#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.
Reply to Catie Mehl of Columbus Birth & Parenting and Angela Horn from Tuscon doulas recently published blog posts about malposition.
Prevalence of OP prior to labour
Up to approx. 30% of babies are OP before labour begins.
Some studies have found that fetal position before labour does not affect birth outcome but others have found the opposite, in one study occipital position was found to be a factor in predicting successful induction 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
But the longer a baby stays OP in labour, the more likely they are to stay that way.
The deflexion associated with OP may be more important than the fetal position.
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
Malposition effects maternal and fetal outcomes
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
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
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
Sims’ posture on the same side as the fetal spine has been recommended to enhance rotation from posterior to anterior
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
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.”
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
“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
In a study using MR obstetric pelvimetry an upright birthing position significantly expands female pelvic bony dimensions, suggesting facilitation of labor and delivery
Women with epidurals that change position (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. Peanut balls have also been found to improve outcomes for women with an epidural. 
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
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
Is operative birth necessary?
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’.
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
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
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. or longer with an epidural although the safety of this is contested by some. 
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
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
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 
Even after arrival at a health facility mean waiting time for women admitted with complications was as much as 24 h before treatment.
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
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]
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
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) 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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Catie Mehl of Columbus Birth & Parenting and Angela Horn from Tuscon doulas recently published blog posts about malposition.
Does baby’s position matter in labor? (Part 1 and 2)
These two women presented on this topic at the 2015 ProDoula Instilling Strength Conference. Their presentation, “OP Babies: A Real Pain in the Ass,” examined common misunderstandings of OP babies and back labor and examined current body of research on these topics.
I would argue that the post might have benefitted from some literature searching support as there are many more studies looking at malposition and posterior presentation that have been published in the past twenty years (a quick search on google scholar shows these number into the thousands) than the twenty they read.
In Part 1 (Catie Mehl of Columbus Birth & Parenting) states:
You can’t prevent a posterior baby and start and stop labor is not because baby is OP
There have been few studies that directly looked at the association of fetal position and length or prevalence of prodromal labour. We do know that women that present to their chosen place of birth before active labour are more likely to go on to have more interventionsand prolonged latent phase (as well as PROM) has found to be a predictor of failed induction.
I have previously discussed this in my blog post here:
An OP position might not stop someone going into labour but it is associated with prolonged pregnancy and we also know that lack of fetal head engagement predicts prolonged pregnancy. [4 5]And that fetal head above the inter-spinal diameter and poor fetal head-to-cervix contact are associated with dystocia in labour. Descent of fetal head is correlated to dilatation of the cervix, and cervix dilatation < 4 cm at admission was associated with an increased risk of dystocia. Women admitted with little cervical dilatation may have unbearably painful contractions. High risk of dystocia in women admitted in early labour has also been found in many studies 
As the blog author states, OP babies tend to be deflexed and another study by Ashour et al. found that in women undergoing induction of labour, prediction of outcome can be provided by determining sonographically the preinduction cervical length, occipital position and degree of flexion of the head which were superior to Bishop score in predicting successful induction.
So this means that OP (and other malpositions) effect flexion and fetal head engagement which can lead to prolonged pregnancy and long latent phase/prodromal labour which is all in turn associated with longer labour more intervention in labour, failed induction, instrumental and CS delivery.
The authors then go on to state: “There is a belief that a person can prevent an OP baby by maintaining specific postures and avoiding others during pregnancy.”
I would agree that the evidence supporting the beliefs that OP is always a problem in labour and is also the only malposition that can effect starting labour and progress of labour is false.
My own position is that whether a malposition is a problem for an individual diad will depend on many factors-
- Pelvis shape/size
- Uterine ligaments
- Baby size
- Baby position (this can also encompass flexion (chin tucking) asyncliticism and arms above the head
- Mothers health both pre pregnancy and in pregnancy (diet and exercise)
- Mothers mobility in labour
- Mothers pain relief in labour
There is no one ideal position. Flexion (which can be effected by fetal position), asyncliticism (Asynclitism is one of the most frequent malpositions of the fetal head, occurring during both first and second stage of labor. Any fetal head position may be associated. OT position is frequently associated with asyncliticism. If the fetal head does not rotate at mid pelvis (spines) to OA or OP this may lead to deep transverse arrest) compound arms, fetal size and position (of both head and trunk) can all effect labor.
There is also little current evidence that it is possible to prevent malposition prior to labour (and as the authors state, the majority of malpositioned babies, rotate and can be born vaginally). Although we do know that the longer a baby stays in a malposition in labour, the more likely it is for them to stay that way. but…
“no evidence of effect” is not “evidence of no effect”
The evidence for maternal posturing in pregnancy to prevent malposition is currently weak. Is this because the right studies haven’t been done yet? Many of the studies finding no effect in pregnancy randomised women to interventions like Hands and knees rocking with pelvic rocking from 37 weeks (for 10 minutes twice daily ) had no effect on POP or outcomes and a Cochrane review concluded that use of hands and knees position for 10 minutes twice daily to correct occipito-posterior position of the fetus in late pregnancy cannot be recommended as an intervention
Those of us that work with women with malposition in pregnancy might see these interventions that have been studied as too little to change outcomes.
There is evidence of the benefit of general fitness in pregnancy on improving outcomes, and also birth ball use (it has been postulated that vigorous circles on the birth ball may aid flexion of the fetal head). A physical exercise program during pregnancy is associated with a shorter first stage of labor
I agree that the evidence is not strong that back pain in labour is due to fetal malposition (at least not always) but excessive pain, especially in early labour is associated with dystocia (which is associated with malposition) and more frequent breakthrough pain during epidural analgesia is common in dysfunctional labors  a recent study found that mothers who experience high levels of pain during pregnancy (lower back and pelvic pain which the authors postulate may be due to occurrence of malpositioning of the fetus during pregnancy.) are at increased risk of complications during labourand the authors go on to say that further investigation into the role of pain during pregnancy, fetal position and birth outcomes is necessary.
There is a large body of evidence that malposition effects women’s pregnancies, and can lead to pain in pregnancy, prolonged pregnancy, longer pre-labour and birth outcomes. There is currently little research that has found evidence of an effect of interventions on preventing malposition. OP is not the only malposition that can effect pregnancy and labour outcomes this is partly due to paucity of rigorous studies that use the range of methods currently being utilised by midwives and doulas..[18-21]. There is evidence for exercise in pregnancy to improve birth outcomes and reduce length of labour, pain and need for augmentation, assisted delivery and CS
I will address Part 2 of the blog (Does baby’s position matter in labour and can we do anything about it?) in a subsequent post
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- LI Y-h, WU N, ZHUANG W. Effect of birth ball exercise combined with free maternal position on labour pain, sense of labor self-control and gestational outcomes. Chinese Journal of Nursing 2013;9(011)
- Perales M, Calabria I, Lopez C, et al. Regular Exercise Throughout Pregnancy Is Associated With a Shorter First Stage of Labor. American Journal of Health Promotion 2015
- Capogna G, Camorcia M. Analgesia for Dystocia and Instrumental Vaginal Delivery. Epidural Labor Analgesia: Springer, 2015:153-66.
- Brown A, Johnston R. Maternal experience of musculoskeletal pain during pregnancy and birth outcomes: Significance of lower back and pelvic pain. Midwifery 2013;29(12):1346-51
- Young D. The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia. Birth 2012;39(1):85-86
- Tussey CM, Botsios E, Gerkin RD, et al. Reducing length of labor and cesarean surgery rate using a peanut ball for women laboring with an epidural. The Journal of Perinatal Education 2015;24(1):16-24
- Abdolahian S, Ghavi F, Abdollahifard S, et al. Effect of Dance Labor on the Management of Active Phase Labor Pain & Clients’ Satisfaction: A Randomized Controlled Trial Study. Global journal of health science 2014;6(3):p219
- Cohen SR, Thomas CR. Rebozo technique for fetal malposition in labor. Journal of Midwifery & Women’s Health 2015;60(4):445-51
I received a text message yesterday to say a woman I had worked with the day before had felt her babies foot kicking n the upper left of her belly! She was on the way to a presentation ultrasound scan (at 35 weeks) and we had done a one to one rebozo turning session the day before (Spoiler: baby was now head down!)
I have been offering malpresentation one to one sessions in the North West (and North/Mid Wales) to encourage babies to turn head downwards and stay head down. I use a variety of techniques including rebozo and Spinning babies.
Babies position in the womb is usually head down by 32 weeks (the head becomes heavy enough at 5-7 months for gravity to pull it downwards resulting in a vertical position) prior to this babies are usually transverse (until 24-26 weeks) or breech (24-29 weeks).
Due to the shape of the uterus babies usually stay in this position (unless the uterus is stretched after many pregnancies when babies can often change position-this is known as an unstable lie).
A malpresentation is a position in the uterus that is not head down (breech, transverse, oblique).
If a baby is not presenting head down towards term, women may be offered an ECV (external cephalic version) to try to turn baby round, or women may opt to birth their baby vaginally (if breech) or plan an ELCS .
I will be publishing a follow up post looking at the evidence on ECV, breech vaginal birth and ELCS for malpresentation.
There are also a number of alternative techniques that women may try to encourage baby to turn head down (including yoga, acupuncture, moxibustion)
I have supported a variety of Mums… including twins (both head down at term and born in a MLU at 40+4), First time mum with an oblique baby at 36 weeks to turn head down, transverse at 38 weeks to turn head down and breech.
Tips for malpresenting babies:
1 Use rebozo manteada followed by inversion for 30 secs, 3 times in a row to promote balance and relaxation in the uterus.
2. Use rebozo of the bottom/hips, in knee chest for 5-10 minutes to help back baby out of pelvis
3. Use turning rebozo technique
After the visit women can continue doing inversions (up to 3 in a row, 3 times a day) followed by breech tilt for 10 minutes
If baby turns head down, she will feel feet kicking where the head was, so in the top right or left of womb.
Some women who have had many babies may benefit from wearing a support belt once baby is head down, this can be a physio belt or a sling can be used
There is a clinical trial underway looking at rebozo use as an adjunct to ECV for breech babies
“Selina came to visit me twice to help turn my baby from transverse to breech to head down and engaged. Using a mixture of rebozo, pelvic tilts, inversions, ball circles and moxibustion. Also a little shoulder massage at the end which helped me to relax after my exercises. Fantastic work, saved me from being poked and prodded getting baby manually turned at the hospital or ending up with a c-section. Cannot thank you enough”
“I’m nearly 37 weeks now with my second baby and was told at 34 weeks… by my midwife that my baby was breech. Selina came to my house to do a one-to-one session to provide advice on techniques I could use to encourage the baby to move to the right position. I found the session very relaxing and really useful in understanding the different techniques and how best to do them. I have been doing them for the last week and today I had a scan which has shown the baby has moved to the right position 🙂 this has made me feel very happy and relieved as I want to have a home birth and the hospital had been advising if the baby was still breech I would have to have a c-section. A lot of the exercises Selina has taught me will also be great for labour and I hope to have a relaxing, peaceful home birth. Thanks Selina for your help and advice. (has since had a sucessful homebirth”
UPDATED (2017) to include a section on the effects of adverse experiences on healthcare professionals, organisations and the wider community
“You know being born is important.
You know that nothing else was ever so important to you.”
(From ‘Being Born’ a poem by Carl Sandberg)
The Kirkup report was published after an independent investigation into the Morecambe Bay NHS Foundation Trust after the deaths of 19 babies and two mothers. The unit was described in the report as ‘seriously dysfunctional’ and that Midwifery actions to support ‘normal birth’ were partly to blame:
“…midwifery care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care… We…heard distressing accounts of middle-grade obstetricians being strongly discouraged from intervening (or even assessing patients) when it was clear that problems had developed in labour that required obstetric care. We heard that some midwives would “keep other people away, ‘well, we don’t need to tell the doctors, we don’t need to tell our colleagues, we don’t need to tell anybody else that this woman is in the unit, because she’s normal”. Over time, we believe that these incorrect and damaging practices spread to other midwives in the unit, probably quite widely.”
The Kirkup report about maternity care in Morecombe bay highlighted the apparent dichotomy between the ‘normal’ and ‘safe’ birth agendas. Proponents from both of these agendas claim to be interested in healthy mothers and babies.
“Midwives and obstetricians should be on the same side of the fence, but they’re still too busy trading insults over it about whose garden is better. Meanwhile, pregnant women are left to one side unsure of who to trust, pulled in opposite directions by competing cultures who both claim to provide the best care for them.”
When we say we all want a healthy mother and baby, what do we mean? It’s not so simple…
The World health organisation (WHO) definition of health (1946) is that: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Public health looks at the determinants of health, from individual health behaviours to social, economic and environmental conditions.
A mother has a fast, intervention free physiological birth, but she is shouted at by staff as things are happening quicker than anticipated. She is frightened and traumatised and struggles to bond with her healthy baby because she believes she endangered him.
A woman has a long, difficult induction, her baby is malpositioned and there are lots of changes of staff. She has over 25 vaginal exams by eight different people. She labours to 9cm but then needs an EMCS which she feels was caused by the induction. She has flashbacks and cannot drive past the maternity unit where she laboured.
A mother has a good birth experience and her baby is healthy. But she is frightened to go home because her partner has started drinking more whilst she has been pregnant. He gets in her face and shouts at her. She’s worried what he’s going to do if the baby cries.
Would you consider the women in these vignettes safe?
We need to recognise that there are lots of layers to concepts like ‘risk’ and safety’ in pregnancy and childbirth.
In 1997 the World Health Organisation published the following definition of a NB “Spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously [without help] in the vertex position [head down] between 37 and 42 completed weeks of pregnancy. After birth mother and baby are in good condtion.”
Does this mean that women that are high risk at the start of labour or women that become high risk in labour can’t go on to have a normal birth?
In 1997 Beverley Beech from the Association for Improvements in Maternity Services (AIMS) defined NB as “a Physiological Birth where the baby is delivered vaginally following a labour that has not been altered by technological interventions”. Specifically excluded from this definition were births that had had artificial rupture of membranes, induction or acceleration, epidural anaesthesia and episiotomy.
Variation in intervention rates
Intervention levels vary between maternity units, even those with similar demographics and levels of pregnancies with increased risk factors. In the US a recent study of over 41,000 low-risk women having their first babies in 20 California hospitals found caesarean rates for this population ranging from 11% – 30%. Statistical analysis found that over half of the variation between hospitals was a result of differing obstetric practices (Main et al, 2006).
Health outcomes related to birth interventions
Intervention in the birth process, whilst intended to reduce mortality and morbidity, may lead to negative health outcomes including increased likelihood of infection, on-going pain, or negative birth experience (Goer et al, 2008) which, may increase the likelihood of women developing post natal depression (PND) or post traumatic stress disorder (PTSD) (Creedy et al, 2000).
However it is also recognised that babies die and are left disabled after preventable events during pregnancy and labour.’ Each Baby Counts’ is the RCOG’s national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. TheRCOG estimate that In the UK, each year between 500 and 800 babies die or are left with severe brain injury because something goes wrong during labour. The Each Baby Counts project we are committed to reducing this unnecessary suffering and loss of life by 50% by 2020.https://www.rcog.org.uk/eachbabycounts
Benefits of birth without intervention
Women who give birth without intervention tend to have less post-natal pain and recover more quickly than those who have had interventions such as a forceps delivery or an episiotomy (Carroll et al, 2003). The length of time it takes to recover physically has implications for other areas of post-natal life, including self esteem (Llewellyn and Osborne, 1990), bonding, increased breastfeeding (Ransjö-Arvidson et al, 2001) and decreased Post Natal Depression (Sutter-Dallay et al, 2003; Soet et al, 2003).
Long term effects of difficult birth experiences
Some studies have found that women remember their births clearly, for example Takehara (2014) found that women remember their childbirth experience clearly 5 years later. Another study by Simkin (1992) found that two decades after birth, women’s memories were accurate and vivid, especially: onset of labor; rupture of the membranes; arrival at the hospital; actions of doctors, nurses, and partners: particular interventions; the birth; and first contact with the baby.
Disempowering experiences during childbirth have been found to persist throughout the lifetime, one study demonstrated that the effects of harsh and humiliating treatment, experienced by a number of Swedish women in antenatal care and childbirth in the mid-20th Century, endured for the rest of their lives.(Forssen 2012)
What happens when caregivers and women disagree about how to have a healthy birth?
There are instances when midwives and doctors might disagree on the best way to have a healthy birth or the parameters that make up a ‘normal’ labour, or at what point, deviation from normal becomes unsafe.
Several studies have indicated that at times midwives ‘do good by stealth’ by actions such as not doing vaginal exams so that women’s progress cannot be recorded on a partogram which could trigger interventions due to the crossing of the ‘action line’. This would then give more time for a slow labour to progress, and there is no consensus internationally on the speed at which the first or second stages of labour should progress.
One example of this ‘good by stealth’ is described on a study looking at midwives in Belgium
“Midwives considered themselves as advocates of normalcy and used different strategies to avoid interventions. Only some midwives openly negotiated with obstetricians about care. They were willing to ‘walk on the edges of the hospital rules’ to obtain normalcy. One midwife gave the example that when an obstetrician asked ‘rupture the membranes next time you examine the woman’, the midwife simply did not examine the woman. She thus ‘obeyed’ the obstetrician while at the same time she gave the woman what she thought she needed. One midwife also found that there was a strong sense of ‘social control’ between the midwives to strive for normalcy.”(Van Kelst 2013)
The study states: devious ways were required in order to achieve objectives that could not be voiced clearly and directly
This to me is the key issue. Lack of communication between health professional groups and women.
A study in Spain (del Roasarion Ruiz 2014) look at midwives and clinicians agreement on clinical practice guidelines for normal birth and found that:
“Midwives and obstetricians often have significantly divergent levels of agreement on key recommendations. The participating midwives saw pregnancy and childbirth as normal events, which should be treated accordingly. In their views obstetricians emphasised risks and hereby sometimes even ‘created’ pathology”
But many clinicians agree that our drive to reduce risk can cause harm at a population level. On one obstetricians blog he states: (http://ripe-tomato.org/2015/04/11/jims-tweet/)
“There is a battle here, and some truth on both sides. Modern obstetrics, the stuff I do every day, is obsessed by reducing risk. Caesareans for breeches, antibiotics for positive group B strep swabs, and heparin for anyone with a risk factor for thromboembolism are all unnecessary most of the time, but heaven preserve the doctor who skips them if a bad outcome occurs.
Our obsession with safety has a cost. It causes anxiety. Fetal monitoring does lead to unnecessary Caesareans. People popping in and out of rooms to review progress, give antibiotics and check heart beats, stops women relaxing and may actually slow labour.
And supporters of natural childbirth are right. Hospitals are not perfect. Too many women still labour on their backs. Doctors make stupid decisions. And even if we were perfect, it might still sometimes be better to take a bit of risk to allow nature to take its course.”
In situations where care givers disagree it has been shown that pregnant women have intervened where communication suboptimal. “They did this by rectifying information flows between community midwives and obstetric caregivers.”(Schölmerich 2013)
When factors that contribute to preventable harm in obstetric care are investigated we find that failure to communicate is prominent. (Berlung 2012)
“Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality”(Lyndon 2015)
Sometimes interventions have unexpected consequences, one example is the introduction of the clinical pathway for normal labour (Normal Labour Pathway) implemented in Wales, UK which aimed to support normal childbirth and reduce unnecessary childbirth interventions by promoting midwife-led care. A study was conducted to look at how the pathway influenced the inter-professional relationships and boundaries between midwives and doctors .It stated that:
“The ‘normal labour pathway’ was employed by midwives as an object of demarcation, which legitimised a midwifery model of care, clarified professional boundaries and accentuated differences in professional identities and approaches to childbirth. The pathway represented key characteristics of a professional project: achieving occupational autonomy and closure. Stricter delineation of the boundary between midwifery and obstetric work increased the confidence and professional visibility of midwives but left doctors feeling excluded and undervalued, and paradoxically reduced the scope of midwifery practice through redefining what counted as normal.”
Midwives training emphasises the benefits of physiological birth, but medical training does not appear to have the same emphasis. One trainee obstetrician shared her experience of colleague’s reaction to the sharing of her birth story.
“I’m a doctor training in obstetrics. I had a homebirth with my first baby. This week I was on a course in London with other junior doctors in obstetrics. I mentioned in passing that I’d had a home birth and was quite viciously attacked by 3 doctors I didn’t know. I’m used to raising an eyebrow or two, but have never had anyone be so rude to me. Words used included ‘mad’, ‘stupid’, ‘crazy’ and not in a nice, jokey way. One even said that homebirth was basically ‘mimicking 3rd world conditions’. I laughed out loud at her and pointed out various reasons why that was a ridiculous comparison. I quoted the statistics on why primips transfer to hospital (ie ‘failure’ to progress rather than acute emergencies etc)… but deep down I was really hurt by their attitude to me and to the women they look after. I just don’t understand some doctors and how they interact with their women… Surely it’s our job to provide information and give women the ability to make informed decisions, even if we don’t agree with them. The thought of these docs meeting one of you guys in a clinic makes me so sad at how they might behave.”
Midwives can also be dismissive and ridicule women’s birth plans and hopes, as has been featured on the Television series ‘One born every minute’.
Where does this lack of communication and teamwork leave women?
Women that experience traumatic births and go on to have another pregnancy need to reengage with health professionals to plan for a subsequent birth. This experience can profoundly shape the choices they make and whether they feel able to move forward feeling empowered or retraumatised.
Three women agreed to share their stories to enhance our understanding of the implications of good or bad communication:
Her first birth was an induction and her daughter was born 3 days later by EMCS:
“I demanded the section after I started to feel the trauma of the internal exams during the 3 day failed induction. When they said I could have a section instead it was like I went to heaven, it meant they wouldn’t touch me again or perform any more examinations.”
Clare really wanted to have a natural second birth. She organised to have a VBAC in a birth center, but at 37 weeks, was told it had now been decided that she could no longer birth there as she had had a previous cesarean.
“They wouldn’t support my wishes to birth on the birth suite because I’d had a previous section after telling me throughout my pregnancy that it was arranged. Called me in at 37 weeks saying I wasn’t welcome on the birth suite and if I insisted on birthing there then I wouldn’t be able to have a birth centre midwife and would have to be continuously monitored. Then when I sent an email in telling them how heartbroken I was they sent an email back telling me they’re sorry they couldn’t help me.”
She then transferred care to another trust that supported her wishes to have a homebirth. She got the pool set up and waited for labour to start, only to go overdue.
“One thing after another. Fighting with everyone. Changing my care. Justifying my wishes. Finding supportive people then to be let down. And then I had it sorted finally at 39 weeks preg I got my pool and was finally ok! Only for my body to not trigger labour. The panic is setting in”
Clare kept on waiting for labour to start, until:
“The scan showed decreased fluid today. Fluid was 4.5 just 5 days ago and is 2 today! So has decrease by half in 5 days and they said can be a sign that placenta isn’t working as well as it was. I’m 15 days overdue now. I’m not wanting to push past 15 days over (my mum went 3 weeks over with devastating results) so the worst case scenario is very close to home. So I requested a natural section. Where they drop the curtain and let you see your baby be born and the baby then goes straight onto your bare chest for skin to skin and all checks are carried out on your chest. I’ve seen the videos of this in the uk. Hospital flat out refused to consider dropping the curtain”
“Can they refuse me? It’s my baby. I want to see him born!! I can’t believe you can have a birth plan for a natural birth but you can’t for a section. It’s still a birth!”
Clare did her best to find a Trust or surgeon that would support her, but was increasingly being pushed into a corner where she either continued going further overdue with reducing fluids or gave up on her birth plan of a natural cesarean.
But at the very last minute, a consultant rang her at home, at night, to say that she had facilitated similar wishes in ELCS and as she was working nights over the weekend, she would add the CS for Clare on to the end of her shift in the morning.
“We did the gentle cesarean and it was the most amazing thing in the world. I watched him come out, They didn’t push at all. They let my uterus contract him out but by bit, first his head, then one shoulder, then the other, then his tummy, hips and legs! He was so calm during the first bits but once he was out to his tummy area the cool air put have hit him and he cried abit but I reached for him and as soon as he was on me he stopped and was calm, sniffed me and started searching for the nipple whilst he was having delayed cord clamping. It was truly amazing! They treated it completely like a vaginal birth! The obstetrician was amazing. I felt in complete control. . It would be easy to say that I could have gone on waiting to go into labour for longer and perhaps got my homebirth…but I’m so happy with the experience we had that there’s no point in feeling that way. For a second choice…it was perfect! No regrets. ! I really do feel that it was meant to be this way now, I can’t imagine it another way. I honestly don’t even think I’ll cry when I get home tomorrow and pack away the birth pool!
There needs to be a change for women who find themselves in a disappointing situation and they need to still be respected as a birthing mother instead of a patient. I even wrote a birth plan and they all took it very seriously! Second plans aren’t always so bad when supported by the right kind of people”
Describing her second birth:
“Despite it having huge potential to be very traumatic the care I’ve received has meant it was positive, and as a result I’m coping much better with life postnatally.
Pregnancy was littered with issues – high BP, low fluid around baby, small for dates, and repeated reduced movements in the third trimester. I was desperate for a “natural” experience, primarily because my first birth was a horrific induction ending in PPH. When Drs said they wanted to induce me at 39 weeks for RFM and small measurements I freaked out and refused. Some guidance and clarity from people on this group (MatExp) , and a clear discussion with a Dr next day helped me feel able to agree to the induction, although I knew my baby wasn’t ready to be born.
The MW who induced me was one I knew from clinic. She knew about my anxieties and was so supportive all day, offering me my own room even though they usually induce you on a ward, and just having a chat when my husband went to get himself lunch etc. Little things but important ones. At change over I met our night mw and her student. By this point I was contracting so they broke my waters. My birth plan stated I wanted to be mobile, but she really wanted to monitor me constantly. We ended up with me sitting at the end of the bed while the student held the monitor for baby on my belly and I gave a sign every time I had a contraction which they wrote down. This meant I didn’t need to go on the sintocin drip and maintained mobility despite it clearly being being a total pain for the midwives. I achieved a pain relief free labour mostly due to this I think.
At 7cm dilated they lost baby’s trace and asked my permission to put one on his head. I agreed and just as well I did as it became immediately clear that he wasn’t happy. His heart rate was at 30 bpm and not increasing, I was put on my side and it stayed low. The mw in charge and Dr came in. Both asked permission to examine me and both introduced themselves. They called a category one c section and even then they explained everything to me. We were running down a corridor with me on the trolley and a midwife found the time to hold my hand and tell me we were going to be fine. In theatre she sat by me and kept hold of my hand. Every single person in that room told me what they were doing and why. When they delivered him he was totally wrapped up in his cord. They’ve since said he wouldn’t have made it if he hadn’t been delivered there and then. I’m told baby was given almost immediate skin to skin with my husband, and as soon as I was awake he was placed skin to skin with me and that was how we stayed for 24 hours.
So many people from that night came in to see us over the next couple of days. They didn’t have to but they did. All just wanted to hold Oliver and check I was ok. The biggest thing about all of this for me has been the genuine care and compassion as well as total honesty about everything. Last time things were brushed aside or down played which made me feel like I was over reacting. Emotional Care is so important for new Mums and Dads and in our case made the difference between a positive and negative experience.”
“My first birth was traumatic… I felt disrespected by my hcps. I was not able to make informed consent. I was not supported to achieve my birth goals and I ended up with an emcs. As a result I developed distrust of the hcps in my local maternity unit.
For my second pregnancy I chose to sit outside the system and hired independant midwives. I chose to birth at home against consultant advice as I didn’t trust them to look after my best interests. I put in a lot or work and effort to prepare myself for a natural birth which payed off as I had a wonderful birth.
But i was very unlucky, my baby was born not breathing 40 minutes away from hospital from which he has sustained serious brain injury and will live with serious life long disabilities.
Now I will spend the rest of my life wondering whether I should have gone against every instinct in my body and done as I was told by people I didn’t trust. If I had done that would my son have arrived safely??
There is no doubt that the interventions they employed after birth saved his life for which I am grateful. And it is likely he would have had a better outcome if he’d been born in the hospital, if I’d been hooked up to cfm. What a shame that my trust had been completely abused and destroyed first time round.”
Nicola said about her birth “Although there were a few reasons why my birth was considered high risk, myself and my midwives went to great lengths to manage and monitor those risks. In the end none of those risks presented themselves. We were just desperately unlucky. Birth is inherently risky. We rolled the dice thinking it wouldn’t happen to us and we lost.”
What can we learn from these women’s stories?
It is vital that women are listened to, respected, treated like competent human beings and that health professionals work as multidisciplinary teams with one goal, a healthy baby and a healthy mother, on all levels.
Women that are disrespected, coerced, humiliated, terrified or traumatised lose respect for health care professionals and become hard to reach, if their attempts to communicate in a second pregnancy are met with rigidity, refusal or ridicule then women can feel pushed into making choices that take them outside of conventional care.
Interprofessional fighting increases risk to women and babies.
Where does this lack of communication and teamwork leave professionals and organisations?
Witnessing adverse events can lead to trauma to health professionals and can have long term effects also on the wider community and organisations community of practice. Both midwives and obstetricians have reported sleep disorders and depressive symptoms (Shroder 2016) and failure to acknowledge and deal with guilty feeling (even with no fault) can effect self forgiveness (Shroder 2017) the authors suggest “that the narrow focus on medico-legal and patient safety perspectives is complemented with moral philosophical perspectives to promote non-judgemental recognition and acknowledgement of guilt and of the fallible nature of medicine.”
Obstetrician Mary Higgins in a blog post for the BMj talks about the ‘fourth victim’ after adverse events which are future patients, and suggests witnessing adverse events can both harm and improve future practice. A study by McNamara (2017) corroborates this view and suggests that while there was some positive gains for HCPs following an intrapartum fetal death, the majority of their experience was negative. There is currently a lack of training and support for staff, teams and organisations to prepare for and deal with witnessing adverse events during childbirth and support systems should be put in place.
- Health professionals need to understand the importance of communication and teamwork, both inter professionally and with women.
- Medical education should emphasise physiological birth and ways to facilitate this for women, placements on community where students could have the opportunity of attending homebirths could be considered
- Measures to improve cohesion between multidisciplinary maternity teams should be considered, staff morale will be improved by establishment of a Community of practice and adequate staffing. Continuity of care would improve safety of mothers and babies
- Education should be provided to students and staff on self-care and training in adverse outcome (emotional) management .
- Consideration should also be given towards the development and maintenance of Schwartz Centre rounds in maternity hospitals
- Physiological birth and safety are not mutually exclusive
- Safe physiological birth leads to healthier mothers and babies in the short and long term
- Women want support for birth choices which increase their chances of a physiological birth, they want access to water, mobility, privacy, the option of a natural cesarean
- Technology exists and is being used in units in the UK to allow continuous fetal monitoring (CFM) that does not restrict mobility and can be used in water
- Women whose hopes and plans for birth are respected and taken seriously, are more likely to feel that care givers are on their side, care for them and want to ensure the safety of them and their baby, they are then more likely to trust their opinion if circumstances change, and negotiate a birth that is both safe and leaves them feeling happy, empowered and untraumatised.
Mobility and CFM
VBAC in water
Commissioning for safe healthy births
Ethics and VBAC
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Schölmerich, V. L. N., Posthumus, A. G., Ghorashi, H., Steegers, E. A. P., Waelput, A. J. M., Groenewegen, P., &Denktaş, S. (2013). Improving interprofessional coordination in Dutch midwifery and obstetrics. European Journal of Public Health, 23(suppl 1), ckt123-161.
Simkin, P. (1992), Just Another Day in a Woman’s Life? Part 11: Nature and Consistency of Women’s Long-Term Memories of Their First Birth Experiences. Birth, 19: 64–81. doi: 10.1111/j.1523-536X.1992.tb00382.x
Soet, J.E., Brack, G.A., Dilorio, C.D., 2003. Prevalence and predictors of women’s experiences of psychological trauma during childbirth. Birth, 30(1), p36-46.
Spitz, B., Sermeus, W., & Thomson, A. M. (2013). A hermeneutic phenomenological study of Belgian midwives’ views on ideal and actual maternity care. Midwifery, 29(1), e9-e17.
Sutter-Dallay, A.L., Murray, L.E., Glatigny-Dallay, et al., 2003. Newborn behavior and risk of postnatal depression in the mother. Infancy, 4:4, 589-602.
Takehara, K., Noguchi, M., Shimane, T., & Misago, C. (2014). A longitudinal study of women’s memories of their childbirth experiences at five years postpartum. BMC pregnancy and childbirth, 14(1), 221.
WHO (1946) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948
*Updated June 2018
There are several situations when it is preferable that labour start sooner rather than later. These include-
- prolonged pregnancy (although the WHO recognises than normal human gestation at term is 38-42 weeks many women, especially older mothers have pressure put on them to accept induction from 40-40+10 days, due to a potential increased risk of stillbirth)
- Elevated blood pressure (gestational hypertension at term)
- Women with type 1 or 2 diabetes at term
- rupture of membranes at term without labour
Although some women are happy to accept induction, others would prefer labour to start naturally or are planning to birth at home so do not want o go into hospital for induction.
I have been offering a ‘Starting labour’ one to one session (in the North West and Wales, UK) for the past few years and have had good results (the majority of women going into labour within 24 hours) although some people have required one or two more sessions and two people have had two sessions and not gone into labour (one was induced, the other went into labour a week later at 43 weeks and had a physiological birth).
Disclaimer: You must not rely on the information on this website as an alternative to medical advice from your doctor or other professional healthcare provider. If you have any specific questions about any medical matter you should consult your doctor or other professional healthcare provider. If you are worried about your babies movements please contact your midwife http://www.countthekicks.org.uk/
The session uses a variety of techniques to try to increase the chances of labour starting by looking at-
- baby position (there is evidence to suggest that prolonged pregnancy is associated with fetal malposition). This post suggests that baby position may effect bishop score http://wellroundedmama.blogspot.co.uk/2012/02/induction-math-importance-of-bishop.html
Starting labour session techniques
I usually start the session by talking to women about their pregnancy, any previous births (this can give clues about issues which may cause recurrent malposition) family history (some women just have longer gestations, if pregnancy is prolonged in each pregnancy and/or there is a family history or longer gestations) and do some belly mapping https://itaintthathard.wordpress.com/2012/10/02/belly-mapping-its-fun/ to see if we can work out if baby position might be affecting labour starting.
Women with too much waters (polyhydramnios) may want to avoid inversions (and anyone with severe high blood pressure)
This is my basic routine and I suggest you try to follow this both in sequence and frequency, without missing out bits if possible (some of it will need a birth partner to help) and can be done in early labour too
- 2 to 5 mins of rebozo sifting (manteada) with you kneeling forward resting your harms/head and shoulders onto a sofa/chair, you can use a sheet or a cotton throw if you don’t have a rebozo http://spinningbabies.com/techniques/activities-for-fetal-positioning/rebozo-sifting
- an inversion http://spinningbabies.com/techniques/the-inversion I would do this 3 times in a row (manteada followed by inversion), when you does the inversion you can wiggle your hips about.
These two techniques combined help the uterine ligaments relax and straighten, resulting in balance which will help baby be able to move into a position which allows engagement and rotation to fit down into the pelvis
*The first study to describe rebozo use for malposition was published in August 2015. There are currently no published studies looking spinning babies techniques (including inversion) in pregnancy or labour
After each rebozo session (or as one 5-10 min session afterwards) you can do some bottom/hip rebozo too and shaking the apples. (wrap the cloth around the bottom, holding the ends close to the body, facing the bottom and shake vigorously like you were shaking an apple tree to make the apples fall down https://www.youtube.com/watch?v=64IiA6N7Ldw then do rebozo lying on back https://www.facebook.com/selina.wallis1/videos/10156451033199120/ this is a great technique if baby is back to back or lying on the right if baby is on the right, try to use some extra pulls on the left side of the rebozo to gently encourage baby to make the short rotation from ROP/ROT/ROA to OA. This should hopefully encourage labour to start by helping the baby to present the smallest part of babies head into the pelvis, putting more even pressure on the cervix for a quicker and easier birth
If you know or suspect baby is OP (back to back) these techniques may be helpful
- 3-10 mins belly dancing, , if you know how, do fig 8s etc plus hip drops, camel walk and shimmy, if you don’t know then copy this video http://www.youtube.com/watch?v=vqVANMw99cQ
Bellydancing has been used for centuries to teach young women about movements that help in childbirth. Bellydancing is also fun and promotes laughter and relaxation which can produce oxytocin and encourage labour to start
- Gentle back and shoulder massage with a carrier oil and possibly some Clary sage/neroli/lavender and then foot massage with acupressure points
A 2013 Cochrane review found one study with statistically significant evidence of a change in cervical maturation for women receiving acupuncture compared with the sham control
- 20 mins of gentle breast massage with oil working all the way round and in towards the nipple 3 times a day.
A Cochrane review in 2010 found breast stimulation appeared beneficial in relation to the number of women not in labour after 72 hours, and reduced postpartum haemorrhage rates and a pilot study in 2015 found that breast stimulation in low-risk primigravidas helps in cervical ripening and increases chances of vaginal delivery.
- 10 mins of vigorous circles on the birth ball (up to 3 times a day)
Ball circles are great to help baby flex (tuck) their head to aid rotation and aid enagement in the pelvis.
A small clinical trial in 2015 found that performing birth ball exercises for 4-6 weeks at the end of pregnancy found that when descent and rotation of fetal head was assessed at the beginning of the active phase. Women who had participated in the birth ball exercises had significantly more babies with descent of fetal head into the pelvis (70%) than the control group (40%) and Complete rotation of the fetal head (OA) (63%0 versus control group (33%)
“After a very straightforward pregnancy, I developed high blood pressure in the last few weeks, and found myself booked in for an induction, something I hadn’t really considered and wanted to avoid if possible. I felt very alone and ill equipped to make decisions, and really felt the need for extra support. I contacted Selina very late in the day – 38+6 and 6 days before I was due to be induced! – and she got back to me immediately and came out to see us on the same day. I was so grateful for how quickly she came round, and it was so important to me to be able to do something constructive and helpful with Selina – it really helped me feel like I had a bit of control back. Her techniques and support were invaluable and enormously calming, and seeing her was a great relief for both me and my worried partner. She left us with lots of exercises to do to help get things moving and help with the baby’s position – after spending a day belly dancing, hula-hooping on my birth ball and using the rebozo she very kindly lent us, I went into labour the following evening and was able to give birth to our beautiful daughter naturally at 5 am the morning after. I’m positive that Selina’s techniques helped and the many tips she gave us made me feel calmer, more empowered and so much less alone. I am so glad I got in touch – thank you so much for everything!” (Anna and Ben Slater, Liverpool)
“After having a very medicalised and quite traumatic birth with my first child, I decided I wanted… to have a homebirth for my second. With the support and advice from Selina and the Liverpool Homebirth Support Group, I became convinced this was the right decision. However, after going five days overdue, I became concerned that if I reached ten days, medically I could be advised against a homebirth. Selina gave invaluable advice and offered my a range of treatments including aromatherapy massage, rebozo and belly dancing. The next evening, the first signs of labour began, the morning after that I gave birth to our beautiful son safely at home. I can’t thank Selina enough for all she did, not only practically but emotionally she got me through to what was ultimately my desired birth.”
“Selina was kind enough to help me when my envisioned homebirth was in danger of turning into a hospital birth with emergency induction. . She did rebozo sifting, which I feel made all the difference! And some acupressure, used some essential oils and we had fun doing some bellydancing moves to jiggle the baby down. I had been niggling for two nights, but nothing regular. Two hours later however, my contractions were every 5 minutes and I had my baby within a few hours”
The report involved: literature review, interviews with the enhanced midwifery team, colleagues and third sector organisations, quantitative data analysis and a survey of women users
The Liverpool Women’s hospital EMT is made up of:
- Six experienced midwives providing vulnerable women in Liverpool with needs based individualised care
- Offered to women with significant mental health problems; alcohol or substance misuse, social services involvement or learning disabilities.
- Women get 1:1 care at home during the antenatal period and up to 6 weeks post birth.
In order to:
- Increase early access to antenatal care
- Improve public health outcomes (breastfeeding, smoking and alcohol, obesity)
- Reduce harm to ‘at risk’ mothers and babies
- The EMT act as an additional safety net to very vulnerable women and babies, they can gain access to women when many other services find engagement difficult and their close involvement with families can uncover hidden risks and dangers that could prevent tragic consequences for mothers and babies.
Summary QIPP points for EMT:
- Q‐ quality of maternity services for vulnerable women demonstrably improved
- I ‐ innovative use of partnership working and individualised care
- P ‐ EMT reduce DNA rates and time lost for Community midwives looking into DNA
- P ‐ prevention through reduced risk of adverse outcomes by engaging vulnerable women in maternity care
*A journal paper based on this work is in progress
A link to the Executive summary booklet is provided below:
“Ritual bathing, washing of hair, massage, binding of the abdomen, and other types of personal care are prominent in the postpartum rituals of rural Guatemala, Mayan women in the Yucatan, and Latina women both in the United States and Mexico” (Kendall-Tackett)
I was taught about the ‘Closing the bones’ ceremony by Stacia Smales Hill, Hilary Lewin and Rocio Alarcon, an ethno botanist from Ecuador, at the Doula UK yearly retreat (which I facilitate and the 2015 one starts tomorrow!). I was the most recent postpartum woman there so I was chosen to experience a closing with rebozo with a large group of women and whilst I began as an interested observer of the experience, I soon found myself moved to unexpected tears.
In the western world, the focus is on pregnancy and birth, not after baby arrives, this can leave women shocked and vulnerable, especially after a difficult or traumatic birth experience and unprepared for the physically and emotionally challenging task of caring for a newborn, usually without the help and support of other women in the community. In 2009 I co-wrote a chapter in the book ‘Essential Midwifery practice: postnatal care’ where we discussed ways to improve postnatal care:
“In many cultures the isolation and lack of support experienced by some mothers in the UK is simply eliminated through communal approaches to post natal care in which there is a tradition of caring for new mothers for forty days, with ceremonies to welcome the woman and her newborn back into the community.. Pillsbury (1978) found that the physical and emotional stresses following childbirth are well identified and managed by ritual in an indigenous community, so that the experience and likelihood of depression is minimized” (Nylander, S 2009)
When Rocio described how women in her community would visit women after they had their baby for forty days and bath and massage the new mother daily, I think many of us present felt envious of this sort of nurturing care which gives recognition to the profound opening that giving birth leaves us with, physically, emotionally and spiritually.
‘Closing the bones’ is a term used to describe a number of techniques used by many indigenous cultures including Mexican, South and Central American peoples and Asian societies like the Malay peoples in Malaysia who practice ‘Mother roasting’
“The use of heat –related practices marks as culturally and psychologically significant a biological-medical event” (Manderson, L. chapter in Van Hoover 2004)
Many practices involve heat, massage to ‘bring up the womb’ (possibly to help the uterus contract and prevent postnatal haemorrhage), application of heated stones or herbs, smoking and confinement to the home for usually approximately forty days. The stomach is bound with cloth (or a Rebozo). The herbs used often have anti-microbial and analgesic properties (de Boer 2011)
I have been taught a few of these techniques, although traditionally these are used by women’s families or local traditional birth attendants, every day or every few days post birth, Rocio Alarcon taught us that, if the ‘Closing the bones’ is never performed, that women are left open and vulnerable after childbirth, that their energy will continue to be lost, and this is why western women tend to have less energy than South American women!
She approaches women she meets in England and offers to close their bones, even elderly women can benefit from these techniques.
In my own practice I incorporate aspects of ceremony (setting intentions, releasing fears) with closing the bones massage and Rebozo techniques and sacred bathing as a way to support women to honour the journey they have made to motherhood, to think deeply about the paths they have trod.
“Ceremonial work helps us to create a bridge between our mind and soul, between the sacred and the mundane. Once we enter a ceremonial space we are reminded that the line between our everyday world and the world of our soul, or even the divine is fine and easily crossed. Ceremony provides experiences that our brain interprets as meaningful and can therefore be transformative” (Mackinnon, C 2012)
The experience can help women to process difficult and traumatic birth experiences and enable them to re-honour their bodies as healing, to bring back together parts of themselves that may feel fractured or absent, the part of themselves that existed before they became a mother, the part that went through the transformative experience of birth (and it is this that can literally or figuratively ‘shatter’ us, breaking us open to bring through the new soul) and the new part which is mother.
“Ritual and ceremony are highly efficient vehicles for accessing and containing intense emotions evoked by traumatic experience” (Johnson 1995)
“I found the ceremony very healing and calming, as well as emotional. It helped me to release some feelings and thoughts that I had been having since the traumatic birth of my daughter and allowed me some space in which to try and reconcile these feelings in some way. It also helped me to feel a sense of acceptance for what had happened and I felt it facilitated the process of me experiencing a feeling of closure that I had not had since the day she was born. Physically, the ceremony was beautiful, I felt very comfortable and safe with Selina and this helped me to relax and enjoy being ‘mothered’. I would not hesitate to recommend this ceremony to any new mother as beneficial to both their mental and physical wellbeing, especially if their labour was traumatic or did not go as they had hoped.” (Sam)
This postpartum practice can be used soon after birth up to many years afterwards and is deeply nurturing and extremely moving to facilitate, much like working as a birth doula were we strive to serve women and provide care as a (archetypal) mother would, so does the work of Closing the bones’ require a profound acceptance of what was, what is and a deep love for the individual who has allowed you to walk this path back towards wholeness with them.
“The day after I was exhausted and slept a lot. The day after that and continuing I’ve been buzzing! I feel sparkling, almost 100% back to being myself! Feeling very energised and can feel a big wave of creativity and enthusiasm building.
THANK YOU so much! Having you open and close the door to motherhood for me was perfect and I’m deeply grateful “ (Deborah)
“Selina facilitated my closing of the bones ritual with tenderness, wisdom and grace. I found the experience to be very therapeutic, with an empowering effect that has grow by the day since” (Rebecca)
- Kendall-Tackett K, How Other Cultures Prevent Postpartum Depression- Social Structures that Protect New Mothers’ Mental Health
- Nylander, S, Shea, C. (2009) Working with partners :Forming the Future, book chapter in ‘Partnership working’ in: Essential Midwifery Practice: Postnatal Care (Editors: Sheena Byrom , Grace Edwards and Debra Bick) Published October 2009
- Van Hoover, C. and Hunter, L. P. (2004), The Manner Born: Birth Rites in Cross-Cultural Perspective. Journal of Midwifery & Women’s Health, 49: 270–271. doi: 10.1016/S1526-9523(04)00096-0
- de Boer, H. J., Lamxay, V., & Björk, L. (2011). Steam sauna and mother roasting in Lao PDR: practices and chemical constituents of essential oils of plant species used in postpartum recovery. BMC complementary and alternative medicine, 11(1), 128.
- Mackinnon, C. (2012). Shamanism and Spirituality in Therapeutic Practice: Soul and Spirit Matter. Singing Dragon.
- Johnson, D. R., Feldman, S. C., Lubin, H., & Southwick, S. M. (1995). The therapeutic use of ritual and ceremony in the treatment of post-traumatic stress disorder. Journal of Traumatic Stress, 8(2), 283-298.
It has been suggested that a tissue called ‘fascia’ (a web of fibrous tissue that permeates the body) may play a part in malposition and dystocia. Some of the techniques that therapists and birthworkers use claim to ‘release’ the fascia (http://spinningbabies.com/learn-more/techniques/other-techniques/abdominal-release/)
But what do we actually know about the fascia and it properties from a scientific perspective?
There is an interesting collaboration between researchers and alternative therapists trying to find out more
But so far it appears that there is little convincing evidence that the fascia has the properties that many currently assign to it, or that it can be physically manipulated to release or relax
Are the numbers of women having posterior babies increasing? Historical references to the Occiput Posterior position
It has been suggested that malposition (and occiput posterior presentation) has been increasing in incidence and also that one cause of this may be our sedentary lifestyle.
In Jean Sutton and childbirth educator Pauline Scot’s book, ‘Understanding and Teaching Optimal Foetal Positioning’ they theorise that our tendency to sit back and relax on soft, semi-reclining furniture like sofas and armchairs as we watch television, and spend more time driving ( in “bucket” car seats), rather than walking, may contribute to the incidence of posterior babies. It is also suggested that historically ‘women’s work’ in the home like, scrubbing floors on hands and knees and also a ladylike posture and good deportment promoted proper alignment of the fetus in the pelvis during the last few months of pregnancy.
Gail Tully at ‘Spinning babies’ agrees that the modern lifestyle is to blame; and also that research studies prior to ten years ago saw a lower incidence of posterior position.
“There is a rising incidence of posterior babies at the time of birth. The high numbers of posterior babies at the end of pregnancy and the early phase of labor is a change from what was seen in studies over ten years old. Perhaps this is from our cultural habits of sitting at desks, sitting in bucket seats (cars), and leaning back on the couch (slouching).”
The current estimates of posterior presentation range from 12-40% prior to labour, 15-50% in the first stage of labour, 19-25% at 10cm dilation and approximately 20% of babies that are OP at 10cm are still OP at delivery (with a range of 3.8 to 12.2% (mean = 7.6%) (Blasi et al 2010, Malvasi et al 2013, Verhoeven et al 2012)
Historical prevalence of OP position
I was interested to see what historical references to posterior position, prevalence and management could be found in the literature. The earliest reference e to OP position I could find was by WILLIAM D. PORTER, M.D. who published a paper in 1929 in the American medical association journal titled ‘POPULAR FALLACIES CONCERNING OCCIPITOPOSTERIOR POSITIONS OF VERTEX’ this described the wok of Smellie in a book of Midwifery from 1744. He was called by a midwife to a case of dystocia, which he decided was caused by posterior presentation and applied forceps (the outcome here is not known)
A study in 1929 found the incidence of OP to be 29.8 (assuming this was detected by vaginal exam or palpation this may not be entirely accurate) but suggests that the prevalence at that time was similar to now and not significantly lower. (Dodek 1931, Torpin 1945). I would assume most women in that era would not have had the labour saving devices that we have now, so that suggests that posterior position may not be caused by a sedentary lifestyle (probably reassuring to women whose babies posterior and may feel it is there fault for not doing enough activity) that’s not to say that I feel there is no point in antenatal exercise as we know that physical exercise in pregnancy reduces the CS rate (see recent review by Domenjov et al 2014)
Historical OP outcomes
Dodek also states that “It often has been said that the vertex occipitoposterior position is the obstetric complication taking the greatest toll of fetal and maternal life and predisposing toward the greatest morbidity and permanent damage among surviving mothers” and TS Wells in 1891 reported that ‘statistics show that the mortality among infants in occiput posterior
cases is 1 in 5’ (TS Wells – British medical journal, 1891 – ncbi.nlm.nih.gov)
Historical OP management
Babies were often delivered by forceps and this contributed to the high fetal mortality. Hoever it appears that obstetricians from the 18th and 19th century know almost as much as we do now about posterior position, its consequences and resulting negative outcomes (although thankfully we no longer expect posterior position to result in fetal mortality)
Gilbert Strachan in 1939 described the signs of a posterior labour as ‘Slow progress with good pains and a roomy pelvis or ‘Primary inertia with early rupture of the membranes’. He also stated that:
“The prognosis of these cases depend almost entirely on the judgement and patience with which they are treated and the greatest virtue is patience.
In cases that rotate the prognosis for mother and child should be but little influenced, it is in those that persist posterior that damage will be done to both parties, with foetal mortality in this series of 26.6% “
The Walchers position (to avoid the use of forceps or facilitate an easier forces birth) was taught from 1838 in England and doctors found that If the legs hung down freely from the conjugate, increases diameter by 1cm (Fothergill 1898)
• What can we learn from this exploration of the historical references of occiput posterior position?
• The incidence of women having babies in a posterior position appears to be similar in the 18th and 19th century
• Obstetricians were aware that it was persistent OP caused a large proportion of maternal and neonatal morbidity and mortality
• Babies that were unable to be birthed were often delivered by forceps, which had a high mortality and injury risk
• Historically obstetricians were aware that the most important management technique in an OP labour was patience (it may be that we see more persistent OP babies because of a lack of patience, and that women may also be less fit going into labour and spend more of labour lying down than would have been common historically)
Into the future
Obstetricians have been aware of the importance of posterior position to the outcomes of mothers and babies for over 200 years, yet very little progress has been made in reducing the incidence or changing management to improve outcomes, considering the large numbers of women that are effected by malposition, very little research is being conducted to look at effective pre labour or in labour interventions to improve rotation
Verhoeven, C. J. M., Rückert, M. E. P. F., Opmeer, B. C., Pajkrt, E., &Mol, B. W. J. (2012). Ultrasonographic fetal head position to predict mode of delivery: a systematic review and bivariate meta‐analysis. Ultrasound in Obstetrics &Gynecology, 40(1), 9-13.
Blasi, I., D’Amico, R., Fenu, V., Volpe, A., Fuchs, I., Henrich, W., &Mazza, V. (2010). Sonographic assessment of fetal spine and head position during the first and second stages of labor for the diagnosis of persistent occiput posterior position: a pilot study. Ultrasound in Obstetrics &Gynecology, 35(2), 210-215.
Malvasi, A., Tinelli, A., Barbera, A., Eggebø, T. M., Mynbaev, O. A., Bochicchio, M., …& Di Renzo, G. C. (2013). Occiput posterior position diagnosis: vaginal examination or intrapartum sonography? A clinical review. The Journal of Maternal-Fetal & Neonatal Medicine, 27(5), 520-526.
PORTER WD. POPULAR FALLACIES CONCERNING OCCIPITOPOSTERIOR POSITIONS OF VERTEX. JAMA. 1929;92(3):221-226. doi:10.1001/jama.1929.02700290031008.
DODEK SM. THE VERTEX OCCIPITOPOSTERIOR POSITION: THE TREATMENT OF MORE THAN FIVE HUNDRED CONSECUTIVE CASES. JAMA. 1931;96(20):1660-1664. doi:10.1001/jama.1931.02720460006002.
Iris Domenjoz, Bengt Kayser, Michel Boulvain, Effect of physical activity during pregnancy on mode of delivery, American Journal of Obstetrics and Gynecology, Volume 211, Issue 4, October 2014, Pages 401.e1-401.e11, ISSN 0002-9378, http://dx.doi.org/10.1016/j.ajog.2014.03.030.
Wells, T. Spencer. “Practical Cure or Disastrous Failure?.” British medical journal 1.1570 (1891): 257.
TORPIN R. THE INFLUENCE OF PLACENTAL SITE ON FETAL PRESENTATION. JAMA. 1945;127(8):442-445. doi:10.1001/jama.1945.02860080014004.
Strachan GI. The Occipito-Posterior Case. Postgraduate Medical Journal 1939;15(165):263-268.
Fothergill WE. WALCHER’S POSITION IN OBSTETRICS. British Medical Journal 1898;1(1931):53.