The EngagED Midwife
The EngagED Midwife
Busy Breasts, Busy Births, And Why Your Peanut Ball Deserves A Raise
A new season meets a new reality: we’re grateful for 100K downloads, proud of students who crossed the finish line after multiple tries, and honest about a recent breast cancer diagnosis that changed the rhythm of our days. Missi walks through the surprise pathology, why we chose an aggressive plan, and what bilateral mastectomy and a forced season of stillness look like for a do‑everything human. We talk openly about anxiety, support, and “aggressive optimism,” because clarity and community make uncertain roads feel possible.
Then we shift gears to a masterclass on the labor patterns every clinician grapples with: malposition and asynclitism. We break down synclitism versus anterior and posterior asynclitism, how to read the sagittal suture and fontanelles, and why uneven effacement is a blazing clue. You’ll hear practical tools for OP and OT that move beyond clichés—mapping interventions to the inlet, mid‑pelvis, and outlet so each position serves a purpose. Think the jiggle as gentle myofascial work, forward‑leaning inversion to free tension, and strict sidelying release with stacked hips. We show how peanut balls, fire‑hydrant, rock‑the‑boat, sacral massage, and internal femur rotation widen the right spaces at the right time.
For second stage, we dig into manual rotation: when to attempt it, how to disengage enough to succeed, and how skilled hands can shorten labor and prevent operative delivery. Along the way we highlight nurse‑midwife teamwork, patient‑centered pacing, and trusted resources like Spinning Babies and the Labor Progress Handbook that give units a shared language and a sharper plan. Variation in fetal position isn’t failure—it’s an invitation to find the position, create the space, and encourage the movement.
If this conversation helps your practice or your spirit, follow, share with a colleague, and leave a quick review. Your support fuels more teaching, more tools at the bedside, and more stories of perseverance and healing.
Welcome to the Engage with Life Podcast. This is Kara. And this is Missy. Welcome to season 13. I know. Lucky 13, maybe? Uh it's Taylor's number, so I mean, gotta be a good one, right?
SPEAKER_00:That's right. That's right. Um, I'm excited for 2026. Um, just as a a refresh, 2025 was kind of hard. So I'm kind of excited.
SPEAKER_01:Yeah, 2025. You know, I said it in a social media post a few days ago that I would like to complain about how terrible it was. Although there were a lot of things in 2025 that brought me a lot of joy. It's because for me it ended so ugly that I'm like, oh, 2025 was awful and I wish it's like a dumpster fire, right? But I there were a lot of good things. I mean, we had we celebrated 100,000 downloads on our podcast. I know.
SPEAKER_00:Woo woo! Thanks everybody for listening.
SPEAKER_01:And if you don't follow us on social media, I posted our wrapped for 2025 and was pretty impressive, like looking at how many students we had enrolled in our programs and the money that we were able to raise for scholarships. And so, um, you know, all of that is because of our listeners, and that's amazing.
SPEAKER_00:I think some of our greatest success um is getting people across the finish line with certification when it was their third or fourth attempt. Um, and as much as like we wish nobody had to take the test that many times, it's been a really um big year with a lot of work that we've done with people. And it just literally, I'm like a proud mom, it almost feels like. Like this is so incredible that these graduates' diligence and perseverance and hard work and emotional work and all of those different things have finally paid off. So I'm so excited. And you you've done a great job of congratulating a lot of our students recently that have been successful. So it's exciting stuff.
SPEAKER_01:And we really have uh we carry a lot of weight of our students, and I think that's something that is hard for us. So when we do see them succeed, it's one of those things where we can be like, okay, right, like this is totally worth all of the weight that we carry for our students. And and that is not me complaining. Like I um I feel a deep commitment to the students that we take care of and that we help. And um, and that just comes with it. I think two, you know, very seasoned midwives who have been doing this for a very long time, you know, feel a responsibility to the students that we help. And so that's just how that is.
SPEAKER_00:Yeah, I I think it's one of my most favorite things is just that people invite us into such personal parts of their lives as we help them get ready. And then we meet with them frequently, you know, a couple of weeks in a row. And yeah, I always I tell everyone, I'm like, the next time I see your annual meeting, you better give me a hug because they do. These people become our friends and we're just so invested and excited for them.
SPEAKER_01:But we get to and it is it is fun when they finally do um right, they come up to us and be like, I wouldn't have done this if I wouldn't have worked with you. And thanks for not giving up on me. And I think a lot of people come to us when other people have given up on them, and so we're, you know, the moms, the cheerleaders, the faculty that they didn't have, etc.
SPEAKER_00:So it's a lot of emotional work too. Yeah.
SPEAKER_01:I know. And sometimes I'm like, gosh, you know, you and I'll talk at the end of the week and be like, gosh, I had all these meetings with students this week. And while it's so fulfilling, there are times where you're just like, my social battery and my teaching battery are all done.
SPEAKER_00:Yes, yes. Yeah. I'm thankful for the holiday break um and break between semesters. Um, but my social battery was used up with my in-laws.
SPEAKER_01:I get that.
SPEAKER_00:Yeah.
SPEAKER_01:Yeah. You know, my social battery was used up for a thousand other things. Yeah. So let's talk about that.
SPEAKER_00:The elephant in the room.
SPEAKER_01:Yeah, the elephant in the room. So we did a podcast episode, what, last year? Um, and talked a lot about our abnormal imaging and our breast, um, busy breasts, as the as the radiologists like to say. And um, yeah, I got diagnosed with breast cancer, which is wild. It is wild. It's wild because um I went in to have excisional biopsies on one side and I asked them to take out something that they said was benign on the other side. And it turns out that what they said was benign wasn't benign, and um, it's invasive doctoral carcinoma. And so that sort of like threw us all through a loop, right, in December.
SPEAKER_00:Yeah. Especially after, especially after your biopsy said it was normal. Like that was not that was not the side that I was concerned about. I was concerned about the other side. Right. Um, I actually had to go back and read through our text to each other because I'm like, wait a minute, lefty's not the bad one. I thought it was righty, but anyway.
SPEAKER_01:Well, and what's wild about it is that I went to the breast surgeon in November after we got back from New Zealand to have her take out the thing on the left that was that they said was benign because I didn't want to worry about it. And she said, but I thought you were here about the right. And I was like, I am clearly so confused. So I myself, even as a healthcare provider, had to go back through all of my pathology and be like, okay, now I understand what's happening. And so we are choosing to be very, very aggressive with my treatment because I have I have confirmed pathology on the left, and then I have still very unknown concerning pathology on the right. And so I'm having a bilateral masteptomy this week. Um, so the last four weeks have been a slurry of appointments, and so many people have sent so many things. And so getting things organized and ready for surgery and the idea of sitting still for eight weeks is wild.
SPEAKER_00:Right. Right.
SPEAKER_01:So um, for those of you who know me and love me, know that like please send all your sparkly energy because it is going to be a challenge. Um, the best news I got from my surgeon though is that after three weeks I'm cleared to fly, which means I can go to the beach and spend a week recovering there. And that never feels like a bad idea.
SPEAKER_00:Yeah, I am not unhappy about us having that planned trip already for work, and we are just gonna have aggressive recuperation. How does that sound?
SPEAKER_01:Yes, aggressive optimism. It's gonna be amazing. Um, if you're following along or you know me on social media, I've been posting updates and I feel good about the plan. Um, I feel anxious about the things that are unknown. Um, yeah, but I think that's a normal thing. And I'm under 50, so we're being super aggressive with my treatment. And hopefully 2026 is the year that we just like kick cancer straight in the butt.
SPEAKER_00:It is also the year that we will celebrate a big milestone birthday for you. And I was just thinking the other day, we'd already been talking about it a little bit, but um, it's gonna be a nice birthday celebration halfway through the year.
SPEAKER_01:Yeah, right? Like a big like get through cancer and then have a big birthday celebration. That'll be so fun. Yeah.
SPEAKER_00:I'm excited. I'm excited.
SPEAKER_01:Yeah. So yeah, um, so my my support team is called Missy Sparkle Squad, which shouldn't surprise anyone who knows me. Um, so spent send all the sparkly energy and good thoughts and just um hope for no complications and nothing more than surgery. So we're trying to really like ward off the evil spirits about chemo and radiation.
SPEAKER_00:Yeah. And I would just say we should probably also send some positive energy uh to the boys in your house because it is going to be vastly different with you being forced um to be still. So uh let's hope for them that things go well with your recovery and keeping you entertained and all of those different things.
SPEAKER_01:Yes. I have gotten several like books, like craft kits. Just I have so many people have sent so many things. I'll have enough things to do, I promise. Um, it's just a matter of like wanting to do them and not wanting to do other things.
SPEAKER_00:It's gonna be no physical activity for you. That's the hard part. Yeah.
SPEAKER_01:I don't even know how I'm gonna sit so well. Now that we've done the thing, broken the news, what am I gonna talk about today?
SPEAKER_00:Well, I mean, how exciting. We're gonna jump right in into malpositioning and asyncletism.
SPEAKER_01:It is my favorite thing to talk about when I'm on labor and delivery, honestly. I am lucky enough to work in a place where so many of my nurses are trained in spinning babies that the ones who aren't will look at me and be like, what positions do you want me to use to try to get the baby engaged, turned, whatever you know we need to do. And so there are a lot of different ways that I think malposition and asyncism present themselves, right? And um and they can look like a lot of different things. And I think part of our job as midwives is to understand what we can do to make it better because it's it's this is the art of being a midwife, right? This is the the touch part of it, right? It's this is not just the the medical knowledge, this is the like high touch part of what we do.
SPEAKER_00:Well, and I think that a lot of people like me, you guys have heard me say that like the idea of long arc rotation and all of the things, all the positioning. Some people their mind just shuts down when they're like given a test question about positioning, or you hear a description, or someone describes what they feel on exam. And I think let's I'm hopeful that by the time that we're done, people will feel like they have a better grasp on it. Um, and I think that you mentioned um spinning babies, but I think that a lot of the techniques have midwives have been doing for years and years and years. They just now have a common language that a lot of nurses are learning and midwives are learning. I've never taken an official spinning babies course. I would love to, but so much of it makes sense. And I've learned a ton from nurses um just about some of the different positioning and so forth. So I'm excited to talk about it today. I hope other people don't feel as intimidated, um, especially by the end of this discussion.
SPEAKER_01:Yeah, and I think we're talking about actually two things too. We're talking about how the baby comes into the pelvis during labor, right? And then how the baby is potentially positioned in second stage. And it's different, right? It's different when the baby is still above zero station, right? And potentially not complete, mom's not complete, versus when a mom is complete and is not positioned in the things that you may or may not have to do. And I will talk some about, you know, some additional workshop resources that I think will be good. And I'll put those sort of at the end.
SPEAKER_00:Yeah. Yeah. So let's start off with a few definitions, if possible, and really understanding what do we mean when we say malpositioning and what do we mean when we say asyncletism? So, kind of like at the most basic, malpositioned is any position that's not allowing labor to progress. But most commonly we're thinking of like persistent OP or OT posterior or OT. I was gonna say ox, but transverse. Those are the most common, like what we think of as truly malpositioning. But then asyncletism, I think of it as kind of like tilted, kind of just like not straight on.
SPEAKER_01:Well, you know, I grew up on a farm, so the word we would use is cadewampus, like it's just not in the pelvis the right way. So let's define syncletism first. So syncletism is when the sagittal suture comes down midway between the symphysis and the sacrum. So there's it's equidistant. That is a synclic baby that is coming down the way you want it to come down, right? Yeah. Um, but there are reasons why babies don't do that. And so um anterior asyncletism, and I'm gonna describe it two ways because you have to pick a way to remember it. Okay. Anterior asyncletism is when there's a lot of space created in the anterior part of the pelvis because the sagittal suture is pointing towards the sacrum. And so when you check a patient, and all of us have felt this, when you check a patient, you put your hand in the pelvis and there's like nothing in the front of the pelvis and everything is crammed towards the back, that's anterior asyncism. So the two ways to think about it are it's either where the space is created or opposite of where the sagittal suture is.
SPEAKER_00:Yeah, I always think of it as where the sagittal suture is and just remembering that it's opposite, but it makes sense that it's also where the space is, because if it's posterior asyncletism, then that sagittal suture is closer to the pubic bone, right? And there's more space in the back.
SPEAKER_01:Tons of room in the back. And so that's when you put your hand in and you run right into the head. But if you reach around the head, there's all the space in the back of the pelvis. So that's creating posterior space. That's posterior asyncotism, where the sagittal suture is then closer to the synthesis. And so there are reasons for those things, right? So when you think about anterior asyncism, which by the way is the most common kind of asyncism, you think about women who have a lot of abdominal obesity or abdominal laxicity. Like the muscles of the abdomen aren't strong. So it doesn't do a good job of holding the baby in a synclic space.
SPEAKER_00:Um, I just even think of a grand multip, like those muscles have just been so stretched over time, they just don't bounce back.
SPEAKER_01:Yeah. Also, big babies um can also be anteriorly async. So a baby with macrosomia or even just constitutionally big baby, right? Um can also be can cause anterior asyncism. But posterior asyncotism is more common in women who have a really tight abdominal wall. And so those are like athletes, people who are runners, people who are like do a lot of yoga. I identify with the yoga thing, but yes, like you have a really strong abdominal wall can cause the baby then to really like push its head towards the symphysis and create space in the back of the pelvis. Um the other thing too is you go into labor quickly or you prom. Um, there's if there's a short cord, if there's any kind of uterine anomaly, those are also all reasons for you know an asyncletic baby. I have seen multips go from like three to complete, and because their labor course was so short, their baby just came down caddy wampus, like not the right way.
SPEAKER_00:We didn't have much time to mold and move and rotate and do all the things. Correct.
SPEAKER_01:So I think understanding that those things can happen is like part of the deal. And being able to put your hand in during a sterile vaginal exam and being able to recognize when the head is not we not in the right place. So, what I was gonna say is like when we were younger in our careers, we would we would probably put our hand in there and be like something just doesn't feel right, but we didn't have maybe the right words to describe why it doesn't feel right. And now I think as we've gotten older, we're like, oh, that's why, because it's asyncletic.
SPEAKER_00:These are those babies too, that after they're born and you look at them on the warmer or as someone's holding them, and they've got that knot on that one side parietal bone. And you're like, oh, thank goodness babies wear used to wear hats, you know, like it would cover up all that misshapen, but they had that big old knot on one side, and it's because they were async. It's not just cap it from being like a ton of pressure at a certain dilation for a long time, but it's like that really off-centered um knot, um, just lots of pressure coming down in that weird position.
SPEAKER_01:Another thing to think about when your baby is async is the cervix will show you signs as well if your baby is not positioned, either OP O T or async, right? This is when you check a patient and their cervix is not uniformly um effaced, is what I would like to say. You may be able to be like, oh, there's six centimeters, but what you'll be like, oh, is there's more thickness, right, in the front, or there's more thickness in the back. If there's if the cervix is not uniformly effaced, it's generally because the baby is either asynclic or malpositioned and putting more pressure on one part of the cervix than the other.
SPEAKER_00:Yeah, absolutely. Absolutely. So some things in labor that could give you an idea would be a slower labor than you're expecting, right? Things just aren't progressing. You've got good contraction pattern, things look really good, but for some reason they're just going slower than you expect.
SPEAKER_01:Yeah, protracted labor, right? Where, you know, maybe somebody's my biggest thing is when somebody gets to six centimeters and then you check every two hours and they're only progressing like there's six, then there's seven, then two hours later they're eight, then two hours later they're nine. And you're like, oh my gosh, we've been in active labor for like eight hours. And you know, in a in a truly like normal labor curve, right? If your body's doing what it should be do, and your baby is in the position that it should be in, active labor should not be one centimeter at a time every two hours, every three hours.
SPEAKER_00:Those are the ones I feel like you're also pulling out the six to seven. Seven to eight. Yeah. Yeah. Exactly. So that can be a pretty common finding. Um, generally, it's not when we think about the peas, right? When we think about the peas of labor and we think of the pelvis and we think of the passenger, and we think in the powers being the contractions, this isn't a powers issue, and it's usually not a pelvis issue. It's that kiddo, it's that passenger that's, as you said, cattywampus.
SPEAKER_01:Well, it's the best way I can describe it, I think.
SPEAKER_00:Oh I mean, I know what you mean when you say that, that's for sure.
SPEAKER_01:Yeah, but I I I I do think like there are so many things in labor that you have to consider if your patient's making slow progress. And one of them, like you said, is are their contractions strong enough? Like also, I I don't want to discount the idea that the pelvis matters so much. I rarely will check somebody and say nothing's coming out of there. I think in probably 20 years of my career, I've maybe said it a handful of times that like that pulp, the pelvis is really contracted, or you know, I can't, there's not, I can't even position my hand appropriately because the pelvis is so like abnormal. I went in, um, um another midwife called me and asked me to come rotate a baby. We're gonna talk about manual rotation in this podcast a little bit later. But and I went in and I'm not even kidding you, I wear a size five and a half gloves. So that tells you how small my hands are. I have very long fingers and very small hands. I could not even squish my hand enough to get it through her outlet so that I could get to the baby and rotate it. Like, and I'm if I squish my hand as much as possible, it's about seven centimeters around. So that means that her actual outlet of her pelvis was seven centimeters. And I'm like, look, I know you got complete, but the reason she was a tollak and I said, but the reason that you had a c-section the last time was a rest of descent in second stage, it's because of your pelvis. Like, I can't even get my hand in there to rotate your baby, and that means it's not gonna come down. Like you could push forever. This is a pelvis issue. And she went for a repeat c-section. She had a really great like understanding of why she couldn't get through second stage. Right. Um, I rarely will say it. However, there are times when you'll check somebody and their arch will be really prominent, or like this this situation with this patient's outlet, like you'll you'll know something about the pelvis. But I am always game for giving somebody an opportunity to like try to figure it out, right? Um, but the pelvis, I think it's just a when I talk to patients about risks and benefits, I'm like, I can't change your pelvis. So if this is a pelvis issue, I can't fix that, right? I could do all the positioning in the world and all the labor interventions in the world, but I can't fix your pelvis. I can fix whether or not you're having contractions. There's things I can do for that. But if your uterus also doesn't want to behave the way it's supposed to, right, I also can't fix that in some cases. So again, back to the art of how we manage all of the things when we're trying to get a baby to rotate or, you know, get an asyncletic baby to straighten out. Uh it's multifactorial at best.
SPEAKER_00:Yeah. Yeah, absolutely. So you talked about how to identify the asyncletism. Real quick, let's talk about if there's ways that we can identify like persistent OP or occiput transverse. And a lot of that is knowing what the sutures feel like on the head and being able to find the anterior or posterior fontanelle. Would you agree? Yep.
SPEAKER_01:Yep. And there's a couple of things that I tell learners when they're on the unit with me that I'm like, these are the mantras that you have in your head when you're thinking about this is diamonds are a girl's best friend. They're in the front of the head. So the anterior fontanelle is diamond shaped. You should feel four distinct points, right? Posterior fontanelle then is triangle shaped. You should feel three. Now, here's the other thing that's interesting that I'm always telling people is if the head is actually well flexed, the anterior fontanelle should be pretty buried in the vaginal world, right? The fontanelle you should be able to get to most easily in a well-flexed baby is the posterior fontanelle. And that's the one you want. That's the one you want to be able to feel. And so those are a couple of like reminders for students. Like you're you really want to know where the posterior fontanelle is. That's the triangle one.
SPEAKER_00:Yeah. And with persistent OP, it is so common to have a lot of back labor, a lot of back discomfort, those really prolonged, protracted. So not just asyncletism, but those persistent OP can be really significant back pain just because of the way the fetus is positioned, right? Like I always think of it as like the back of their head is like on, you know, it on the spine. It's face up. So it's it's putting a lot of pressure there on the back.
SPEAKER_01:Unless you've got a pelvis that's meant for OP babies, right? Right. I mean, because some people have a ton of room in the posterior area. I had two OP babies, and that was just how my babies wanted to come out. And it's just because of the shape of my pelvis, and that's fine. So OP is only a problem if your pelvic type is not meant to deliver OP babies, right?
SPEAKER_00:Right. So when people have a lot of room in the anterior posterior diameter, right? Like maybe they get a baby that's in an OP position and they've got a lot of space front to back, the kiddo doesn't have to rotate all the way around to an OA to be able to deliver because there's enough room for the kiddo to come through that pelvis in an OP position a lot of times. But when it's occiput transverse and they maybe have a short AP diameter, there isn't you can't you just no rotation. You there's no rotation and you can't deliver transverse, right? Like and so it's that it's that really short anterior posterior, is when I tend to think of particularly transverse arrests. I do think in some ways it's easier to feel transverse because you know if that sagittal suture is in the transverse plane, but um yeah, yeah, it's it doesn't have the classic like back pain and that sort of thing. It's just like that kiddo's just not going anywhere and it's because it can't rotate.
SPEAKER_01:Or even the dysfunctional labor pattern. So you may see somebody who's like doubling, like, or you know what I mean, coupling or tripling their contractions, and that's generally a sign of malposition um because their uterus is trying to figure out why their baby isn't OA and well flexed. So you might see lots of different signs about your baby being malpositioned. So again, the idea of like that weird cervix as well. And so let's talk for a second, I think, about what do we do when we have odd cervixes?
SPEAKER_00:Like that I think this is the most fun. What do we do when we have an asynclinic kiddo? What do we do when we have a person that's an OP? And yeah, and this is where I think midwives can shine.
SPEAKER_01:Well, I mean, the first thing is I think it all really depends on whether your patient's medicated or unmedicated, because we do different things when people are unmedicated. And I and I need people to understand that I am pro-epidural. Do not get me wrong. My badger says diamonds and epidurals are a girl's best friend. So I am not against a good epidural. However, if you get an epidural and you do not move in labor, your baby will be malpositioned. The likelihood is really high. And malposition then leads to lots of interventions and operative deliveries and operative vaginal deliveries, et cetera. We know that, right? It's not the epidural that causes it, it's the inability to move and reposition that causes those things. Okay. So if you have an unmedicated patient, the likelihood is that they're moving anyway, right? Um they are on a ball, they are standing, they are swaying, they are squatting, they're in hands and knees, they're in puppy pose, they're doing the things, right? Unmedicated moms can still have babies that are malpositioned or asyncletic, which is less common because they're up and moving and their babies can figure out navigating the pelvis. Really, I think we get into a place where we need to understand the interventions is when our patients are epiduralized.
SPEAKER_00:Yeah, and sometimes the fact that they are epiduralized allows us to do a lot more things in some ways to help resolve the issue.
SPEAKER_01:Yeah. So, so like I talked about, cervical swelling is a thing that can happen with asyncletism or with malposition. And there are definitely position things. My nurses are always saying, like, Missy, which way do you want to um position this patient to get rid of the cervix on the right? Or which way do you want to position the patient to get rid of the cervix on the left? Um, or is there anything that you want to do because her whole cervix is swollen? And so position changes. So I'm gonna talk about the spinning babies thing here in a second. But I also want to add some, you know, Benadryl, melatonin little plug here for things that might help cervical stuff. There's actually some really good articles, right, about adjunct things for cervical swelling. Um, crazy that one of them talks about ice. I'm like, if anybody tries to stick a glove full of ice into my vagina, we're gonna definitely have words. But if you're epidroilized, maybe you don't feel it. So that's great.
SPEAKER_00:I don't know. I don't know. You know, sitting next to us at annual meeting was literally a product that is basically an ice cube for your vulva um for any discomfort. So it might feel good to some people.
unknown:I don't know.
SPEAKER_01:I also am like, could we put sterile water in a popsicle um mold and just put that in?
SPEAKER_00:I don't know. We've definitely talked about cervical swelling before. So yes, we've talked about um some of the different options, but um, I'm curious. I you have done a lot more labor and birth than I have in my career. But if if there was more cervix on one side or the other, I used to turn towards that side. Yes. Um, to try to put pressure on that part of the cervix, hoping that the contractions and that pressure together would melt that cervix away.
SPEAKER_01:Yep. Last night I had a patient who had a persistent anterior lip, and my nurse was like, Well, where is it? I'm like, it's literally anterior. It's like from 11 to 1. It's just sitting right there. I said, So do exaggerated runners on the right for 20 minutes, go exaggerated runners on the left for 20 minutes, then sit her in throne and call me. And actually, like after the first 40 minutes, he called it. She's like, She's feeling a ton of pressure. And I went in and she'd come from like zero to plus three, and she pushed like 10 minutes.
SPEAKER_00:And I was like, runners for the win. I was just gonna say, even say up on hands and knees.
SPEAKER_01:Like I love hands and knees for a lip because that's putting pressure on the lip, right? The letting gravity work. Although recently I've had a lot of very dense epidurals, and so it's really hard to get a patient in hands and knees with a really dense epidural.
SPEAKER_00:I used to like to get people up on their knees hanging over the back of the bed, even like just uh kind of more upright on their knees, putting pressure on the front. It would let the belly hang forward.
SPEAKER_01:Well, and our beds have squat bars on them built in, and so we can do the same thing like in the bed, which is super nice. So, um, you know, so like those are some easy labor interventions, but you know, there are all kinds of positions. You know, my nurses left because we we sell a t-shirt, right? That has labor positions on it. Um, and it's not just for funsies, right? There's a reason that we use all of those positions. Um those positions that look different in first stage versus second stage, right? And it also looks different whether or not you're dealing with a baby that we're trying to get into the pelvis or out of the pelvis, right? Is the baby, you know, not at the inlet yet? Is it in mid-pelvis or is it at the outlet? And that depends on the interventions that you would do as well.
SPEAKER_00:Yeah, it makes me think so much about I learned so much when people started talking about closed knee pushing or and thinking about inlet versus outlet. So just even that kind of concept of understanding when to pull out the right intervention so that you're you're really thinking about physiologically supporting this kiddo, moving through this pelvis and making progress. So I also think that it's important for us to think about, depending on what intervention you're using and in what stage of labor, it may have impacts on your fetal heart rate tracing. So knowing when to expect that, you know, what is it, waltchers that, you know, you're hoping that kiddo will do a nose dive to get down into the pelvis. Well, you might see some crummy looking strip for a little bit, but it's going to straighten itself out.
SPEAKER_01:Correct. When you take spinning babies, one of the things they will tell you is that it's mom's job to dilate, but it's the baby's job to rotate.
SPEAKER_00:Oh, I love that. Yeah.
SPEAKER_01:So sometimes we have to help that out. Um, so the things that I would say in terms of interventions, especially, I mean, even in first stage and early second stage, you know, have to do with the balances. So in spinning babies, they call them the three sisters, right? And so the jiggle, I love the jiggle. It's a little like um a myofascial release. It is not shaking someone. It literally is what I would consider like a low frequency vibration with your hands. That's like the best way I can describe it. And it helps, like when you do that on each hip, right? It helps to mobilize the sacrum, it have it helps to open the posterior pelvis, and it will help directly engage the ligaments. And so um, you don't want to jiggle someone. You can jiggle people before labor. That's the point, right? In third trimester. Um, but 10 to 15 minutes.
SPEAKER_00:Just so I can ask, because you know this so well, this is different than shaking the apple tree.
SPEAKER_01:Yes, this is different than shaking the apple tree. Shaking the apple tree is actually like an actual shake of the baby in the uterus. This is a you put hands on, like I said, a low frequency vibration for 10 to 15 minutes, right? Usually will help the pelvic floor relax. That sounds kind of nice. I know, right? The second thing is forward-leaning inversion. So um, this helps the urosacral ligament. Um, and again, you can do this before you're in labor, but it's also a labor intervention. You were just talking about forward-leaning inversion, right? Um really, I think of this as um like what we do in yoga, which is cat cow. And so you're like in hands and knees, right? Forward leaning inversion. So you um in cat, you arch your back, but in cow, you extend. And then in puppy pose, you put your arms on the ground and put your bottom straight up, right? So it's that range of motion through those, which is forward leaning inversion. And then the one that everybody always talks about is sideline release, right? I'm gonna do sideline release on either side, right? It helps to straighten the head. Um, but the position is so important, right? They have to, their spine needs to stay in alignment, their bottom leg is straight and their bottom foot is flexed. So let's, for example, if the patient's laying on their left side, their left leg is straight and their left leg is flexed, where their right leg is the one that hangs over, right? In the air in a sideline release. So, but you have to maintain all of the integrity of the spine. You have to maintain alignment because if the hips are off and not straight, this doesn't work.
SPEAKER_00:Yeah, I've heard it said as the hips are stacked, right? Like they need to be straight and it's just the leg that's hanging over, it's not hanging the whole pelvis over.
SPEAKER_01:Yes. So for yogis out there, this is not like a um, this is not a twist, a supine twist where the pelvis falls over itself. This is like literally keeping the pelvis in alignment, right? And just letting the leg dangle. So um, you know, I think also like understanding labor and understanding sympathetic versus parasympathetic nervous system kinds of things, right? And what we're encouraging in labor, which really should be their parasympathetic nervous system, which is their like rest and relax part of their brains, versus the sympathetic nervous system and all of the um fight or flight sort of hormones that come with that. And we talk a lot about psyche, right? Um, when you're in labor, and that also has something to do with us.
SPEAKER_00:So I think one of the things that's important for us as providers and helping nurses with labor support and so forth as well is that with this sideline release, just how we were mentioning that that you want to keep the pelvis in alignment or keep it stacked, is that we can help put um kind of some pressure on that upper hip so that it's not rotating forward, right? Like we can help them stay in alignment. But a lot of what I've done in my reading of different things with spitting babies is that you really do want the patient to be doing most of the position. Like we're not putting them in a position per se, but like, you know, she should have her legs straight, her lower leg straight. It's not that we're straightening out her leg and holding it there straight, but we could offer some support so that she's not rotating. And so there's ways that as helpers we can do that, but we really, her body is doing the work, the baby, the baby's doing the work of rotating, hopefully.
SPEAKER_01:Yeah. Yeah. And so I'm gonna break it down even a little bit more. Like with the like when we talk about inlets. So these are babies that are high, right? And we're trying to get them to come down into the pelvis. This is when we think about things like flying cowgirl is a great position for this. Um, hands and knees, right? Um, this is where you shake your apple tree when you're talking about. So shaking the apple tree is a full forward inversion. So think hands and knees leaning forward and shaking with contractions. Now, all of these interventions, you really only are doing them for like three to six contractions. So this is not like relax, yeah. Yeah, what you're doing. Um, and then you know, we let them recover after we've done these interventions, right? So, and then what so that's inlet kinds of things, right? So mid-pelvis, right? What's happening in the mid-pelvis? This is where your sideline release is really important. Um, we want to like stretch the muscles, open the sacroiliac joint, um, like let the sacrum be free. Be free, sacrum, be free. Um, and then open the pelvic floor. And so, um, like I said, the sideline release is great, especially for patients who are um epiduralized. But also, this is the thing where um we can use our peanut ball and put somebody in almost like a fire hydrant and then just roll back and forth with the top leg over their um peanut ball for like a rock the boat situation. We're like going back and forth with the peanut ball.
SPEAKER_00:And these things with the sideline release and the peanut ball and those sorts of I I feel like I've also read that we really want to be doing them on both. sides because we don't want to leave them uneven, if that makes sense. Like you're really you're not trying to get things out of whack in another direction. You want things to you want the pelvis to be even and stable. Is that correct? Yeah. Yep. Okay. Yeah.
SPEAKER_01:It is. I also then when we talk about outlet things, right? The outlet things are where the sacral massage really help a lot. Like if your patient's in hands and knees, like the low sacrum kinds of massage can really help with relaxing the pelvic floor and relaxing the sacrum. And then the pressure is halfway between the sacrum and the sit spones. That's the place where you for outlet right massage. And then this is the thing you were talking about, right? With internal rotation of the femur, right? To push also will help. So yeah. So some people describe it as like pushing with a peanut ball between your ankles.
SPEAKER_00:Yes.
SPEAKER_01:Right.
SPEAKER_00:Yeah. Well and if for anyone that's still questioning the idea of how putting your knees together helps the outlet, just sit on your chair right now and feel your sit bones and open your knees really wide. Like we always said, you know, like open the pelvis, widen the pelvis and feel how those bones move on your chair and then put your knees together and really feel those bones kind of separate at the outlet. And I really do think there is something about feeling that yourself that can really help you then explain it to patients as well. Cause I remember being really skeptical when I first heard this and then it really just all of a sudden clicked and made sense of is it an inlet issue or is it an outlet issue? And how should we be thinking about that?
SPEAKER_01:I will also say this is a big shout out to my vanny nurses. We have a lot of new nurses that come through night shift rate. But my seasoned night shift nurses and my charge nurses and my resource nurses know the things, right? And they will come help my newer nurses be like hey have you tried this position? Have you tried that position? Have we tried everything? Or I'll be like do you know how to spin her? And if not I will find somebody who can assist you.
SPEAKER_00:Yeah yeah. So we've talked about a lot of different positioning things that can help. You talked a little bit about like a persistent lip and we talked about um some ways that we could kind of help with that and some positions. I certainly have tried to push past a lip with a patient before but if it doesn't like melt away in a couple of pushes I don't continue that. But I think the one thing that a lot of midwives haven't had training on and is an area where we could be really helpful is as you start to think more about like manual rotation for some of those kiddos that need it. And I know it's something that you've talked about I know they had a workshop on it that was quite popular at the annual meeting, but it's something that people could learn about and be able to offer their patients.
SPEAKER_01:Yeah. Okay. So you just said it there is always a manual rotation workshopslash session annual meeting. I think it's great. I did not really have enough confidence in myself probably until I was 10 years into practice to really try to effectively rotate babies. And now I feel like it's one of the greatest tools in my box. If we have tried all of the spinning things and my baby is especially in second stage, right? And the baby is persistently OT or L O P or ROP and I'm and they're not making a lot of good progress the if you can successfully rotate a baby it will prevent C-sections.
SPEAKER_00:It will just well or even operative vaginal delivery right so like the use of force or vacuum it it really is intended in second stage fully dilated and can shorten labor and can certainly improve outcomes related to operative delivery. Right.
SPEAKER_01:So manual rotation in the simplest in the very simplest definition is disengaging the baby from the pelvis and turning it and it's a one-handed maneuver and um it really does require adequate analgesia if if in order to be successful. But the one caveat is is that the baby doesn't move the baby doesn't move and you can't make it move. And you also have to have enough confidence to actually really disengage the baby and be careful because there's always a risk for pro cord prolapse when you do that. But you can't just kind of disengage the baby the baby has to go up by you know two or three stations right to be able to adequately turn. And then part of it too is is like keeping your hand there until they push and hopefully the baby like stays there versus spinning back.
SPEAKER_00:Yeah. I recall um I worked with a wonderful physician when I was a labor nurse and she was a teeny tiny little gal and I always used to uh call it her forces by her name because she literally had this tiny little hand that could but she was strong and mighty and she could rotate a kid really nicely. And I mean she didn't do it all the time. You don't need to do it on everyone right but when it was needed it was so so helpful in the same way that I've worked with some wonderful physicians that are so skilled at forceps for rotation. And I would a hundred percent myself want my kiddo rotated with forceps if that was going to be the thing that would prevent me from needing a C-section. And it was a skilled provider. So same kind of idea of like in the right hands, these are really great interventions that can prevent surgery.
SPEAKER_01:Yeah I a hundred percent agree I think that um I you know we've talked I've we I drag I brag on Dr. Webb all the time about if I had to have forceps I would want Dr. Webb to do them. But yes I would you know it's the it's essentially the same idea rotational right assistance. So if you don't love that you don't feel comfortable with it like go to a training like that's an easy skill that will decrease your c-section rate honestly.
SPEAKER_00:Yeah it's been fun I've seen a lot of um providers here at the end of the year doing kind of their wrapped statistics for how many boys did they have how many girls how many c-sections what the outcomes were for perineums and so forth. And I know you and I were just having this discussion I think earlier today. Tell everyone like what was your vaginal birth rate for the patients that you've cared for this year.
SPEAKER_01:Well in the last in Q3 and Q4 I had a 0% C-section.
SPEAKER_00:That's crazy. I know crazy and that's where really having such a great interprofessional team that you do and I know you have really incredible nurses there, but then the tincture of time and patience because you've also got providers in-house all the time and a really pro-midwifery environment as well. I think that helps in those situations because you're not taking care of a super low risk population all the time.
SPEAKER_01:Right. And I also think that 20 years of experience gives me some ability to tell people like let me try the things right my goal is always to get a baby out vaginally. But I also am not one to say like oh no everybody has to have a vaginal delivery some people have to have c-sections and that's just how that works out. Now I will say I did not start my 2026 all that well because I called a section the other night on a TOLAC let's just be clear who had a TOLAC score of 43% and I think it was her pelvis and not anything about her or her labors. I think it was her pelvis.
SPEAKER_00:You know sometimes it happens sometimes some of us have have a placenta that implants itself in the wrong place.
SPEAKER_01:C section correct so I um you know I think that when you have the right tools in your toolbox and you have enough knowledge I mean you know because this is something that I have done a lot of over 20 years is I want to add as many skills as I can not because I crave skills but because I want to have every like bit of skill in my arsenal when I'm caring for people. And so that was ultrasound certification, that was OB emergency certification, that was manual rotation and circumcision and all the things it's it's mostly because I want to be the best version of myself as a midwife. And so I think if there are skills that you want to learn, you should learn them. And it's going to do nothing but make you a better midwife in the long run. Yeah and so take a spinning babies class it's not inexpensive but it's worth it. When I was at Emory we used to pay for our students to take spinning babies we would bring them in and we would give spinning babies to all of our students which I think is a great gift. That's awesome. So um I think you I think understanding malposition why it happens how it happens what it looks like what it feels like how it presents as well as asyncism and then also knowing how to fix it if you can, right? In first or second stage and having the skills and the knowledge to be able to do it just matters so much. And that's why I thought I think this conversation was so great.
SPEAKER_00:Yeah I think there's a great summary that I found online about this with malpositioning asyncletism and it's basically saying these are not failures. They are just variations that need a little more attention and skill but it said to find the position create the space and encourage the movement and I think you just said it's just such a nice way of summarizing everything that you've said of knowing what you're what what is the situation, creating the space to allow for those different interventions and knowing what's in your toolbox and bringing out the right interventions at the right time and then encouraging the movement through different positionings, helping with rotation and whatever that is I think building confidence I would agree with you that the further I've gotten into my career, the less intervention I feel like is necessary because I've got so many other I guess they are interventions, but other tools I think of um I feel a lot more calm and confident in labor progressing when we pull out that knowledge and those skills that we have.
SPEAKER_01:Absolutely absolutely so fun. This is one of my favorite things to talk about because I feel like it we can affect so many things in labor. Like we can help advocate for our patients um we can you know improve our vaginal delivery rates like this is such a great skill and I honestly feel like when you're in midwifery school you're really just learning how to safely catch babies and you really can't like operationalize we would say you're like so focused on the perineum. Yes. I actually delivered a baby yesterday and you know as she was delivering I just looked at her and I said look down like I want you to see your baby coming out and it's that's a that's something that I've been doing for probably 10 years. But when I was a brand new student I couldn't focus on telling the mom what to do what I I just was like delivering what I was doing my hands. Correct correct so you know don't be discouraged if you're like I don't know any of these things and I'm a midwifery student. You will learn them but there's lots of opportunities to learn them and like lots of great programs out there that will help you be a good version of yourself.
SPEAKER_00:Yeah so we're gonna also link some resources on our podcast page so that you guys know that. But there are some great resources available on spitting babies. This is a topic that's sometimes hard to um envision, especially as you're listening to us. So we don't have videos and we don't have slides in front of us and that sort of thing. So the website does a really good job of that there's one other resource that I want to mention and um it's super I bought copies of it from the nurses and put them at different nurses stations when I was practicing full scope but it's the labor progress handbook. It was originally done by Penny Simpkin um but it is an excellent excellent compilation of different positioning and different ways to identify malpositioning and asyncletism and really helping people with labor progress. So we'll make sure we have all of those resources linked for you. Yeah fan freaking tastic fan freaking task I also feel like I am going to communicate for all of our listeners to you Misty I hope you know that we all hope that your recovery is fan freaking tastic and um you've got lots of goodwill being sent your way and and things are gonna we're gonna have very aggressive optimism sparkle energy and aggressive optimism for the wind yes yes all right well great conversation so fun thanks for joining us for the engaged midwife podcast we can't wait to talk to you again.
SPEAKER_01:Take care