CPD???? Could I be one of the unlucky ones?

[shorty]

My first baby, Logan never engaged till birth.

[paradise lost]

Hi,

Ok, let's be clear that CPD is a REAL condition, it is just very very rare. I know that seems like an obvious statement but it does mean that for SOME women, the diagnosis of CPD will have been correct.

Kyliealysha it's hard to know if you had true CPD. The head %ile, believe it or not, isn't hugely relevant - in general c-section babies with 41cm heads would have been vaginal birth babies with 38cm heads - the skull moulds to such an extent, you can never REALLY know how it would have gone down if the birth had been vaginal (or a section, if it WAS vaginal). I know my vaginally birthed DD had a 35cm head the day she was born and a 37cm head on day 6...

What WOULD be an indicator is a baby that remains high for all the attempted 2nd stage with no descent. -1 is in fact descended to some extent, but since her head was entirely unmoulded it is possible she simply didn't fit into the pelvic inlet. There is a homebirth midwife's account here of a true CPD labour. Her lady was fully dilated for many hours too and they tried all kinds before they decided to section - the baby never came down past -3 and the head was unmoulded at birth.

The good news is that CPD is not a permanent diagnosis - it ONLY applies to that baby and that labour. Studies show that around 65% of women with section due to CPD do NOT have it in the next pregnancy and go on to birth vaginally.

I would urge you to surround yourself with positive people, use positioning techniques to gets bubs in the best position, learn good birthing positions for bigger babies (supported squats, deep squats, hands and knees) and THINK POSITIVE for your future VBAC.

CPD is very rare and though you're slightly more likely than most to experience it, having had it once, that doesn't mean you will - even having had it once you're still more likely to birth vaginally successfully than have CPD again.

Best of luck.

Bx

[~mamaspice~]

Hoobley, I think that was very well said.
Kyliealysha, I am going to take my second pregnancy and birth as a whole different experience. I am hoping for a VBAC and I will be doing everything in my power to try and achieve this. At the end of the day though none of us can be certain that our birth WILL go as we want it to. I wish you all the very best for your next birth

[suse]

I was given a diagnosis of CPD; after a long labour, full dilation and three hours of pushing (posterior bub), heartrate was starting to drop and he was showing signs of distress. The ob suggested that it would not be safe to try an instrumental birth at that stage, as bubs had not descended enough and was already starting to distress. He had not engaged prior to labour, which was started naturally 11 days postdates.

The ob said that she would check my pelvis during the surgery and see if there was any reason due to pelvis shape / width that would prevent me having a VBAC. She said that true CPD is very rare and that hopefully it was just a case in this instance of bubs getting stuck in an unfavourable position, but later debriefed me that I do have a pelvis that is unusually narrow and that even a smaller, anterior baby could not be birthed through my pelvis. In my case I am apparently one of the genetically unlucky ones. I too have questioned whether my own diagnosis has been a genuine one, and intend to have it confirmed, even though I trust my ob and know that she is very supportive of VBAC.

Euan had fairly significant moulding though (and a relatively narrow HC of 33.5cm), so it is interesting to hear that other CPD babies have not had any moulding. Does anybody know if lack of moulding is a trait common to all CPD babies?

Kel, I do agree with you that we are the result of natural selection, and that diagnoses of CPD are bandied about quite unnecessarily at times. It is unfortunate that the term is not more accurately used (aside from the implication to the birthing mother), as any studies on the incidence of CPD would undoubtedly be skewed.

Having said that, it is quite feasible that the occurrence of CPD as a genetic trait (which may be either due to mutation or a combination of multiple slightly unfavourable genes that were not sufficient to cause true CPD on their own) will rise in this and future generations due to the incidence of c/s surgery - before this, women with genetic CPD would have died in childbirth. It would be interesting to see some accurate studies done on this.

[kyliealysha]

Thanks everyone!!

I will definitely aim for a VBAC next time and intend to be much better prepared

[HotI]

Hi

I can't help you on the CPD issue, though i have learnt alot here from what has been written.

After the emergency c section I noted that her head was a perfect shape. She had no bruising or shaping suggesting she was even almost there.

When my niece was born (vaginally), they had 3 goes with the suction cap, and then used forceps to get her out and she still came out with a perfect shaped head with no marks!

best of luck with your next bub,

k

[paradise lost]

Suse,

the baby's head moulds in the pelvis, so no, in general a CPD baby would not have a very moulded head, as CPD is when the baby's head is unable to fit into the pelvis. Unless you have had a disease like polio, rickets or an injury to the pelvis where the bones were broken or some other thing to cause a deformity of the bones, it is very very unlikely that your baby would fit into the pelvis but not out of it.

What positions did you push in for those 3 hours? In general, because the sacral and pubic bone joints are loosened by relaxin during pregnancy, a baby that fitted IN will fit OUT - the looser joints make the whole pelvis like a hinge, if you press on the two highest pelvic arches (top of your hips) it opens the bottom of the pelvis - this is called a "pelvic press" and is a way of unsticking babies who are taking a long long time to mould and seem to have problems fitting through. Did your care providers try this?

Another sign of a CPD baby is that they remain high - women generally do not have a pushing urge or never have it consistently (every contraction) because the head is not low enough to press on those nerves which drive expulsive pushing. Did you have an urge to push or were you coached to push? I read your birth story and think i remember you had an epidural which they turned down? When you pushed then did you feel you wanted to or did they tell you push when you felt the contraction?

With posterior babies all bets are off - it is HARD for a posterior bubs of average size to get out - the normal pushing time for a first posterior bubs is 2 or more hours, from that POV although you pushed a long time, it was not abnormally long for that sort of labour (i know a woman who had a brow baby, pushed for SIX hours!). The pelvis/baby combo is the perfect shape for an anterior baby to fit through, and the head of a posterior bub is back to front, the neck has to flex more than it would normally, various little geographic features inside get in the way and make the process longer and harder.

In addition the kind of pelvic measuring the ob did (either with fingers or scans) is very unreliable - it's about as accurate as sizing the baby with ultrasound - it can be ok but is often WAY off. There is really no way to tell if a baby will fit through except by trying it (have a look at Kel's tiny women birthing big babies to see what i mean) and i suspect until someone is actually able to give birth inside an mri machine the mysteries of the mechanics of the female form will remain mysterious.

I'm not sure about genetically linked CPD - how would a trait like that have survived the 80,000 years of humanity before c-sections? Were you a c-section baby? Was your mother? Was her mother? These are the sorts of things that would have killed humanity off many many thousands of years ago. The only thing i think is reliably being passed down due to the high diagnosis of conditions like this and c-sections in response is fear. I know several women who had c-sections because their mums had them and they did not BELIEVE the women in their family could birth!

It sounds from the size/shape of your baby's head that he had definitely begun the arduous task of fitting back to front through the pelvis. Posterior labours can be so hard and painful, the back pain was terible for me until she turned (my bubs was possie for the first part of my first stage, spent ALOT of contractions backwards on chairs, rocking on my knees, crawling about etc. and luckily she turned).

ETA- ok, i've had a read of your birth story again and i would say that....with a posterior labour the first stage is often slow (days and days) as prelabour is what turns the baby. The fact that they tried to induce things when they were slow meant your bubs was pushed hard down into the pelvis while still posterior. It can take a long time (know a woman on another board who had prelabour (i.e. painful ctx but very little dilation) for 8 days before bubs turned anterior while she was scrubbing her kitchen floor) for the prelabour to turn a possie bub, but if you're well-supported and know which positions will help bubs turn they often will, and then labour follows swiftly and smoothly.

Once you were under way and had pethidine and the epidural, this is another factor. I had very brief possie labour and believe me, i KNOW how painful just a tiny taster of it is, so i'm not questioning why you went that route, i just want to point out that the route itself has complications. Pethidine passes to the baby, who needs to be alert in order to turn. I did read a study not long ago (on paper unfortunately) that suggested the rate of positional problems is significantly higher in bubs whose mums had pethidine or morphine during labour - maybe one of the other ladies will have a link - babies usually make vigourous efforts to assist their own births, and babies who have had drugs cannot do this so well. In addition the pelvic floor muscles, the deep ones, actually assist in turning the baby and with an epidural this doesn't happen. With the epi it is usually impossible for mum to get her weight off her sacrum entirely. Sitting up can be some help with an anterior labour but with a possie you really need all your weight off your butt and gravity helping you.

Your baby became distressed, it is very unlikely that by the time that happened there was ANYTHING you could have done to avoid surgery - he was no longer coping with the labour. High forceps delivery is dangerous and usually very damaging to the perineum and vaginal canal, from that POV a c-section would have been the best option for your Ob at that time - possie bubs are hard to extract as well as birth through the vagina!

However i do think that it's INCREDIBLY likely that you would be able to birth an anterior bubs, when even a possie one had moulded to that extent and fit into your pelvis, and that even with another possie, if you avoided certain elements that featured in this labour your body would be able to either turn the baby or get it out facing the wrong way itself.

HTH

Bx

[~mamaspice~]

Hoobley, what you said is very interresting. Especially the bit about moulded heads. My bub was born with quite a pointy head and I was very surprised considering she was a cs baby. It certainly gave me the impression that she was in the right spot (although my OB said she wasn't at all engaged) her head is still a little pointy nearly 8 months on - although MIL says this is the rusky in her from FIL's side (european head apparently )

RE; the evolution/natural selection thing - I do remember my Chiro telling me that your back and hip alignments etc are usually worse then the generation before you. Is this true or is he just trying to drum up business?

[paradise lost]

Engagement can be a funny thing. I used to check DD's engagement daily and more in the last 2 weeks of PG (she was born 11 days past EDD). The MW would check - 2/5ths. I would go home, go for a swim, check myself - completely free. Later on, check again - 1/5th. The next day, again, free while reclining, 3/5ths while stood. That evening, free while stood. Babies with room (i'm 181cm) CAN and DO move up and down. The first time i felt her fully engaged (widest part of head in the pelvis) i had had 5 hours of contractions and my waters had been gone for all that time. Right up to the day she was born she could have appeared too big to fit, but she wasn't at all. Glad i didn't have to get her out posterior though! Any pointiness your DD had that went away in the first week or two after her birth was moulding, if that helps.

RE; the evolution/natural selection thing - I do remember my Chiro telling me that your back and hip alignments etc are usually worse then the generation before you. Is this true or is he just trying to drum up business?

Honestly, i think he's probably trying to drum up business, but that there will also be SOME truth in what he is saying.

The incidence of posterior labour is higher in the west than in the east, because women here sit on sofas or up a desks all the time, whereas there they sit on the ground or squat, both of which do much to help bubs lie anteriorly. We do not (in general, i know some do) exercise our bodies well - women in India and North Africa are hard muscle and bone and little else because their lives are physically very demanding. By contrast western women have weak core muscles (abs/lats) and pelvic floors. Stress incontinence in African girls is almost unheard of and even after a baby (past the first week or two) it is rare, in the west it affects a high enough percentage of women that many rather than seeing the doctor just buy incontinence pads as if it were a normal thing!

Because the chiro sees a lot of people he probably sees the older generation who had very physically demanding lives and jobs when they were young and growing, who have far better muscle tone and alignment than younger folks who do not do heavy work. But this does not mean that the bodies of the younger generation are defective; anything a chiro can fix is aquired, not genetic. If it was genetic it would be un-fixable - a chiro can fix a functional leg length discrepancy (where the pelvis is tilted on the spine and thus one leg SEEMS shorter) but only invasive and risky surgery can fix a leg which is genetically shorter.

The problem with all out technology, as wonderfully easy it has made life, is that our body is MEANT to move. Muscles waste if you don't use them. If the first time you need tone in your pelvic floor is when you're lifting 30litres of water onto your 12-year-old head to carry it home then by the time you give birth it's going to be really strong and able to help your baby turn, with a great blood supply to allow an easier birth and post-partum time. If the first time you ever need it to be toned is to push your baby out you might be in trouble.

If you look at Ina May Gaskin's stats for the farm birthing centre she has run since the 70's which looked at the outcomes of 2028 pregnancies 1970-2000, they show that if you don't interfere at all (they give NO drugs unless you have a PPH, no pain drugs unless you need to be stitched after, nothing during labour), don't prioritise speed as a marker for a "good" labour, and support the woman as fully and as lovingly as you can, around 95% of women will birth vaginally, at home, without major problems. Those who did not either asked to transport to hospital by choice, or had to because of medical emergency. Their c-section rate is 1.4%, forceps is 0.5%, vacuum extraction is 0.05%. They have had 0.5% face presentations, all but one delivered vaginally, 0.4% brow presentations, of which half were born by section, half vaginally. Their VBAC women made up 5.4% of the whole, 108 women attempted VBAC, 106 succeeded. These are every kind of american woman, from hippies to middle class ladies. The only thing they all have in common is the desire to birth their babies in a home-like environment (you get a little birthing house when you go to The Farm) gently and without medical interferance. From when you arrive you are expected to work and help out on the farm every day, pregnant or not. They get your body moving and working so your labour will be easier on you.

I know it is hard to believe when we are surrounded by and our ears filled with the stories of labours gone wrong, but it really doesn't have to be this way. The human body almost always works if you let it. Every step one takes away from the completely natural route comes at a cost and takes you one step closer to the surgical route. There are always risks to be weighed but more often than not they aren't worth it. And how can a woman ever know until it is too late? So many of us grew up believing birth was hard and labour hurt like hell - in some countries they have a different WORD for the pain of a contraction - the word describes the harmless pain, not the pain of danger and injury. How we think about things, and how much we know about things makes such a big difference.

Take induction - it is a STANDARD response to a woman dilating slower than 1cm/2hours. But the book's "1cm/hour" is an AVERAGE, some women will take 4 hours to go from 4cm-5cm and then go to 10cm in the next contraction. We do not trust our bodies to labour, we do not think our butt knows how to get the baby out. But the SECOND you intoduce artificial sinctocin you introduce risk - some babies cope fine, many get distressed, some labours progress well, many progress fast towards the point when they can no longer continue because the slow start would have re-positioned bubs slightly had it been allowed to play out, some uteri (plural of uterus anyone?) cope well, others rupture.

The uterine rupture rate for post-dates induction is the same of that for VBAC, one is done as a matter of course once 10-14 days have passed after the EDD, the other warned against, discouraged, frowned upon.

Ah, this has been mammoth, it is close to my heart. I have known about The Farm stats for 8 years now, and i look around me at the women in the UK hospital system with their outcomes and i just see that SOMETHING IS WRONG HERE. If you do little but love and support it works 95% of the time without instruments or knives. If you do it "properly" in hospital it doesn't even work 55% of the time. Terrible.

Bx

[suse]

Bec - thank you for such a thorough reply. You truly are amazing, you know that, right? (I only just saw your second "mammoth" post - which is a whole other level of amazing again!). The stats on May Gaskin's birth farm are very interesting indeed!

What you have written gives me yet more incentive to investigate further into a VBAC, and to find out whether the diagnosis of CPD is accurate. The ob checked from the 'inside' so to speak, it has yet to be confirmed by scan or x-ray. I understand that scans and finger measurements can be highly inaccurate, at the time I wasn't able to ask the nitty gritty of how they check the pelvis during c/s but I assume that it would be visually.

To answer your questions - pushing occurred post epidural, so it was in a slightly reclined sitting position. (So, no, not a favourable position for posterior birth). We tried all fours, but I didn't have enough sensation in my legs. I don't believe that a pelvic press was done - I don't recall it. I never felt that overwhelming urge to push at any point - I think that things may have been different if I had. So yes, the pushing was coached. The likelihood is that I was subject to the typical cascade of intervention effect, although I was quite aware of the implications of what I had chosen. Prior to the epidural I had been using active birth techniques but with very little progress. Labour had stalled several times in the early stages and whilst I was intellectually aware that this was entirely possible, even probable with a posterior labour, I lost the instinctive sense that my body was doing what it was supposed to. I have no doubt that this smoothed the path towards pain relief, instead of feeling confident that my body was doing what it should I felt only that something was going wrong and sought relief from that. There's no real way of knowing whether my instinct was right (and that things were not going as they should) or whether the subsequent pain relief was what contributed to the failure to progress. Would the result have been different had I made different choices - I don't know. And to be honest - I don't care. What's done is done. If I can make different choices next time and get a different result, then great, but I am not unhappy with the way the birth progressed even though it was the polar opposite to what I had hoped for.

As for the potential for a genetic predetermination towards pelvic disproportion, no, my mum didn't have a c/s with me, although I was eight weeks premature, whereas my bub was two weeks over and five pounds heavier than I was. And my grandmother has quite a different body shape to my mother and I. I do not know my biological father, so do not know what contribution his family's genes have made to my body shape.

What I mean when I suggest that pelvic disproportion of a genetic nature is possible is based on the assumption that it works in the same way as any other genetic 'disorder' (I am making an assumptive leap here as I don't know for certain that this is the case - I have not encountered any studies which demonstrate that there is a particular gene marker for pelvic disproportion, but lets assume for the sake of the argument that there is). I suspect that I'm not telling you anything you don't already know here (and probably know better than I) - but statistically, if two parents carry the gene for that disorder, two in four of their children will also be carriers, one in four will not, and one in four will have the disorder itself. In most cases, those with a severe disorder are unable to bear children, they are the evolutionary dead end. But those carrying the carrier gene are what propagates the disorder. Most genetic disorders are extremely rare, in terms of their effect on an entire population. Based on these standard principles of genetic inheritance, I believe that it is feasible that genetic CPD can occur without adverse effect to the species as a whole.

The other thing that I have considered when forming my belief that genetic CPD is feasible is human evolution itself. Humans have been evolving for a relatively short time compared to many animals and it can be argued that our physical evolution is not yet complete. Evolutionary science suggests that bipedalism creates a birthing trade-off, that due to the re-angling of the pelvis (and subsequent reduction to the size of the pelvic cavity) to enable us to be bipedal, human babies are born at a much lesser stage of development compared to quadrupedal mammals simply so that they will still fit through the pelvic cavity, even factoring our slower rate of development to maturity. Any larger and they would not fit. Any smaller and they would not survive. (As an aside, this in part informs the theory of the Fourth Trimester). It is not impossible that deviation from the norm beyond tolerable limits can occur.

I'm just throwing ideas around here, they are not informed by concrete data, which is why I would very much like to see a substantive study performed on the actual incidence and causes of CPD. I agree that unnecessary medicalisation and over-diagnosis of what is a very rare condition is not helpful to our understanding (just like the over-diagnosis of ADD and ADHD). I'll personally be seeking more definitive answers in preparation for my next birth!!

Thanks again!!

xx suse