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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