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The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
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The best way to avoid a lip? Keeping mom active and helping her
change positions if she's resting -- rotate positions every half
hour at least. Next best way? Don't look[Grin]! If a lip is
holding things back you will find out very quickly.. if it isn't
you'll see the baby soon.
My experience shows that cervical lips are common. I have
helped them manually and never had cervical tearing. You can
wait and have a woman not push while it goes away, which can
assist with maternal exhaustion, or you can hold it back.
The way you do that is to hold it up before the next cont begins,
then keep it there when the head comes down past it.
Cervical lips aren't indicators of problems, but usually a cx that
stays at 7 or 8 cms is telling you something is up.
Posterior, military, ascynclitism, cockeyed. I just had my biggest
baby ever yesterday, just 10 1/2 #, and the mom was 7-8 when
I arrived, and 7-8 3 or 4 hours later. I gave her blk cohosh
tincture, she laid on her left side, the baby rotated and I held
the cervix back while she pushed. The guy del'd in 11
minutes. Anyhow- sometimes these slight angled posterior
will rotate, and sometimes they wont. Sometimes the mom dels
a posterior (persistant posterior) and sometimes the baby needs to
get sectioned. But doing nothing for a real long time isn;'t
in my repertoire, because if we can't get affect change, and
knowing the hospital takes HOURS to get things rolling, it can
comprimise the moom and baby to just hang out.
I know I have posted this suggestion before, but it bears repeating. If you detect a lip on the cervix, it indicates that the head is not symmetrically applied (creating unequal pressure of the dilating forces). What you need to do is change the angle of the fetal head against the cervix before the fundus cranks down impressively against the butt and shoves the head through the pelvis at the wrong angle (creating decels, and nasty cervical and vaginal tears, among other things).
My time honored trick to reposition the head against the cervix
is the have the mom blow through two contractions on her left
side, two contractions on her right side (you can do this even
with an epidural running for those of you in the hospital), then
two contractions on hands and knees, and the last two in
knee-chest position (not possible with the epidural, but you can
roll her back to the right side and adduct the left leg into the
frog (McRoberts)position for the two contractions and do the
opposite on the left side instead of H&K and KC. Or you can
elevate her hips with pillows higher than her head for the last
two sets of two contractions). Then check her again. I have never
had to run through more than two sets of the eight contractions as
set out above to correct the asynclitism. A whole lot nicer than
attempting just to shove the lip back, which encourages the head
to come down while failing to correct the asynclitic presentation.
The anterior lip is a dead giveaway that the peg is not fitting
through the hole at the correct angle. So if you can't directly
change the angle of the head, then change the angle of the mother.
Something will give. Saves icing the lip and manipulations, etc.
Manipulation of a cervical lip can make it more prone to tearing,
etc.- not someplace any of us doing OOH births really want to go
or repair!! If it helps you to visualize this, try it with a doll
and a pelvis and see if you can observe that an asynclitic head
(usually anterior) will creat the unequal cervical pressure and
the anterior lip.
There appears to be some anecdotal evidence that mother-directed
pushing can be done without fear of swelling her cervix.
So... What, in your experience, makes cervixes swell?
If a swollen cervix presents itself, what do you do about it?
Evening Primrose oil to the cervix--has worked every time almost
immediately. I love it.
Dystocia as in feto-pelvic disproportion..........a swollen
cervix (like a fat donut), in its true form, is NOT a good sign!
Prayer, frequent change of position, drugs to relax mother, more
prayer.
Your answer surprised me! A caput usually spells a
malpresentation with a cephalo/pelvic disproportion. Not a
cervical lip. I have never seen a swollen cervix when my
babes won't descend. Just caput.
In my experience, I have to disagree with. A caput can obviously form with a correct presentation and a large baby who has to accommodate to the size/shape of the pelvic inlet. While this can indicate a malpresentation as well, it can also be a normal occurrence. A cervical lip usually indicates that the angle of approach to the pelvic brim is not correct (asynclitic) and the pressure of the contraction is not equally distributed around the circumference of the cervix, resulting in unequal dilation. I usually suspect either a nuchal hand/arm changing the angle of the approach, or with multips with lax abdomens, simply that the abdominal muscles are not holding the baby's body at the correct angle. Both problems can be addressed by using the "Pancake Flip" - changing the mother's position (2 contractions on the left side, 2 on the right side, 2 on hands and knees, and 2 in knee-chest position) and reassessing the situation. It is necessary to back the head off the pelvis a bit to allow it to realign properly, and this will usually do the trick with one round of 8 contractions. If the lip is truly swollen, it may be necessary to apply Evening Primrose Oil to the cervix, and I have also used ice successfully to reduce the swelling.
I have always felt that a caput was a healthy adaptation of the baby to the particular size/shape of the mom's pelvis. BUT it can be a clue that there is some disproportion here as well. With experience, a midwife will learn to distinguish true descent from increasing caput as far as progress is concerned.
I hardly ever see swollen cervixes ..... But I also strongly
encourage my moms to "blow the baby out", or use open mouth
pushing if they cannot blow through the contractions. Much
easier on the baby's head and the mom's bottom - assuming that the
FHT's are acceptable of course. Does make for slightly
longer second stages, but the trade-off is well worth it.
Nothing in my post referred to 'caput' OR 'cervical lip'; only 'swollen cervix'.
In my experience, the 'Swollen cervix', like a 'fat donut' or
'bagel' doesn't occur that often but usually somewhere between 4
and 8 cm, in conjunction with either feto-pelvic disproportion
(which doesn't mean it can't be overcome), with or without caput
(that would depend on a number of other factors such as Vicki
described well) and/or possibly a malpresentation like an OP, just
plain tight fit OR a labor providing a great deal of force from
above with a great deal of resistance from below as in 'rigid'
cervix. I think of the 'swollen cervix' in the mother as similar
to the 'caput' in the fetus; both are caused by 'extreme'
pressure' and some people's bodies are no doubt more susceptible
to forming edema in the labor process. I don't like seeing it
because it usually means more work for mom AND me and I, for one,
am getting old, impatient and tired (of seeing women have to
struggle through dystocia). The whole 'cervical lip' thing is yet
another conversation, may or may not persist with a complete,
evenly swollen cervix and I would have to say again, Vicki summed
up that scenario very well. I see (usually small) caputs on some
babies who are completely OA, not asynclitic and come out without
too much fuss, sometimes in labors commencing with PROM/AROM, pit
indxn/augs and just lots of pressure against a particular spot
with subsequent physiologic response. Not always pathologic. As
far as why our 'differences'? although we service widely divergent
patient populations, birth is birth and these situations
will just come along, it's the 'luck of the draw'.
I think a swollen cervix is a symptom of disproportion or uterine dysfunction -- rather than a "cause" of delay. If we can fix the dysfunction with herbs/meds/relaxation/time -- or fix the disproportion by finding a better angle or position -- then we might actually fix the problem and get a vaginal baby.
A anterior lip is kind of a different problem -- sometimes it ain't anything other than just the last bit of cervix to get out of the way, and sometimes it's easy to treat with position, our hands, or time -- but sometimes it's got the same cause as a swollen cervix and is gonna be a big battle.
My experience with lips is they either go away in a couple contractions with repositioning -- or they go away within a few minutes if we hold them up - or they aren't gonna budge no way for nuthin.
And of course == if we don't do so many vaginals, then we don't find so many lips to begin with... ... at least not the transient kind which are going to disappear shortly on their own without any "treatment".
but what do I do for stubborn lips and swollen cvxs?
Sometimes time is the best treatment, so I monitor carefully, keep mom eating and drinking. try to get her to relax in whatever position works best. Maybe try resting in bath, Maybe try squatting or other position to bring more pressure on cervix. Maybe try the opposite and take pressure OFF the cervix by getting mom on hands or knees or elevated Simms. Maybe try ROM (or else wish I had not done ROM).
I don't know what works. Sometimes nothing does.
I have tried various herbs and homeopathics but haven't had the miracle success that others have. Once tried ice but it didn't work. One time got mom positioned on side with butt in the air and a good-sized swallow of rum and she went to sleep. That seemed to work a treat.
I haven't had to transport often, but this is the most common reason -- a cervix nearly dilated, or dilated with a remaining lip, or just no further progress and beginning to swell. Oh -- usually the baby is posterior too. (As we've been able to reduce the numbers of posteriors, this scene becomes less common of course.)
re caputs -
A caput is a pretty normal process in labor -- normal enough with
primips to be expected - at least the small to moderate ones are.
Big ones can be a sign of a tight fit though -- and sometimes you
think the baby is coming, but all you got is caput. That's not a
fun scene at all.
True, a caput doesn't mean the head won't come in, but can mean it won't. In its own right it can be a 'failure to progress'. You can have a caput that progresses and then you can have those that don't.
After reading everyone's description of a swollen cervix, I can
only conclude that I have never had one. I have had lips and
yes they can be caused by a head that isn't entering 'right
on'. I have mom push with contraction as I push them up,
babe comes down and it is all over.
My experience with CPD is that although the cervix may feel like
a donut, it's been a rather floppy, formless donut rather than a
fat, swollen donut.
I have not had swollen cervix for sooo many years I am not sure
how to answer you except to say that I think that the cervix gets
trapped between the head and the pubis. The head CAN go
around it or someone can push it up. The longer it sits
there the more swollen it becomes. I, personally, just push
it up and don't let it swell.
Give counter pressure to unswell it, hold up over head (even between conts), and have push past the cx.
I have had lips and yes they can be caused by a head that isn't
entering 'right on'. I have mom push with contraction as I
push them up, babe comes down and it is all over.
Wish I could say the same as you, but not my luck. maybe you're
pushing harder than me, but I've had a couple of stubborn ones
over the years.
Hmmm. I never had one I could not get up. I may have
to go with a position change, but still, with a contraction, I
push them up as mom pushes and once the head passes that point, it
doesn't come down again. The position change seems to make it
easier for mom to know how to push.
The
Anterior Cervical Lip: how to ruin a perfectly good birth
[Midwife Thinking blog from 1/22/11, updated March, 2016]
The anterior portion of the cervix is the last part to get out of
the way... it's not pathological -- it's just the way they are
made. Give them a
bit of time and the lip will disappear. Tincture
of time is my usual remedy for a lip. Getting mom to relax,
rest and wait. Water and darkness are great tools at this
point. I think something needs to change -- either the
position of the baby (kid probably needs to complete rotation), or
time or better contractions, or a rest in order to "get" better
contractions later, or better maternal position.
Pushing on hands and knees will help!
I rarely use time . . . if the mom is pushing, I hold the cervix
back between contractions and allow the head to slide right past -
usually in one contraction. I totally agree that if it
doesn't work in 1 or 2 contractions, it's not ready, but it's rare
for it not to work.
I was taught to hold it out of the way also.. went through the
same process of discovering that "most" of them will go away just
as fast if we do nothing as they will if I held them up (man, does
this cause cramps in the midwife's shoulders, arm, fingers and
back[Grin])! We try positioning and getting mom to relax and
breathe through a few contractions.. we do add "side lying" to the
above list of positions. Also a good time to float in a
tub[Grin]..
I think that "usually" a lip will resolve itself more easily on
mom and at least as quickly if we use the hands off approach.
(Again, not always, and there's the unusual situation where
holding the lip is needed.. but I think it's rare).
How do I decide whether to attempt to hold a lip or rest the mom?
Waiting for a few contractions to see if the uncontrollable
pushing urge kicks in often decides the issue[Grin] but "if" I
feel a swollen lip I might try lifting it. If it melts away and
stays away during the next contractions, then I'll try that for
perhaps one or two more. If it is tense or if the lip comes right
back down during-or after-- a contraction, then I think it doesn't
do a lot of good to keep holding it -- it will eventually go away
if I do that (or not).. but I think that sort of lip will go away
just as fast without me in there...
RE -- observing a lip come down with the baby.. Actually that's
not too uncommon and probably wouldn't matter whether you tried to
move the lip out of the way or not. It's not impeding birth and
you probably couldn't have avoided it anyway (ever held a lip up
"forever" got it out of the way, mom pushed well and lip STILL was
visible with baby? It happens sometimes... might even be a normal
variation).
I believe cervical lips are sometimes a sign of an
OP/OT/asynclitic position, and I don't believe they impede
progress. Don't forget, that last centimeter or so is not
dilatation in the horizontal plane, but the cervix being slipped
past the baby's head as it descends vertically. If they get
really, really edematous, I believe they should be slipped up just
so they don't get so edematous that they get trapped by the
symphysis. It is easy, and not terribly painful, if you push them
up between contractions, hold them up past the symphysis,
and have mom push with her next contractions.
If you are open to homeopathy, arnica 30x given throughout labor
helps reduce swelling, thereby helping to reduce cervical lips. I
also had a midwife who would have the woman roll flat on her back
for one contraction and try to put her knees to her ears. The
theory is that by curving the back, the baby's head is lifted out
of the pelvis enough that it gives the lip room to slide back on
its own. Haven't tried it, but she says it works every time, and
in one contraction. And is significantly less painful than pushing
it manually.
If positioning & Arnica don't work, and the lip can't be
reduced over the baby's head during a ctx ( or the mom is toooo
uncomfortable), I've used an ice cube applied directly on the lip
with fast results. The ice melts quickly, and the mom usually
loves the coolness where there is sooooo much heat.
When I use Arnica for a swollen anterior cervical lip, it's
homeopathic arnica 30c, 3-5 pellets under the tongue and repeated
in 20-30 min if necessary.
We have had to transport in for pit to get her to the pushing
stage. First time we went in at 7 cm. Monday we made it to just a
rim but couldn't get past that. Baby does fine no problems at all
so I waited and waited and waited. She was at 9 for 24 hours. I
know that is outrageous but she was not in labor. She slept a good
6 hours and when she awoke had contractions only 7-10 minutes
apart.
I've seen them do this.. and the general consensus here is that IF THE WATERS ARE NOT BROKEN and if there have been NO or very limited internal exams; then there should be little stress on the baby -- and the decision then is based on how the mother feels. If labor is light with weak and sporadic contractions, and mom is sleeping and eating and willing to wait for good labor to kick in - - - well; I think most would wait.
I lot o f "if's" there though...
I did have one woman who stopped at 8 cms... We left the place and gave privacy (not much point in us being there if there are not good contractions)..... Good labor started again the next day..
Some would call this uterine inertia -- some would call it a normal but uncommon labor pattern.. Gotta figure out what's going on and if there is any problem contributing to it (for instance, a tight fit -- but then you would expect to see GOOD contractions, which peter out as the uterus and mom get exhausted. Doesn't sound like what you describe).
Best advice for this type of labor is to do no internals until
contractions are consistently under five minutes and/or mom is
showing transition signs.. Assuming intact membranes, the major
risk of this easy, light labor is infection -- so no internals
until CONSISTENT labor pattern!
My non-invasive methods of reducing a lip are: arnica 30c po q15
min, change in position first left lateral and later if needed
(mom doesn't like lying on side) hands and knees. If I have a fat
lip, and mom's circumstances are that I need to get it out of the
way, but I will take more than just slipping it over the head
during one ctx......I'll set her on the toilet, and hold it during
and between 3-4 ctx. If it's not gone by 4 ctx, we take a
rest......her body and my hand need a rest by then. If I feel any
increasing edema, I will stop immediately and go back to the
position changes. I always give the arnica though.
From Polly Perez - Here is the tip I use the labor support workshop I do:
Rock forward straightening legs and leaning down looking at the ground
When contraction starts- "hang" from someone with your arms
around their neck
(the second movement help the baby descend/
Hands and knees works well for me. I have had several
mothers use this and the lip was reduced with minimal cervical
trauma (as can be the case when manually reduced by a nurse/doc)
and reduced fairly quickly within a couple of contx.
So how many of you subscribe to the theory of putting pressure on
the lip helps get it out of the way? And how many subscribe to
letting the pressure off helps get it out of the way? Translated
means: Who has her do hands and knees and Who has her
semi-recline?
I do arnica and hands and knees. If she can't stand hands and knees I will ask her to stay way over on her side (practically on her belly).
When I was interning, I saw lots of ladies who would come to
delivery with an urge to push. On VE I would feel no cervix on one
side, and about 2 -3 cm on the other. Generally it was because in
labor they would lay on one side and stay there (they didn't have
much choice, they often shared two to a single size hospital bed,
so each would lay on one side and avoid disturbing the other lady.
) The side they laid on was invariably the side that was more
dilated. We would just make them lay on the undilated side for
about 15 minutes, and voila! they became complete.
I haven't used it in relationship to posterior cervix, but I don't know why it won't work for the same reasons.
What I have had experience with is when there is 8-9 cm cx that is more on one side than the other. What I find is that it is like that because the weight of the baby is on the cervix, so that if they are lying on their left, there is more cervix on their left side. Usually removing the weight of the baby (turning them to their other side) remedies this. So I don't know why the same things won't work for the posterior cervix. (provided that the baby is well applied to the cervix)
Therefore my vote is for the semi-reclining to take the weight
off of the anterior lower uterine segment.
I'm not so sure that hands and knees, or side lying, helps a lip
or poorly dilating anterior portion of the cervix "by putting
pressure on" the region -- I think the reason it might help is
because we seem to see more efficient contractions (for most
women) in this position. Not sure where the "pressure" really is
in various positions...
Several midwives in my area have taken to giving arnica 200 c. or
triple potency's Muscle and Joint Injury when labor starts, and at
the beginning of second stage, and just after birth. They have all
been noticing that there have been fewer anterior lips... we are
all wondering, but it makes sense!!
I have used these Homeopathics with good results over 18 years
for cervical lips: Aconite 30 when it's due to fear, tension and
it's a tight dry lip that won't budge. Gelsemium 30 can be used
when it's a real tight lip, or it's one of those loose floppy lip
that still won't move. Each one of these can be used with several
doses, but don't give them together. Take them orally.
I have on occasion used oil of Primrose to soften up the rim.
Evening primrose oil doesn't work 100% of the time, but I would
say at least 80%.
See also: Sterile Water
Papules
I just saw the sterile water injections done for the first time
by one of the midwives in my new job. It worked amazingly well.
The Mom felt instant relief and was able to rest for a bit, allow
the lip of cervix to go and push out a beautiful baby 7-5 who
rotated right before delivery.
I put on a sterile glove, pick up some ice, and put on another
glove so that the ice is between my fingers. Then I rub the cervix
with the ice. It seems to decrease the swelling, and the head
moves on, so to speak. Occasionally ice feels good on the perineum
if the mom's experiencing the 'ring of fire'. Yes, instead of warm
packs, I try cool ones. Work for some women.
I have recently heard of a very experienced midwife who routinely
manually dilates the cervix to speed up labors. The mom who had
been attended by this woman was very grateful, since she felt her
labor would have been very long, otherwise. Something about this
doesn't "sit right" with me. I know that any unnecessary
intervention (and I would, in this woman's case, call it
unnecessary) only hinders normal labor, and can affect mom's
emotions in many ways that we do not even see. Can you tell me
what the physical risks of manual dilation are?
Most attempts at manual dilation are a matter of pressing the
cervix open during a contraction while the uterus pulls up on the
cervix and the head presses down through it. Many midwives
consider it an "intervention" that would only be used when
progress was slow enough to be considering transport. In any case,
it would not be done vigorously enough to tear the cervix.
Sometimes it works beautifully, and sometimes it only seems to
work. That is where the danger of cervical tearing comes in. If
the cervix opens all the way with your manual assistance, then
gradually closes and swells up, then pushing could cause a tear.
This wouldn't usually happen, since even pushing on an 8cm cervix
wont usually cause a tear. Tearing of the cervix is pretty rare in
a non-forceps delivery. But that would be about the only physical
danger from manual dilation. To minimize the chance of cervical
tearing, manual dilation should be fairly gentle, the cervix
should continue to be assessed after the procedure, and the mother
should not push until she feels the descent of the baby. As far as
using manual dilation to START a labor, I don't know why this
would cause tearing several hours later at birth unless it was
torn just a little with the manual dilation (remember the
excessive bloody show) and then the little tear spread to a bigger
one during pushing. We must remember that all interventions, even
midwife ones, can have some risk. We are always trying to balance
out the risks of what we do at home against what we suspect will
happen in the hospital.
I wonder if "holding a lip" causes the baby's head to deflex?
I think it is probably the other way around....a deflexed head causing
the lip to start with.
I assume we are talking anterior lip that is getting caught and
starting to swell when the woman pushes down.... and a good
pushing urge. This is an interesting question. Possibly this could
happen if the baby was OP, but then posteriors are often not as
well flexed, but it seems like the reverse might be true if the
baby were OA, don't you think?
I often find that it's even the head that is just trying to turn to OA from LOA or ROA that will drag down that lip that just won't go, no matter how strong the urge or how "push-backable" the lip seems to be. We usually have the woman lie on her side for a contraction or two to assist in completing the rotation, which generally gets rid of the lip very nicely and - voila - a baby! This, BTW, seems more often to be a problem with multips than primips, in my experience.
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