Never Give In Until You Say It’s Over

I had met her the evening before. Her primary nurse had wanted assistance with Leopold’s maneuver. This is an assessment that I encourage on every admitted patient on the labor and delivery unit. The conclusion will allow us to determine if she should start doing some maternal positioning right away to help get her infant into the optimal position for birth. At the time of her admission, she presented with a birth plan, her husband and her doula. They were a team on a mission, having discussed her birth plan and how to support her. We were also ready to help her achieve her goal.

22 hours later, as a group of evening nurses stood in our scrubs, we waited to hear which patient we were assigned to. This is always a moment filled with anticipation and excitement, yet a bit of dread for the hard work ahead. I saw her name and heard her story, yet she was not my assigned patient that shift. I was given the title of what we label, “resource nurse.” I had scored! This assignment is always my favorite as I love to assist others; nurses, physicians and our beloved patients. I love going into a room to serve in the role of “second RN,” where my job is to attend to the newborn. How privileged are we to have the job of gently wiping, stimulating, evaluating vital status, weighing, assisting with first feedings, and encouraging the bond between parents and child? I after, all these years, still am in awe of each and every birth.

This above mentioned patient was a woman who was pregnant with her first child, a primigravida. She was ultra fit, a person who had a job where she spent the majority of her word day on her feet, had no underlying pregnancy related diseases, and had an infant who was not measuring large for gestational age. She had reached 10 cm dilitation after 20 hours of labor, and had been pushing for 2 hours when I was asked by her physician to evaluate her current status and report if there is anything I would suggest doing so as she could continue on the path of a vaginal delivery. She was very tired and her nurse had not noticed any descent of the fetal head in the past one hour of pushing.

I went in and calmly discussed who I was and that I had been asked to come in, as I have had special training in what is called maternal positioning for optimal fetal positioning. I asked permission to do a sterile vaginal exam in order to help determine what position the fetal head was in at this time after pushing for two hours on her back. The infant had significant molding to it’s head, yet I could palpate the swelling going horizontal verses vertical. This means that most likely, the infant’s head was transverse. Per my research, more cesarean sections are done for transverse arrest of descent than for any other malposition related to “arrest of descent.” I knew that if this babe was going to be born vaginally, it needed to be given the space to turn it’s head to vertical, may it be occiput posterior of the better choice, occiput anterior (looking down at the floor).

I explained this to the patient and her birth team. I listened to her questions and her insistence that she wanted to continue to try to deliver vaginally. I instructed her and her nurse to stop pushing as of this moment in time. I gave them each a job. First of all, it was important for her to drink some caloric fluids. Who can run a marathon without supplemental energy? Her husbands role was to encourage a sip of fluid every 5-10 minutes. Her doula was to assist me in position changes. Her nurse, having been working hard for the last two hours of pushing, had some charting to do, so I encouraged her to do so.

My immediate goal was to get this little one’s head out of the maternal middle pelvis, enough to allow for a small rotation, so as to decrease the diameter of it’s head, by going in straight verses transverse. Open knee chest was the way in this situation. She had an epidural, so it is always important to determine her ability to get up on her hands and knees. In asking her nurse, she had been able to change lateral positions with very little help throughout this shift. The patient herself felt that she could get up onto her knees with assistance. OK, let’s go! Her doula and I were on either side, one person’s job is to balance her legs, shoulder width apart, her arms supported over a peanut ball at the head of the bed. The other person has her hand under the maternal belly, so as there is never any weight placed on the infant and can adjust the fetal monitoring when needed. Dad was then asked to help support her legs by holding a folded sheet that I had placed through her V shaped body laying across her thighs. He positioned himself at the foot of the bed and helped hold her up, kind of like holding the rope of while water skiing. Slowly, she is positioned into a A shape verses a L shape. It is important that this shape is encouraged as it allows more room due to the front on the pelvis (symphysis) is allowed to open up. She was held in this position for two contractions (or 5 minutes), breathing into her belly with no pushing allowed. Calm relaxing breath, maternal coaching encouraged, instructing her own infant to come out of the pelvis, in order to go back in a more comfortable and safe position. After a few minutes, the doula stated that she felt “a lot of movement.” She was easily returned to her lateral position in bed. I reassessed the infants position via an exam. The head was further up in the pelvis and the swelling was running up and down now! Now it’s time to push!

Lateral pushing is best, as it allows for the sacrum to tilt back to allow for the infant to come into the pelvis, and then once the head is low by the pelvic outlet, it tips forward to allow for the space to open for delivery. After 20 minutes of pushing in the lateral position, her baby girl was born into her waiting arms. Momma was what I call, a “rock star.” I left the room, knowing the beauty and magic of maternal positioning yet again.