Baby Positions

Labor

Pregnancy

What to do now

The Spinning Babies Parent Class on Video November 10th

Belly Mapping Workbook

Wondering how to Belly Map?

The Blog

Our Events

The Fetal Occiput Posterior Position...

PennySimkin, PT

From Birth Volume 37 Issue 1, Pages 61 - 71

The occiput posterior position challenges every aspect of labor care. Trying to prevent OP fetal position, diagnosing the OP position, correcting the OP position, supporting labor and making decisions about what to do for labor, and the delivery itself. Mothers and babies outcomes are often worse with both physical and psychological trauma being more common than with fetal occiput anterior positions. Here Penny Simkin highlights nine common beliefs and shows which are myths. Gail comments afterwards.

Penny Simkin teaches doulas about the posterior fetal positionMs. Simkin got her information from looking at studies reported on the PubMed and the Cochrane Library,  obstetric and midwifery textbooks, books and websites for the public, conversations with maternity care professionals, and years of experience as a doula.

Results: The nine prevailing concepts Ms. Simkin identified are:

(1) That prenatal maneuvers can rotate the occiput posterior fetus to occiput anterior;

(2) That it is possible to detect the occiput posterior fetus prenatally;

(3) That a fetus who is occiput anterior at the onset of labor will remain in that position throughout labor;

(4) That back pain in labor is a reliable sign of an occiput posterior fetus;

(5) That the occiput posterior fetus can be identified during labor by digital vaginal examination;

(6) That an ultrasound scan is a reliable way to detect fetal position;

(7)That  maternal positions help the rotation of the occiput posterior fetus;

(8) That epidural analgesia makes fetal rotation happen;

(9) That manual rotation of the fetal head (usually done by an experienced doctor) to the occiput anterior improves the rate of occiput anterior deliveries.

 

Concepts 1, 2, 3, 4, 5, and 8 have little scientific support whereas concepts 6, 7, and 9 are supported by promising evidence.

 

What Ms. Simkin conclusions: Many things we do for women who labor with an OP baby are unsatisfactory. Midwives and doctors to often fail to identify and correct the problem and thus contribute to high surgical delivery rates and traumatic births. Ultrasound examination is far better able than palpation (feeling the abdomin with the hands) or doing a vaginal examination of the baby's head with the midwives or doctor's fingers to tell baby's position. Accurate identification of a baby's position by ultrasound has the potential to improve outcomes. Research studies are needed to examine the efficacy of midwifery methods of identification, and the effect of promising methods to rotate the fetus (simple positional methods and digital or manual rotation). Based on the findings of this review, a practical approach to care is suggested. (BIRTH 37:1 March 2010)

Spinning Babies adds:

Penny Simkin has added a great deal of education to the maternity field in the topics of posterior fetal position and slow labors. She teaches us the difference between labor pain and actual suffering. Its so important to listen to the mother and intervene in a respectful way if the mother crosses from effort to meet a challenging labor into true suffering and a sense of helplessness.

Penny Simkin and Ruth Ancheta wrote The Labor Progress Handbook to help maternity workers help women who are going through the challenging labors whether due to fetal position or other causes of long labor.

 

Ms. Simkin graciously contacted me in the writing of this article. This prompted me to update my site and make improvements. Lots more could be made! Belly Mapping also appears in Chapter Three of Labor Progress Handbook. Penny Simkin sees promise in Belly Mapping to enhance midwifery skills in identifying fetal position but realizes a study would help support her confidence. If any of my readers would like to sponsor and host a study, I would be happy to assist in a design that would reflect authentic Belly Mapping skills.

 



 

Here's Gail's comments on Penny Simkin's nine concepts:

(1) That prenatal maneuvers can rotate the occiput posterior fetus to occiput anterior;

Though not studied well in the medical literature, there are some things both women themselves can do and body workers can do to help a baby rotate from OP to OA (or LOT) in pregnancy. Again, as read elsewhere in this website, Left Occiput Transverse (left occiput lateral) is as good as Occiput Anterior for the start of a straightforward labor.

(2) That it is possible to detect the occiput posterior fetus prenatally;

You know I think this is true. That's my premise behind Belly Mapping. The general rule of thumb is, if you can feel little wiggles in front, on both sides of the linea nigra, down near the bladder, you most likely have an occiput posterior baby. Baby may be Right Occiput Posterior or Left Occiput Posterior as well as direct OP.

(3) That a fetus who is occiput anterior at the onset of labor will remain in that position throughout labor;

This assumption doesn't take Right Occiput Anterior, Right Occiput Transverse, or a deflexed head into consideration. Nor does it's affirmation observe the  effect of laying in bed or slouching during labor on fetal position. Nor does it look at which level the head is at when labor starts. The deflexed right occiput anterior head is likely to rotate to the posterior, especially when the baby had not engaged at the start of labor.

The researchers who poo-pooed this statement to the point of thinking fetal rotation is random also didn't acknowledge the partial rotation of an anterior baby to transverse and back to anterior again as engagement and/or further descent occur. Right and left transverse is not understood by these researchers. The recent data on this discussion was not fully disclosed because it wasn't understood to be important. Therefore, the current discussion on this matter is incomplete.

Fetal rotation is not random! Its simply not invariant.

However, most babies who start anterior will finish anterior. And for that matter, most babies who start posterior will finish anterior.

(4) That back pain in labor is a reliable sign of an occiput posterior fetus;

This is not reliable in pregnancy nor in early labor. Back pain should be investigated with tight cervical ligaments or sacral imbalance in mind. Also women with smaller than average pelvi or pelvic outlets will experience more pain than others. Short women often have more back pain than non-short women. Pelvic exercises have good success with overcoming pelvic imbalance, weakness and pain in pregnancy and can probably be considered to reduce back pain in labor - on average - for women who routinely and correctly do pelvic strengthening and balancing exercises.

(5) That the occiput posterior fetus can be identified during labor by digital vaginal examination;

Give me a lesson, I'd like to get better at this, too!

(6) That an ultrasound scan is a reliable way to detect fetal position;

Too bad that ultrasound has not been proven to be safe for babies. I worry about exposure to our children. But also, Karen Davidson, who did a good job of recording all the ultrasound data for Lieberman's 2005 study (so influential to Penny Simkin's presentations on this topic) had to throw out a pretty big number of ultrasounds because they couldn't be read. So ultrasound isn't perfect. It surprises people that ultrasounds are not 100% accurate.

(7)That  maternal positions help the rotation of the occiput posterior fetus;

Fortunately, this is true. Now we have to get better about matching which maternal positions to phase of labor and station of fetal head.

(8) That epidural analgesia makes fetal rotation happen;

Why does it work sometimes and mess things up (prevent rotation) other times and how can we get better at predicting which way it will go for a woman?

(9) That manual rotation of the fetal head (usually done by an experienced doctor) to the occiput anterior improves the rate of occiput anterior deliveries.

This we know, but sometimes it ain't pretty.  And it ain't easy. If it were easy the baby his or herself would have done it! A cesarean is quite likely to be avoided by manually rotating the baby's head to the anterior to fit the pelvic outlet better.

Any OP fetal position is reason to refer a baby to a skilled craniosacral therapist (with newborn training which has different "rules" than adult CST and/or to a pediatric chiropractor, but this is ten times more important after this little trick.

 

 

 

Flag Counter

Pageviews since January 1, 2014
Spinning Babies - on the web since 2002

 
Sense and Sensibility Blog gives

Spinning Babies street cred