Saturday, January 30, 2016

Don’t say Posterior? Does silence serve?


Doulas and patient-centered providers of all types have a well-placed desire to protect a woman’s confidence to cope with childbirth. 

Birthworkers must navigate the topic of fetal position between a natural birth ideology and the medical research on posterior presentation.
I didn’t say we have to choose between natural birth and research, mind you. But we move from personal proclivity to interpreting complex and sometimes incomplete research from which to make sense of fetal position changes. 

Social ideals for natural birth pull against the expanding variables of fetal rotation. My interest is to offer a functional understanding from which the doula and provider can discuss posterior position with parents and others in an empowering way.  

You can read a portion of such a discussion with midwives in my article Posterior Perspectives in Midwifery Today, Issue 114, at https://www.midwiferytoday.com/enews/enews1716.asp#main

Rachel Reed, midwife and PhD, and insightful blogger of Midwife Thinking poses the fact that “most babies rotate” as ideology in Celebration of the OP baby,  “These situations only become problematic when we apply generalised expectations about how labour should be to an individual woman, baby and situation.” To quell the fear-factor risen about posterior fetal position over the last two decades, Catie Mehl from Ohio, and Angela Horn from Arizona, two active doulas doing good things for families in their communities promote the ideological viewpoint which seems, at first, to reject challenges due to fetal malposition. Each blogger seeks to cast fear from the examination of proclaimed complications about birth, through which stating concerns might alarm pregnant women: the large baby, the overdue baby, and in this case, the posterior baby. Their post at once acknowledges the risks of posterior, and rejects the advantage of proactive support of the woman’s  birth companion, or doula (doo-la), in  discussing activities to prevent or prepare for such a labor. Selina Wallis keeps a scholarly eye on posterior issues on her blog, Magical Birth. She did a fine job discussing  Catie and Angela's conclusions so I will say less rather than more. 

Our heroines claim their resistance to educating women is because evidence is lacking to support maternal position changes to rotate babies out of the occiput posterior position (OP). They propose doulas should not discuss OP as a concern in pregnancy with clients, as these have the “potential to influence how pregnant women perceive their preparation for birth and the experience itself.” For now, let’s look at the justification for discarding proactive preparation. The ideology over physiology argument rests on missing data points and over stating research conclusions. We’ve already established the value of these doulas in their community so we will follow this advice from Angela Horn with what might be missing from her assumptions.

“The research shows us that most babies will be OP at some point in labor, and the vast majority of the time it does not cause issues with the labor. When it does, we need to focus on the comfort of the laboring person rather than rotation, as there is no evidence to suggest maternal posturing will fix baby’s position, and most babies will rotate just fine on their own.”

Does the fact that “most babies” will rotate on their own is true, permit well meaning doulas to ignore those that can’t rotate for themselves in our discussions with pregnant families?  Sizer found 65% of OP babies rotated to OA and Lieberman found about 4 out of 5 posteriors rotated at each labor phase observed for fetal position.


Relying on the fact that  “most” babies rotates leaves, the 15-35% of babies that don’t rotate to potentially long labors with cesarean surgery, or as Angela Horn cites, uterine rupture and occasional death (Fantu). And though Lieberman shows 20% of posteriors turning to face a hip, 24% of those ended labor with a cesarean for deep transverse arrest.


Randomly posterior?

Lieberman’s 2005 study seemed to limit posterior studies to comparing ultrasound diagnosis to the doctor’s fingers until recently. If fetal position changes were random, then why study fetal rotation? The fact that Lieberman observed that 36% of the babies were OP at one time in labor is not equal to their requirement to be OP, or that some women’s pelvises must have an OP baby.

Assuming the wrong conclusion slowed research. The question should be, if one variable doesn’t explain the pattern of fetal position changes, what else might we explore?

Going back to the 1800s we see physician description of right obliquity of the uterus (Dakin). This anatomical normality of uterine shape then might be a variable in deciding flexion or extension of the fetal spine and, so, head diameter. Spinning Babies Workshops illustrate this possibility.

“It’s a hypothesis, GG. A hypothesis is a way of looking at the world to see if something you think about will work in that world,” Alton, my four-year-old grandson, told me while I tucked him in at bedtime after his Little Scientists class.



Accuracy to determine occurrence and cause may need the addition of multiple variables. Extension and the dynamics of the pelvic floor are two such variables. 
Pelvic floor dynamics play a part in the extended baby rotating to posterior as the more front of the head becomes the rotation denominator, rather than the round crown. 

So the baby from the Right Occiput Transverse position will more often rotate to posterior (Sutton). So if the Occiput Transverse position whether right or left was counted as one single data point in Lieberman's study, for instance, flexion and extension are ignored twice, once because the angle of the head for flexion was not measured and two, because right or left occiput transverse was not considered different.

Variables of fetal position may include degree of fetal head flexion or extension, size of baby, asynclitism at or after 0 station, and shape of parietal eminences; maternal anatomical features -- such as which of three levels of the pelvis (described in America as stations of the pelvis) in which the baby was, and whether the diameter of that level matched the baby’s anterior, transverse, or posterior position (which is to say, the head was in an unfavorable diameter) -- pelvic floor tone and relative symmetry, sacral mobility, size of pelvic outlet, and location of placenta.


Can a variable have a variation?

If the strategy for support and care for posterior labors hung only on the seeming randomness of a single variable fetal position change and the usual success of the birth process, might we only expect 80-90% of babies to survive birth. And would rejecting proactive measures seem to have the doula accept William Barth, Jr.’s sobering treatise on the high maternal morbidity of OP? Not to repeat Fantu’s heartbreaking report on obstructed labor in Ethiopia. The justification for neglecting proper pregnancy counseling is confusing.

Thankfully, we do have medical interventions for the mothers of the persistent and non-fitting few OP babies, especially since repeated studies find only 17.4% of first-time mothers with OPs have a spontaneous birth without medical interventions (compared to 76.2% of anterior), with 64.7% of women finishing their posterior labor with a cesarean (compared to 6.3% anterior, Lieberman).

While maternal position research study sample sizes are small, they open evidence-based pathways to application of techniques. Maternal positions studied were found favorable as comfort measures. Guittier et al studied maternal positions suggested by de Gasquet  in Trouver sa position d’accouchement Paris: Hachette Livre; 2009:126. But none of the proposed positions opened the inlet. (Reitter, 2015) where the posterior baby needs the room to move from the anteriorposterior diameter to the oblique or transverse direction of the opening to the pelvic passage.

Desbiere’s interesting attempt to compare three maternal postures to rotate baby did find that all women that used hands and knees position and recumbent were successful in rotating baby out of the posterior position. Strebler also found some success. There is evidence for maternal positioning to rotate a baby out of posterior.

For birthworkers, Ms. Simkin advises, “Avoiding OP positions is a worthy goal” (Simkin 3). I agree and bet my life work on it. The challenge comes, of course, in choosing truthful words to speak to a mother whose baby remains OP. Spinning Babies serves doulas, providers and parents who choose to explore the small samples in the research and explore concepts proven in physical therapy models and apply them to birth.

Spinning Babies celebrates physiological and spontaneous birth and seeks to understand the variables to replicate the environment of success for that still-significant percentage of women whose babies won’t spontaneously turn. Many don’t need a cesarean.  Many avert their cesarean by applied techniques without control study evidence. .

How do we reach these women? We actually don’t have to speak of posterior fetal position! We can easily promote the comforting and effective maternal positioning techniques “to make room for the baby!” Many women enjoy being proactive in her pregnancy. Women seek physiologic options before resorting to obstetrical and mechanical interventions.

I will continue to help women have a healthy, safe, even happy birth with the mother's reports as my evidence. Its true that some women would have had a shorter easier second birth than their first posterior labors, but the frequency of short subsequent labors might be worth investigating. The Spinning Babies approach to maternal positioning strategies for fetal rotation are sufficiently successful and ever improving. Gentle techniques with scant research but abundant anecdotal evidence to support them are now spread worldwide with the social networking enthusiasm of birth activists and appreciative parents. Certainly, women are benefiting now from my and others recommendations for maternal positioning. (Gizzo) I add myofascial (muscles and connective tissue) passive stretch techniques to make room, or reduce tightness, in the path of the baby.

World fame may be transitory without convincing research. I so want research specific to Spinning Babies’ approach to provide a third leg of the stool to balance the two opposing strategies of Wait-n-see vs. Cut-em-out. There are more than two answers to any argument. And this is certainly the case for labor progress solutions for posterior and other challenging positions.


A Research Dilemma

How shall we study something as complex as a paradigm?

For a premise like Spinning Babies, scientific clarity begs multivariable factors for the
flexion, rotation and descent of normal cardinal movements of birth. For instance, we cannot consider that all the factors for a progressing labor are exactly similar in a non-progressing labor. Most pelvises have been shown to be “adequate” after cesareans. Most babies estimated to be large are found, after the cesarean, to be smaller. Might there be other elements of the anatomy than that bony pelvis at play with birth?

Can the most simple solution be the answer to a complex problem? The Karminia study is often cited to disregard maternal positioning, though only hands and knees and pelvic rocking was studied and only 11% of study subjects fully complied to the 2 ten-minute periods for the full three weeks before birth. Even with that low compliance we should have seen a difference in outcomes for those few. But we learned that this highly-recommended comfort measure is not also a rotation measure in pregnancy. That’s all. In labor, hands and knees position helped OP babies rotate (Stremler), especially when adding Rebozo sifting (Cohen) .

At Spinning Babies, our solutions to stuck labors begin by looking to the level of the pelvis where the baby waits to match a corresponding technique(s) (Vitner, Iqbal). In other words, we don’t use an outlet technique for an inlet problem and expect it to work. While squatting might work for an OP baby below the midpelvis, the Abdominal Lift and Tuck with a flattened lumbar (Janie King’s Abdominal Lift with Penny Simkin’s adaptation of counter-nutating the pelvic sacrum) is specific for helping an OP baby rotate off the inlet. However, the research community prefers a single variable study. How one variable may determine the validity of a holistic method seems more suited to starting a study than applying it in real life situations. Single variable investigation is the nature of control studies that confounds scientific exploration from paradigm review (KC Johnson).



Conclusion

Neglect of prenatal and intrapartum care for the laboring woman and her posterior fetus may result from a lack of understanding on the part of her doula or provider in interpreting evidence. There is sufficient evidence to justify the doula and the provider offering non-medical, “physical theory” prophylactic strategies for the posterior fetus. Anecdotal evidence of a collection of concepts and techniques put forth as Spinning Babies is gaining popularity for comfort and resumed labor progress for posterior and undetermined fetal positions collected through the timestamped emails and posted Facebook testimonies. Increased understanding of the birthing baby’s rotations through the pelvis may come from combining variables in prospective research observations.

By rephrasing our advice to pregnant women away from concerns about fetal position, towards the enjoyment of bonding (“binding-in” in pregnancy), we are truly proactively preparing for easier childbirth. “Making room for the baby” replaces potentially trauma-inducing words like “uh-oh!” and “malposition” or “stuck baby”.  The diagnosis of fetal position becomes suddenly less vital. Meanwhile we are sensing and observing, guiding a pregnant women towards full range-of-motion for the best flexibility, mentally and physically, for the upcoming expression that is her birth.

Call to action: I need a research assistant to help prepare for studies who has office software skills and is in school for their doctorate or is post-grad. Email me at Gail@ you know the website! (robot dispelling email hint)

1 comment:

Jo said...

I took advice to heart about sleeping on my left, not doing the TV slump, and trying to adopt forward/hands and knees postures when I could. I had two easy presentations, and my labour pain as compared to those I know with OPs was fine. Manageable, is the word I'd use. None of the language around agony and horror that I hear others using.

It might be ok to take positioning out of the pregnancy dialogue if everyone had beautiful homebirths with supportive midwives and doulas who know all about taking time. But the truth is, the majority of women are in hospital without enough calm, knowledgeable support, and under massive time pressure. Surely in that situation, OP means induction and section in many cases? I'd rather do soemthing about it during pregnancy than during labour.

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