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Penny Simkin brought notice to several myths about the OP Fetus to the
forefront of discussion during the 2006 DONA International Annual
Conference.
A few doulas have even told me they
didn't try certain techniques with a mom in the midst of a long labor
because the mom didn't have back labor. They were astonished when out
came a little face-up baby. Had the doula known, she said, she'd have
had some suggestions to help the mother more effectively, perhaps to
shorten her long labor.
Because a pattern of challenges seem to
point to posterior labor, students of birth have tended to lump these
challenges together under the heading of posterior labor.
Longer labors
Back labor
Painful labor needing
medication
This can be naive.
Changes in Fetal Position
a 2005 study by Ellice Lieberman and her research group in Boston busted
some of the myths that have been growing up around posterior labors. The
study was an amazing effort to understand the connection between
Epidurals and posterior presentation. You can open a new page and read
the
Green Journal's full text version of Changes in Fetal Position...
Unfortunately, reading the study
casually could lead one to conclude that fetal position changes at
random throughout the course of labor.
Yet, if we read the data carefully we
find several consistencies with previous research on
the posterior fetal presentation. There are similarities in labor
patterns and the effects of posterior presentation, and similar
percentages of how many posterior babies end up posterior at delivery
throughout the last several decades. In other words, we still have the
same problems (only more of them with current Obstetric trends).
What is new in the 2005 Lieberman
report is the proof that Epidural anesthesia does increase the rate of
posterior presentation at the time of delivery. Another new finding is
that interventions are increasing in childbirth and especially in the
care of a posterior labor.
The Kariminia research team
investigation as to whether Pelvic Rocking can prevent posterior
presentation at the start and the end of labor seems to have busted the
myth that hands and knees position can benefit posterior labors. I
address this in another commentary exploring that paper in depth.
There is some truth and some myth in
all this.
But, we must be careful! We don't want
to replace one dogmatic idea for another!
Penny Simkin brought notice to several
dogmatic myths about the OP Fetus to the fore front of discussion during
the summer of 2006 at the annual DONA International conference. She
listed several myths the birthing community has about Posterior labors.
So, I'd like to start with the list of
myths which Penny Simkin has helped us identify. After each myth, I'll
give my two cents worth.
The
Myths
MYTH: It is important to know
the fetal position.
Midwives have been debating this,
gently, for years. But still we can think, if only I knew what position
the baby was in I would know what to do.
However, it isn't the position that
directs our actions so much as the labor pattern. Each labor is
different, each mother is different. So knowing isn't what gets the baby
out. More often today, knowing that the baby is posterior adds stress.
The mother may be alarmed and the doctor may even suggest a cesarean. He
or she may think, why go through labor if a cesarean is the end result
anyway? How atrocious! Only a relatively few babies will need such help
to finish birth.
Most posterior babies will come out on
their own. Well, with the help of a strong labor and a patient mother!
Ms. Simkin asks, Will outcomes be improved by this knowledge?
In spite of the lovely
Belly Mapping pages on this website, knowing position is not
as important as responding to the needs of any given labor.
What is more important than knowing
fetal position is relaxing the soft tissues associated with
childbirth. The muscles, ligaments and bones may need acommodation
regardless of fetal position. In other words, tension in the psoas pair
of muscles or pelvic floor can delay an anterior baby and a posterior
baby. Extension of the anterior fetus' head can prevent engagement in
some pelvises. The main point is that we can, generally, promote
progress regardless of fetal position.
MYTH: If we prevent OP before
labor than we can prevent OP in labor
Helping the baby rotate with abdominal
stroking or by pelvic rocking hasn't shown lasting effects.
I think this is because the environment
that the baby is in will not be effected by such measures. The
symmetrical womb allows for an anterior baby. A twist in the lower
uterine segment, or pelvic misalignment are reasons for a posterior
baby. If the baby has been lured out of the posterior position without
addressing uterine symmetry the baby is likely to slip right back into
the position that the uterus is shaped to.
To answer Karaminia's question of
Pelvic Rocking correctly we would have to study 2nd trimester prevention
excersizes among one group of women with no prevention methods in
another group. Why? Because while most babies that start labor in an OP
position will rotate to OA before the end of labor.
There is a consistent small group of
babies who are OP throughout labor. This group are the mothers and
babies that need Spinning Babies and Optimal Fetal Positioning. But how
do we identify this group without helping the other mothers, too? And
why wouldn't we help other mothers. We will. But because most OP babies
rotate to OA , about 68% according to Gardberg, we shouldn't ignore the
15% (Lieberman) who are OP when they are born, either vaginally or
cesarean.
MYTH: If the baby is Occiput
Anterior (OA, the "best" starting position) in early labor the baby will
stay in a good position throughout labor.
The recent Lieberman study confirmed
statistical trends of earlier studies. 83% of the OA babies who were OA
in early labor were OA when they came out. But a small 5.4% rotated to a
direct Occiput Posterior position for birth.
MYTH: Midwives and Doctors can
tell the baby's position.
Ms. Simkin points out that the Leopold technique, commonly used to feel a
baby's position through the abdomen) was found to be only 68% accurate.
That means sometimes we can and
sometimes we can't.
There are three common ways a baby's
position is sought. By hands-on palpation, or feeling the abdomen. The
bumps in the belly mean something to a practiced hand. The problem is in
the variation of bellies and bumps. Sometimes the bumps don't make a
picture that the person feeling can make out. Bellies come in different
thicknesses. Babies can be curled up in interesting ways, looking far
over a left shoulder with the feet aiming to the right, perhaps. Lots of
amniotic fluid or muscle strength can hide details that might be needed
to "see" the position.
Feeling inside, through the open cervic
sometimes gives clues. But the little sutures (not stitches, but lines
showing where the skull bones meet) can be just out of reach or the edge
of the soft spot (fontanel) can feel like a suture, oddly enough.
Feeling baby's position is not as simple as it looks in the books or on
the plastic chart on a hospital L & D unit.
MYTH: Ultrasound can tell you the
baby's position with 100% accuracy.
Ultrasound allows a technician to
through dark water at a 3-D person displayed on a 2-D screen.
The crucial landmarks of the baby's
head may be blurred, or the viewer can make a mistake in interpretation.
Dr. Karen Davidson, the Ultrasound sonologist for the Lieberman group,
studied 1,766 women in labor. She found that she had to exclude 162
women because their ultrasound pictures were uninterpretable. In the
first six-months of the study Dr. Davidson found 13% of early labor
ultrasounds were uninterpretable. As the study went on, her accuracy
improved, the report stated. Since she was the Ultrasound expert on the
study, I would think her early rates must be at least on par with the
nation's Ultrasound interpreters, if not better than most.
Of the 1,562 births remaining in the
Lieberman study, 51% had an intrepretable Ultrasound picture in late
labor. That means 49% didn't. With those percentages, I don't think we
can hang our hats on Ultrasound. And furthermore, how the baby's back is
situated doesn't always tell us how the head is facing.
Many new obstetrical studies are being
reported on discussing what is the best way, whether for accuracy or
cost effectiveness, to determine a baby's head position. Transabdominal
or vaginal Ultrasound access are currently being compared.
MYTH: Back pain is a sign of an
Occiput Posterior (OP) baby.
Dr. Lieberman's
Changes in Fetal Position study did not find a difference in
back pain reported among women at 4 cm whether or not they had an OP
baby. While this may be a bit too early in labor to make a blanket
statement about back pain and posterior labor, experienced doulas and
caregivers have all seen posterior labors that proceed without back
pain.
The women with OP babies in early labor
(3 to 4 cm mostly) enrolling in the Lieberman study did not report more
back pain at 3-4 cm dilation. After that, as 92% of the women had
epidural analgesia, back pain was not investigated further in labor. As
a doula of women with and without epidural pain relief, many without, I
have noted that OP back pain, when it does come, often comes between 4
and 6 cm, rather than before 4 cm.
Some women have relatively
straightforward OP labors. (After Lieberman's report, we can wonder if
we are still permitted to call labors by the fetal position name.) Women
with OP labors that progress without stalls often do not report back
pain at any intensity that would get a nurse questioning fetal
position. Some have no more labor pain in their backs as they do in the
front.
A few women have severe back pain early
in labor, at 2 cm. These women are candidates for an
inversion as soon as possible, if they will accept the task. Back
pain is more about the fit of the baby than the position. Some posterior
babies fit their mother's pelvises better than others.
Some women finding themselves in one or
more of the following categories Might get some back pain in labor:
Short women, women whose joints aren't
flexible, women who've had accidents effecting thier pelvis or necks,
women who have weak back muscles, some women with posterior babies, or
women whose babies have one of their arms up near their necks in late
labor.
MYTH: When a woman is having
prolonged labor without back pain, it is from a reason other than
posterior position.
Oh, thank you, Penny Simkin, for
bringing this myth to our attention. I can't list the times a midwife,
doula or nurse has told me their frustration at not being able to help a
woman in a long labor, then say something like, "I thought of the
Open-Knee Chest position (or another technique) but didn't try it
because she didn't have back pain. But during the cesarean, the doctor
said the baby was posterior, and that's why the baby wasn't coming
through the pelvis." Back pain is not the signal that tells us whether
or not the baby is posterior.
A delay or a stall in labor, with or
without back pain can often be corrected by one form of
inversion or another.
Back pain, with or without a stall in
labor, may also be soothed by
inversion.
Sometimes back pain is from a spasm in
a ligament low in the back of the uterus, such as the ligament holding
the cervix to the sacrum. Inversion gives that ligament a gentle stretch
and then when the mom gets up the ligament can relax. Ahhh.
There are some protective guidelines
about inversion. See the article, and ask your care provider if there is
"a medical reason not to do it?" That great little question comes to us
via Penny Simkin, too.
Some posterior labors can be fast, some
slow. Some posterior labors are very painful, some are not. Some
posterior labors are associated with needing help from vacuum, forceps
or cesarean surgery to get born. Many need Pitocin (Syntocin) to
progress in the hospital. Some parents hoping for a homebirth have to
transfer to the hospital for one or more of these interventions to
finish their birth when the baby is posterior. Knowing what to expect
from a posterior labor can be confusing.
MYTH: Position changes can
change the OP position in labor
There are only a couple of studies on
this topic. Neither has been studied using the
1st Principle. The studies tell us that
several minutes on hands and knees are not enough to overcome the
tension in a womb that holds a baby in an unfavorable position.
These studies are why I developed the
order of techniques, "3
Princibles of Spinning Babies." First, you have to relax the
involuntary muscles, including the muscle fibers mingled in the uterine
ligaments. It isn't until after than that you get gravity, the 2nd
Principle, helping and 3rd, move the pelvis to help the baby move.
For instance, if the head is stuck high
at the brim, you don't open the bottom of the pelvis to help the baby
out. Then, wonder why squatting works for some women and not for
others. If your front doorbell rings do you open the back door and
wonder where you company is at? Why don't you see your visitor? When
your neighbor across the back fence comes to call you always find her
when you open the back door, so why does it work for one and not
another? I'm just showing you the logic that is behind the assumption.
To bring these Posterior Myths
together, you may enjoy reading
The Long Labor that Wasn't. The pictures are wonderful. But then I'm
biased!
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There
is a growing dogmatism about fetal positioning. 
If
a first time mom's baby doesn't engage into the pelvic brim by the time
labor starts (or doesn't during very early labor) her chance of having a
cesarean is far greater than for women whose babies have "dropped."
