Upcoming twitter chat #MatExpHour: Malposition and maternal position Friday 5th February
#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
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.
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:
The advice given by midwives was the most important factor in this study influencing the choice of birthing positions.
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?
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:
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
SUGGESTED QUESTIONS FOR TWITTER DISCUSSION
- Should midwives tell women the position they believe their baby to be in antenatally?
- Can antenatal maternal posturing effect fetal position and outcomes?
- Can maternal posturing in labour effect fetal position and outcomes
- How can midwives and birth partners best support women with malpositioned labours for comfort and to improve outcomes?
- Do midwives and doctors facilitate or hinder movement in labour?
- How can we support high risk women to be mobile in labour? What about telmemetry and pool use/VBAC
- Should pool use be promoted to increase mobility?
- How does birth room environment design effect mobility?
- 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.