to the ischial spine!



 Here is a picture of the baby's head even with the ischial spine.  It is engaged, and at "zero station":


This baby here, is not engaged at all! (some babies are lower than this, but still not considered to be engaged yet).  


The baby's station can be anywhere from -5 to +5 - measured in centimeters above or below the ischial spine.  Do a quick Google search and type in the words "pelvic station" and you will find many images that explain it much better than I'm doing here! 

For those of you out there giving birth for the second, third, or more times - please understand that your baby will most likely NOT drop until well into labor (or even pushing), and that your provider should not be doing a cesarean on you for this reason alone! 

For you first timers, it is more common for a first time mom to have her baby “drop” before the onset of labor, but she doesn’t have to feel broken if baby has decided to stay comfy higher until she is well into labor.  I’ve assisted many first time mothers whose baby was high at the onset of labor, and none of them had a cesarean because this was the problem. When my clients tell me that their baby has not dropped, I shrug my shoulders and smile.  It’s common even for first time moms, and it’s no.big.deal :-)   Another very interesting thing to note is your racial ancestry!  A study from  Philpott  and Castle found that African Rhodesian primigravidas did not have engagement until the late first stage of labor.  (So in other words, almost time to push before engagement)!  The Oxford Handbook of Obstetrics and Gynaecology, states that “In women of Afro-Carribean origin, engagement may only occur at the onset of labor, even in nulliparous  women due to the shape of the pelvic inlet.”  Going back over my doula notes, I did have more of my mama’s of color not have any fetal descent until late in labor, (but I also had Caucasian mother’s do the same)! 

Studies like this, http://www.ncbi.nlm.nih.gov/pubmed/7076337 suggest that there is no difference between needing a cesarean and the baby’s station.  However, there are plenty of other studies that seem to state otherwise, which is most likely why your doctor finds a cesarean the best solution in his/her practice.  A provider might see that there is an increased likelihood of having a cesarean and thinks “well, she is going to end up with a cesarean anyway, I might as well save her the trouble.”

I think that we need to consider something about these studies:  First of all most of the mothers were induced.  Induction on a good day, with baby nice and low, can lead to a cesarean in approximately 1 in 4 women.*1  So if women are being induced because baby is high, and they have a cesarean can we really blame it on the fetal station?  Secondly, if a baby is sitting high in the pelvis, it might take some time before dilation progress occurs.  Think about it; if baby doesn’t sit on the cervix, it may not open as well.  What if this takes more time than your provider would like to give?  (Studies do show that an unengaged baby may take longer).  It’s no wonder failure to progress is the leading cause for cesareans in the United States!  Finally, it is true that babies can be misaligned  (in other words the head just isn’t quite where it should be), and that this misalignment is holding the baby up.  Some providers go straight to a cesarean in this situation because they know that Pitocin can just bang baby into a bad position and that can also lead to a cesarean anyway...  This is why it’s so important to have a doula and to learn the art of optimal fetal positioning.  If you are induced, you are likely not to have a lot of time to birth your baby, and you are also not likely to be able to get into positions that would facilitate rotation and decent of your baby - so guess where that leads you? (Yes, cesarean would be the correct answer)!  The good news is that you have a choice to wait, and work on getting baby into better alignment (and more than likely neither an induction or a cesarean will NOT be necessary :-) Even if you do nothing to get baby into a better position, your body will most likely work on it anyway with or without you! 

So when is it a problem?  One study, says that it’s a problem if a mother is at 7cm dilation, and the baby has not descended yet.  According to Varney’s Midwifery Text “Lack of engagement at the onset of the second stage of labor in muliparas is abnormal”.   (Second stage is the pushing stage of labor, and muliparas - means a woman who has given birth before).  In other words, we can’t call it a problem until you *are* in labor, and you *are* pushing!   How can doctors be giving moms a cesarean for this before labor begins?  This not a medical reason for a cesarean!  A trial of labor should always be given if this is the only reason for the cesarean! 

What if we went back about 40 years when our cesarean rates were about 10%, or even 20 years ago when our cesarean rate was about 20%?  How come those women did not have to have a cesarean for such a common situation?  Did they have poorer outcomes because they didn’t do cesareans or inductions for this?  (The answer is no, our outcomes are worse now by far then they were back then). 

So what can you do, what are your options?

Your first option is to wait.  It’s boring, it’s not easy, and it’s downright uncomfortable.  (I’ve heard that cesarean recovery can be uncomfortable too, so there isn’t a perfect solution is there)?
While you are waiting, it’s time to learn some spinning baby techniques, and for this you can visit this website: www.spininngbabies.com .   Perhaps it’s time to consider chiropractic care that specializes in the care of pregnant women.  If your pelvis is out of alignment, your baby may not want to settle down into the pelvis.  Consider the risks of being induced, and having a cesarean.  Now think about the risks to waiting?  Which one has the shorter list of risks? 

Induction: If your provider is suggesting an induction just remember that if your body isn’t ready, you will not be likely to have a vaginal birth, no matter what your baby’s position.  But wouldn’t you rather try that then go straight for a cesarean?  I’d also like to offer this little piece of advice:  If you do decide to get induced, you might not want your waters to be broken until your baby has descended lower into your pelvis.   This can lead to ‘cord prolapse’ in about 1% and this situation requires an emergency cesarean delivery.  (Cord prolapse occurs when the waters are broken when the baby is high in the pelvis, and the cord slips down into the vagina before the baby’s head.  The baby’s head can then pinch the cord against the pelvis, which cuts off it’s blood flow and subsequently, it’s oxygen).   It is not recommend that induction be done before the 39th week, and you might even consider waiting until you are 42 weeks.  Induction of labor increases your risk of having a cesarean, so again, consider waiting it out.   May I also suggest working on baby’s position prior to the induction, and then do what you can during labor as well.  

If you go straight for a cesarean, you have to consider all the risks for you and your baby.  Subsequent pregnancies are also at risk with each cesarean you have.*5, 6


The Risks of Elective Repeat Cesareans vs. The Risks of VBAC from ImprovingBirth.org

I think it's time that we start using cesareans for the situations that really warrant them.  Remember, it's never too late to change providers, and for the love of doulas, get one! 


2 comments:

David Schrock said...

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Unknown said...

I had c section because absence of pain and artificial induction