Transverse presentation - not vertex!

epiphany · Sep 7, 2005

They do the usual suprapubic incision, get to the baby, and her arm pops out. They stuff it back in. It pops out again. Again, it is stuffed in. Two docs pulling and tugging and cannot get a good hold on this baby.

Hi RaeT:

I'm just a newbie, and waiting to hear what the L&D nurses here have to say, but could you explain why they would stuff the arm back? Is that bad that the arm is out?

RNLaborNurse4U · Sep 7, 2005

Hi RaeT:
I'm just a newbie, and waiting to hear what the L&D nurses here have to say, but could you explain why they would stuff the arm back? Is that bad that the arm is out?

You want to deliver the infant either head first, feet first, or buttocks first. You would not be able to pull and infant out of an approximate 5-7 inch wide incision in the abdomen, if you try and pull the infant out by the arm. They would place the arm back in the uterine cavity, and reach in and try to turn the baby in one direction - either head first or butt/feet first.

And, to treat a broken clavicle, the arm is immobilized against the chest through tight swaddling, and it will usually heal well on it's own.

Jen

L&D RN

epiphany · Sep 7, 2005

You want to deliver the infant either head first, feet first, or buttocks first. You would not be able to pull and infant out of an approximate 5-7 inch wide incision in the abdomen, if you try and pull the infant out by the arm. They would place the arm back in the uterine cavity, and reach in and try to turn the baby in one direction - either head first or butt/feet first.
And, to treat a broken clavicle, the arm is immobilized against the chest through tight swaddling, and it will usually heal well on it's own.
Jen
L&D RN

Thanks, Jen.

JentheRN05, RN · Sep 7, 2005

When my first child was born (15 years ago) he had severe shoulder dystocia. The doctor refused a c/s and ended up breaking my sons clavicle. It wasn't discovered for 2 days however, and it was at my insistance that something was wrong with his R arm! They didn't do anything at all for it. Nor did they give me any instructions on how to care for it. I was only 18 at the time

PegRNBSN · Sep 7, 2005

This points to the need to always do Leopolds manuevers on your patients. I do it on every patient I admit or take care of. The more you do it the better at it you become. We are lucky at our hospital to have the immediate availability of ultrasound if there ANY questions about presentation. All the MDs know that we will ask for a confirming ultrasound if our initial VE casts any doubt about presentation. In our area we are no longer doing any lady partsl breech deliveries after the ACOG bulletin, what about elsewhere??

babyktchr, BSN, RN · Sep 7, 2005

AMEN to the leopolds. Not being sure of a presenting part and pitting them...yeesh. It sounds like an obvious transverse lie to me...just by what you described. Shame on the practitioner for not checking which part was coming first.

We don't do breech vag deliveries. We have done them, but moons ago. Sometimes it is a shame to have a multip sectioned for breech, especially if they present fully dilated (it happened to me last week). It was double footling though, and not the best presentation for breech delivery.

It comes with time..that speaking up thing. You will learn this. It protects you too. There is no harm in a quick scan to verify a vertex presentation. And.....its how we learn.

**canoehead, BSN, RN** · Sep 7, 2005

We used to have to document presentation before starting Pitocin. HAD to be vertex, or no Pit was given. Perhaps nursing could have been a bit more inquisitive about the positioning and plan of care before just following orders,

PegRNBSN · Sep 7, 2005

It comes with time..that speaking up thing. You will learn this. It protects you too. There is no harm in a quick scan to verify a vertex presentation. And.....its how we learn.

I have learned over my twenty some years that the only bad thing that happens if I speak up when I know/suspect something is wrong is that I may get a negative response from a physician. If I don't speak up there can be many bad things that can happen to my patient. I have gotten very good at being assertive in my communications, not taking those verbal abuses. However, at the start of my career I had many a cry in the break room after confrontations with physicians. As a charge nurse now I always encourage my staff to use me in their communications if they fear a bad response. It is support for them and a learning experience in how to deal with aggresive behavior.

USA987, MSN, RN, NP · Sep 7, 2005

In our area we are no longer doing any lady partsl breech deliveries after the ACOG bulletin, what about elsewhere??

As a rule, we don't do them either.

But in the last 6 months we've done two. One came in breech and 10 cms...delivered in minutes. The other was a twin who flipped after the 1st twin was born...he was delivered by the OB footling breech (longest 3 minutes of my life!!!).

SmilingBluEyes · Sep 7, 2005

If you do not know or are not comfortable with Leopold's manuevers, you really do need to work on it and get there. It's not an outdated intervention, despite the advent of advanced u/s and technology.......

Documentation of presentation of the fetus is CRITICAL before beginning any induction. This is a given. Not to do so, leaves you wide open for liability. And you can't trust what they said at the dr office, either. Even at the last minute, a baby can flip to an unfavorable position.

I love to use Leopolds (with VERY WARM HANDS FIRST) as a way to "lay hands" on my patient, beginning soft, gentle touch-contact. I don't know, it really is a nice way to "break the ice" before I go checking cervices or starting IV's. It's a way to establish warm contact w/the patient for me.

Like I said, first, I warm my hands, then request permission to touch the patient and tell her what I will be doing. I tell her what I am feeling at each juncture/position. If the baby's sex or name is known, it is at this point I begin to refer to him/her this way. I will, for example say, "OH look at this, I feel Jose's little buttocks here.....here, Mom, Dad, FEEL THIS!" Or "wow I feel those little feet and hands moving around, check it out"......

:)

Doing Leopold's this way does a couple of things. The humor "de-tenses" the situation many people are feeling when in the hospital---and makes them know I consider them and their babies special people, worthy of referring by name or at least sex---or at least as people, not just patients. If unknown, I still say something to the effect "wow little mystery-child here has quite the dancing moves"....it almost always elicits a smile and laughter from the expectant mom/couple.

And of course, in doing Leopold's, I gain the valuable info of knowing, w/o checking the cervix or having u/s, which way is baby pointed and is baby OP or OA? (this is very good to know) Is the head engaged or floating? This is a much less uncomfortable way for the patient, of finding these things out. I defer cervical checks unless we are inducing labor or contractions are present.

The challenge can come in very large or obese patients, but with practice, you will learn to ascertain things, even w/these gals.

Really, practice Leopold's on every patient you take care of. You will really be good at it, after time. It's a way of establishing physical contact w/your patient w/o being too invasive or making her uncomfortable, and a way to document you are checking the proper presentation of baby prior to beginning your induction.

Good luck!!! You are doing a marvelous job in that first tough year----and keep asking questions as they come up. That is why we are here!!!!

Long Term Care Columnist / Guide · Sep 7, 2005

My dd was one week overdue when she and her OB decided to go with a C-section due to suspected macrosomia and CPD. Turned out my grandson was transverse.........thank goodness she didn't have to go through induced labor with all the extra risk and pain, only to wind up having a cesarean anyway! Talk about the worst of both worlds........ :uhoh21: