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Archive for February, 2016

Upcoming twitter chat #MatExpHour: Malposition and maternal position Friday 5th February

matexphour

@Unlockingbirth

#MATEXP IS A POWERFUL SOCIAL CAMPAIGN INVOLVING PEOPLE FROM ALL WALKS OF LIFE FROM ALL ACROSS THE UK AND BEYOND

It aims to:

  • Encourage and empower users of maternity services to join conversations about their experiences of maternity care, and what really makes a difference to that experience.
  • Get health care professionals (in and beyond the NHS) and local communities to listen and work in partnership with women and families to improve maternity experiences.
  • To enable anyone to take action to improve maternity experience, however big or small, whoever you are: user, partner, community group or NHS staff

http://matexp.org.uk/

Maternal mobility in labour

How often do you end up shouting at the telly when ‘One born every minute’ is on, and a labour is slow to progress or baby is not coping well and a woman is lying down? Try getting her up!

There’s a large body of research evidence that movement in labour improves outcomes so why do so few women feel able to change position in labour, especially in the second stage?

In 2015 in the UK, fewer women gave birth in a bed than in 2007 and more women chose a water birth or birthing pool (but still <10%)

But approx. 50% of women in 2015 having an unassisted vaginal birth gave birth lying down or lying down with legs in stirrups. The most common position for women to be in when they gave birth was lying down with legs in stirrups (35%), which is a 3% increase from 2013. It should be noted that 15% of women had an assisted vaginal delivery, which would normally require stirrups.

http://www.cqc.org.uk/content/maternity-services-survey-2015

What affects choice of birthing position?

Barriers to maternal movement in labour have been suggested to include: (1) lack of space, (2) inadequate support, (3) use of unwarranted debilitating technology, and (4) movement restricting pain relief.

The link below shows how it is possible to achieve mobility with an induced multiple birth:

https://gasandairblog.com/2016/02/01/the-birth-story-of-ottilie-and-delilah/

The advice given by midwives was the most important factor in this study influencing the choice of birthing positions.

http://www.tandfonline.com/doi/abs/10.1080/01674820410001737432

In one study where women were randomised to use a birthing stool or usual care, despite being randomised (rather than freely choosing), women who gave birth on the seat were statistically significantly more likely to report that they participated in decision-making and that they took the opportunity to choose their preferred birth position. They also reported statistically significantly more often than non-adherers that they felt powerful, protected and self-confident.

Midwives should be conscious of the potential impact that birth positions have on women’s birth experiences and on maternal outcomes.. An upright birth position may lead to greater childbirth satisfaction. http://www.sciencedirect.com/science/article/pii/S1871519213000723

What about Dad’s and birth partners?

If a woman gives birth upright, the father is more likely to see the birth as positive, says a study from Sweden… http://fb.me/7BlBeD9fR

What about malposition?

doula (1 of 1)

Many women start labour low risk but experience a cascade of intervention, although there are a number of factors that cause this, I believe the (often) unrecognised missing cause in the majority of emergency caesareans, assisted deliveries and interventions causing long term morbidity to low risk women and their babies worldwide is malposition.

Malposition’s are positions where a baby is head down but is presenting in a way that increases the diameter that needs to pass through the pelvis and birth canal. This can be ‘back to back’ (or occiput posterior known as OP) where a baby has its spine against the mothers spine. Babies in this position are usually ‘deflexed’ (chin not tucked to the chest) and this can cause more pain and delays going into labour or in the first and second stage. Although most babies rotate into an easier position to be born, the longer this takes, the more likely it is that women will have interventions like induction, augmentation, systemic pain relief. Women whose babies stay OP (known as persistent OP) are much more likely to need assisted delivery, episiotomy and caesarean section. They also have a higher chance of perineal tearing, post-partum haemorrhage (blood loss) and postpartum infection. Babies are also more likely to show distress in labour, meconium in the amniotic fluid, lower Apgar scores and need time in NICU.

As well as OP other factors that can result in malposition are asyncliticism (a tilt to a baby’s head in late labour) and compound arms (up above the head)

Recent research indicates there is no ‘ideal’ birth position. But OA babies (with their backs to a mother’s front) are more often flexed (head tucked) which presents a symmetrical and smaller circumference onto the cervix. This leads to less prolonged labour and riper cervix.

Whether a malposition is a problem will depend on many factors-

  • Pelvis shape/size
  • Uterine ligaments
  • Baby size
  • Baby position (this can also encompass flexion (chin tucking) and arms above the head
  • Mothers health in pregnancy (diet and exercise)
  • Mothers mobility in labour
  • Mothers pain relief in labour

Can we do anything about malposition in labour?

I addressed this in my latest post here:

https://magicalbirth.wordpress.com/2016/02/03/does-babys-position-matter-in-labour-and-can-we-do-anything-about-it/

I concluded:

There is a body of evidence that maternal mobility in labour improves outcomes and may aid rotation. More research is needed that can adequately measure maternal mobility in labour and interventions that match the multifaceted practices that midwives and doulas use to support women with prolonged labour or suspected malposition.

Women may want to mobilise in labour but feel restricted by social/cultural expectations (for example the use of the bed in the maternity room)or restricted by the technology being used (CFM, drip).

Comments on facebook about the topic have so far included:

“I think we should change the language. Maternal mobility is not important to women. It is essential to the process of birth. Birth is not able to process as well. We don’t say ‘mobility is important to men when having sex’ or ‘mobility is important to people emptying their bowels’. Saying it is important to women means it can be overridden by welfare of the baby. Suggest Margaret Garrett ‘dynamic positions’ book to anyone who thinks it is nice but optional.”

“Restricting mobility is a dangerous, and unproven, intervention. Spontaneous positioning is the NICE standard of care for ‘normal’ births & should be for all births. It is a human right. Great topic! Emerging evidence for upright breech birth | The midwife, the mother and the breech

http://breechbirth.org.uk/…/emerging-evidence-for…/

 

SUGGESTED QUESTIONS FOR TWITTER DISCUSSION

  1. Should midwives tell women the position they believe their baby to be in antenatally?
  2. Can antenatal maternal posturing effect fetal position and outcomes?
  3. Can maternal posturing in labour effect fetal position and outcomes
  4. How can midwives and birth partners best support women with malpositioned labours for comfort and to improve outcomes?
  5. Do midwives and doctors facilitate or hinder movement in labour?
  6. How can we support high risk women to be mobile in labour? What about telmemetry and pool use/VBAC
  7. Should pool use be promoted to increase mobility?
  8. How does birth room environment design effect mobility?
  9. Does malposition make it harder for women to move in labour due to pain? How can we support them?

I will post a second blog post to summarise the twitter discussion after Friday.

Resources

Books

http://www.amazon.co.uk/Books-Preparing-Gentle-Birth-Pelvis-Pregnancy/dp/1594773882

http://www.amazon.co.uk/Dynamic-Positions-Birth-womens-bodies/dp/1780661150/ref=sr_1_1?ie=UTF8&qid=1454584225&sr=8-1&keywords=dynamic+birth+positions

http://www.amazon.co.uk/Labor-Progress-Handbook-Interventions-Dystocia/dp/1444337718/ref=la_B000APTRPO_1_2?s=books&ie=UTF8&qid=1454584280&sr=1-2

 

Blogs

http://www.positivebirthmovement.org/pbm-blog/childbirth-get-off-the-bed-get-off-your-back

https://magicalbirth.wordpress.com/

http://naturalbirthinkitsap.blogspot.co.uk/2010/07/optimal-fetal-positioning-how-babys.html

http://midwifethinking.com/

 

Links

https://www.facebook.com/UnlockingBirth/

https://www.facebook.com/birthenvironment/

http://spinningbabies.com/

http://dancingforbirth.com/

 

 

 

 

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Does baby’s position matter in labour and can we do anything about it?

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Reply to Catie Mehl of Columbus Birth & Parenting and Angela Horn from Tuscon doulas recently published blog posts about malposition.

http://tucsondoulas.com/does-babys-position-matter-pt2/

Prevalence of OP prior to labour

Up to approx. 30% of babies are OP before labour begins.[1]

Some studies have found that fetal position before labour does not affect birth outcome[2] but others have found the opposite, in one study occipital position was found to be a factor in predicting successful induction[3] with cervical length being longer in OP positions prior to induction.

Around 80% of babies that are OP before labour begins, will rotate in labour[1]

But the longer a baby stays OP in labour, the more likely they are to stay that way.[4]

The deflexion associated with OP may be more important than the fetal position.[3]

Malposition effects labour progress

Persistent OP is associated with prolonged first and second stages of labor and augmentation [5-7]

Malpositioned labours significantly more often cross the partogram action line[8]

Malposition effects maternal and fetal outcomes

Women whose babies that are malpositioned during labour and birth are more likely to have obstetric interventions, including assisted delivery and operative birth [6 9 10]

The incidence of persistent occiput posterior position was associated with significantly higher incidences of induction of labor, oxytocin augmentation of labor, epidural use, and prolonged labor[5]

Maternal movement in labour improves birth outcomes

Can maternal position changes in labour effect rotation from OP to OA?

Most intervention studies using maternal position to try to rotate babies from OP to OA have been unsuccessful[9 11]  although studies have tended to be for short durations (-10 minutes), and include participants that have an epidural (approx. 90%)

One study has been successful in effecting rotation from OP to OA using maternal movement. The authors conducted an observational cohort study of women in Padua, Italy having their first baby. They grouped women into Group-A when they spent more than 50% of their labour in recumbent position (supine or lateral) and in Group-B when they preferred an alternative position (upright, squatting, sitting on the ball, or “on all fours” position) the OP rate at the start of labour was comparable in two groups with 40.6% in Group-A and 36.5% in Group-B.

A strong significant difference was found in terms of delivery outcome.

CS was necessary in 27 patients: 46.4% in Group-A compared to the 12.3% in Group-B.

Significant differences in terms of OP persistence at delivery were also found in those delivering vaginally: in Group-A patients, OP persisted till birth in 39.6% of the cases while in Group-B only in 28% of the cases[12]

Other evidence for benefits of maternal movement in the first stage

Upright positions increase contraction strength. Women labouring in upright, non-recumbent positions have fewer POP deliveries, shorter labours and lower rates of assisted deliveries and CS[12]

Sims’ posture on the same side as the fetal spine has been recommended to enhance rotation from posterior to anterior[13]

Prince of Songkla University Cat (leaning over back of bed at 60 degree angle on knees)and upright positions together with music reduced the duration of active phase of labour and labour pain in primiparous women compared to oxytocin[14]

Cochrane review: Maternal positions and mobility during first stage labour-“Walking and upright positions in the first stage of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural, and does not seem to be associated with increased intervention or negative effects on mothers’ and babies’ wellbeing.”[15]

Other evidence for benefits of maternal movement in the Second stage

Any upright or lateral birth positions compared with supine or lithotomy positions have been associated with reduced duration of second stage of labour, reduction in operative delivery, reduction in episiotomies, reduced reporting of severe pain in the second stage, fewer abnormal fetal heart patterns[16]

“Use of the supine position is associated with negative maternal, fetal, and neonatal hemodynamic outcomes. Despite the persistence of the use of recumbent positions for birth, the evidence supports the merit of upright positions. “

Kneeling squat position significantly increases the bony transverse and anteroposterior dimension in the mid pelvic plane and the pelvic outlet[17]

In a study using MR obstetric pelvimetry an upright birthing position significantly expands female pelvic bony dimensions, suggesting facilitation of labor and delivery[18]

Epidural use

Women with epidurals that change position[19] (every half hour from hands and knees, sitting etc in the passive part of second stage (giving time for the head to come down) and push in a lateral position with the upper hip abducted had greatly reduced assisted delivery rates (19.8% vs 42.1%) higher rates of intact perineum ( (40.3% vs 12.2%), lower episiotomy rate (s (21.0% in vs 51.4%) and time actively pushing, without incurring any other adverse maternal or fetal outcomes[20]. Peanut balls have also been found to improve outcomes for women with an epidural. [21]

Squatting

The use of the squatting position in managing the second stage of labor results in less instrumental delivery, extension of episiotomy and perineal tearing compared with the supine position[22 23]

Women prefer freedom to move in labour

Freedom to change positions in labour has been identified as integral to a feeling of control and the management of pain in labour, due to the physical and psychological benefits[24]

Women have described being in more control over their pushing in the second stage when they were in an upright position compared to a supine position[25]

 

Is operative birth necessary?

CPD

In a review of >225 thousand birth records in the United states (2002-08) half of Caesarean Deliveries for dystocia in induced labor were performed before 6 cm of cervical dilation. Among intrapartum CDs, approximately half were performed for ‘failure to progress’ or ‘cephalopelvic disproportion’.[26]

It has been reported that most cases of reported cephalopelvic disproportion (CPD) result from malposition of the fetal head within the pelvis (asynclitism) or from ineffective uterine contractions. True disproportion is an unlikely diagnosis because two thirds or more of women undergoing cesarean delivery for this reason subsequently deliver even larger newborns vaginally[27]

https://www.youtube.com/watch?v=roFVkDV45MM

Could we reduce intervention for dystocia and malposition with more time?

A review of the evidence relating to dystocia found that current understandings rest on outdated definitions of active first stage of labour, its progress and on treatments without a strong evidence base. These include the cervical dilatation threshold for active first stage, uncertainty over whether a reduced rate of dilatation and reduced strength of uterine contractions always represent pathology and the effectiveness of amniotomy/oxytocin for treating dystocia[28]

It has been suggested that one of the ways to safely prevent primary caesarean deliveries is to increase the active phase of labour start to 6cm and the safe duration of the second stage to at least 2 hours for women having a second or subsequent baby and 3 hours for women having their first baby.[29] or longer with an epidural although the safety of this is contested by some. [30]

International findings

Obstructed labour mostly caused by malposition (and often labelled as CPD) is common in lower income countries and has a high rate or maternal and fetal mortality and morbidity. More needs to be done to prevent and resolve malposition in situations where safe obstetric intervention may not be feasible to save mothers and babies lives and futures[31]

Women in Low and middle income countries (LMIC) are described as having three delay to obstetric care. (1) deciding to seek appropriate medical help for an obstetric emergency; (2) reaching an appropriate obstetric facility; and (3) receiving adequate care when a facility is reached[32]

http://blogs.msf.org/en/staff/blogs/may-the-forceps-be-with-you/one-foot-in

Maternal and fetal morbidity and mortality is often due to this delayed treatment.

Prolonged obstructed labor can result in fistulas. Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. Women may not deliver in health care facilities if they do not meet their needs. (this includes the need to move around in labour and use upright positions to birth in, which may be discouraged in the hospital setting) There may be transport and cost implications or Beliefs that problems in labor arise from disturbances in the social environment (and may be caused by actions of the mother) rather than as simple problems of obstetrical mechanics [33]

Even after arrival at a health facility mean waiting time for women admitted with complications was as much as 24 h before treatment.[34]

http://blogs.msf.org/en/staff/blogs/may-the-forceps-be-with-you/before-the-beginning

Barriers and facilitators maternal movement in labour

Barriers to maternal movement in labour include: (1) lack of space, (2) inadequate support, (3) use of unwarranted debilitating technology, and (4) movement restricting pain relief[35]

Difficulty in conducting research relating to maternal movement in labour, which is often dynamic and needs to be directed by the woman, means that amassing strong evidence of the efficacy of maternal movement to resolve malposition is complicated. Cultural influences and provider influences also effect choice of maternal position. [36 37]

Use of a pool in labour has been suggested to increase maternal ability to change position[38] and also mobile telemetry for high risk women to allow greater mobilisation and use of the pool.[39]

Fathers with a partner having an upright birth position were more likely to have had a positive birth experience, to have felt comfortable and powerful compared to spontaneous vaginal births where women adopting a horizontal birth position[40]

SUMMARY

Malposition’s are the root cause for much of the morbidity and mortality and unexpected intervention in labours worldwide. There is a body of evidence that maternal mobility in labour improves outcomes and may aid rotation. More research is needed that can adequately measure maternal mobility in labour and interventions that match the multifaceted practices that midwives and doulas use to support women with prolonged labour or suspected malposition.

Women may want to mobilise in labour but feel restricted by social/cultural expectations (for example the use of the bed in the maternity room[41]) or restricted by the technology being used (CFM, drip).

Doulas and midwives can help to facilitate women’s choices by:

  • Antenatal education that provide women and their partners practical experience of maternal positions that can facilitate labour and birth
  • Discussing the barriers and enablers of maternal movement
  • Practical support in labour if technology is needed (suggesting mobile telemetry as a possibility if available, holding monitors in place while women use birth balls or change position with CFM)
  • Suggesting movement changes in labour that might aid women’s comfort or rotation
  • Suggesting the use of a peanut ball if women have an epidural or need to rest in a recumbent position
  • Suggesting position changes in the second stage (particularly if there is a delay or little change in descent)
  • Rebozo can be a useful tool when women have difficulty moving (due to exhaustion, pain, pain relief or technology that restricts movement)42]

 

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  3. Ashour ASA, ABDELLA RM, GHAREEB HO, et al. Preinduction ultrasonographic measurements as a predictor of successful induction of labor in prolonged pregnancy in primigravidas. 2013
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  40. Hasman K, Kjaergaard H, Esbensen BA. Fathers’ experience of childbirth when non-progressive labour occurs and augmentation is established. A qualitative study. Sexual & Reproductive Healthcare 2014;5(2):69-73
  41. Townsend B, Fenwick J, Thomson V, et al. The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space. Women and Birth 2015
  42. Cohen SR, Thomas CR. Rebozo technique for fetal malposition in labor. Journal of Midwifery & Women’s Health 2015;60(4):445-51