Can We Prevent Persistent Occiput Posterior Babies?

January 29th, 2013 by avatar

Today, regular contributor Henci Goer, co-author of the recent book, Optimal Care in Childbirth; The Case for a Physiologic Approach, discusses a just published study on resolving the OP baby during labor through maternal positioning.  Does it matter what position the mother is in?  Can we do anything to help get that baby to turn?  Henci lets us know what the research says in today’s post. – Sharon Muza, Community Manager


In OP position, the back (occiput) of the fetal head is towards the woman’s back (posterior). Sometimes called “sunny side up,” there is nothing sunny about it. Because the deflexed head presents a wider diameter to the cervix and pelvic opening, progress in dilation and descent tends to be slow with an OP baby, and if OP persists, it greatly increases the likelihood of cesarean or vaginal instrumental delivery and therefore all the ills that follow in their wake.

Does maternal positioning in labor prevent persistent OP?

This month, a study titled “Is maternal posturing during labor efficient in preventing persistent occiput posterior position? A randomized control trial” reported on the use of maternal positioning in labor to rotate OP babies to occiput anterior (OA). Investigators randomly allocated 220 laboring women with OP babies either to assume positions designed to facilitate rotation or to recline on their backs. The positions were devised based on computer modeling of the mechanics of the woman’s pelvis and fetal head according to degree of fetal descent. The position prescribed for station -5 to -3, i.e., 3-5 cm above the ischial spines, a pelvic landmark, had the woman on her knees supporting her head and chest on a yoga ball. At station -2 to 0, i.e., 2 cm above to the level of the ischial spines, she lay on her side on the same side as the fetal spine with the underneath leg bent, and at station > 0, i.e., below the ischial spines, she lay on her side on the same side as the fetal spine with the upper leg bent at a 90 degree angle and supported in an elevated position.



The good news is that regardless of group assignment, and despite virtually all women having an epidural (94-96%), 76-78% of the babies eventually rotated to OA. The bad news is that regardless of group assignment, 22-24% of the babies didn’t. As one would predict, 94-97% of women whose babies rotated to OA had spontaneous vaginal births compared with 3-6% of women with persistent OP babies. Because positioning failed to help, investigators concluded: “We believe that no posture should be imposed on women with OP position during labor” (p. e8). 

Leaving aside the connotations of “imposed,” does this disappointing result mean that maternal positioning in labor to correct OP should be abandoned? Maybe not.

Of the 15 women with the fetal head high enough to begin with position 1, no woman used all 3 positions because 100% of them rotated to OA before fetal descent dictated use of position 3. I calculated what percentage of women who began with position 2 or 3, in other words fetal head at -2 station or lower, achieved an OA baby and found it to be 75%—the same percentage as when nothing was done. What could explain this? One explanation is that a position with belly suspended is more efficacious regardless of fetal station, another is that positioning is more likely to succeed before the head engages in the pelvis, and, of course, it may be a combination of both.

Common sense suggests that the baby is better able to maneuver before the head engages in the pelvis. If so, it seem likely that rupturing membranes would contribute to persistent OP by depriving the fetus of the cushion of forewaters and dropping the head into the pelvis prematurely. Research backs this up. A literature search revealed a study, “Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001” finding that artificially ruptured membranes was an independent risk factor for persistent OP. Returning to the trial, all women had ruptured membranes because it was an inclusion factor. One wonders how much better maternal positioning might have worked had this not been the case, and an earlier trial offers a possible answer.

In the earlier trial, “Randomized control trial of hands-and-knees position for occipitoposterior position in labor,” half the women had intact membranes. Women in the intervention group assumed hands-and-knees for at least 30 minutes during an hour-long period while the control group could labor in any position other than one with a dependent belly. Twelve more women per 100 had an OA baby at delivery, a much bigger difference than the later trial. Before we get too excited, though, the difference did not achieve statistical significance, meaning results could have been due to chance. Still, this may have been because the population was too small (70 intervention-group women vs. 77 control-group women) to reliably detect a difference, but the trial has a bigger problem: fetal head position at delivery wasn’t recorded in 14% of the intervention group and 19% of the control group, which means we don’t know the real proportions of OA to OP between groups.

Take home: It looks like rupturing membranes may predispose to persistent OP and should be avoided for that reason. The jury is still out on whether a posture that suspends the belly is effective, but it is worth trying in any labor that is progressing slowly because it may help and doesn’t hurt.

Does maternal positioning in pregnancy prevent OP labors?

Some have proposed that by avoiding certain postures in late pregnancy, doing certain exercises, or both, women can shift the baby into an OA position and thereby avoid the difficulties of labor with an OP baby. A “randomized controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth (2547 women) has tested that theory. Beginning in week 37, women in the intervention group were asked to assume hands-and-knees and do slow pelvic rocking for 10 minutes twice daily while women in the control group were asked to walk daily. Compliance was assessed through keeping a log. Identical percentages (8%) of the groups had an OP baby at delivery.

Why didn’t this work? The efficacy of positioning and exercise in pregnancy is predicated on the assumption that if the baby is OA at labor onset, it will stay that way. Unfortunately, that isn’t the case. A  study, “Changes in fetal position during labor and their association with epidural anesthesia,” examined the effect of epidural analgesia on persistent OP by performing sonograms on 1562 women at hospital admission, within an hour after epidural administration (or four hours after admission if no epidural had been administered), and after 8 cm dilation. A byproduct was the discovery that babies who were OA at admission rotated to OP as well as vice versa.

Take home: Prenatal positioning and exercises aimed at preventing OP in labor don’t work. Women should not be advised to do them because they may wrongly blame themselves for not practicing or not practicing enough should they end up with a difficult labor or an operative delivery due to persistent OP.

Do we have anything else?

Larry P Howell aafp.org/afp/2007/0601/p1671.html

We do have one ray of sunshine in the midst of this gloom. Three studies of manual rotation (near or after full dilation, the midwife or doctor uses fingers or a hand to turn the fetus to anterior) report high success rates and concomitant major reductions in cesarean rates, if not much effect on instrumental vaginal delivery rates. One study, “Manual rotation in occiput posterior or transverse positions: risk factors and consequences on the cesarean delivery rate,” comparing successful conversion to OA with failures reported an overall institutional success rate of 90% among 796 women. A “before and after” study, “Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section,” reported that before introducing the technique, among 30 women with an OP baby in second stage, 85% of the babies were still OP at delivery compared with 6% of 31 women treated with manual rotation. The cesarean rate was 23% in the “before” group versus 0% in the “after” group. The third study, “Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position,” compared 731 women having manual rotation of an OP baby in second stage with 2527 women having expectant management. The success rate of manual rotation was 74% and the overall cesarean rate in treated women was 9% versus 42% in the expectantly managed group.

Manual rotation is confirmed as effective, but is it safe? This last study reported similar rates of acidemia and delivery injury in newborns. As for their mothers, investigators calculated that four manual rotations would prevent one cesarean. The study also found fewer anal sphincter injuries and cases of chorioamnionitis. The only disadvantage was that one more woman per hundred having manual rotation would have a cervical laceration.Take home: Birth attendants should be trained in performing manual rotation, and it should be routine practice in women reaching full dilation with an OP baby.

What has been your experience with the OP baby?  Is what you are teaching and telling mothers in line with the current research?  Will you change what you say now that you have this update?  Share your thoughts in the comment section. – SM

References and resources

Cheng, Y. W., Cheng, Y. W., Shaffer, B. L., & Caughey, A. B. (2006). Associated factors and outcomes of persistent occiput posterior position: a retrospective cohort study from 1976 to 2001. Journal of Maternal-Fetal and Neonatal Medicine19(9), 563-568.

Desbriere R, Blanc J, Le Dû R, et al. Is maternal posturing during labor efficient in preventing persistent occiput posterior position? A randomized controlled trial. Am J Obstet Gynecol 2013;208:60.e1-8. PII: S0002-9378(12)02029-7 doi:10.1016/j.ajog.2012.10.882

Kariminia, A., Chamberlain, M. E., Keogh, J., & Shea, A. (2004). Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. bmj328(7438), 490.

Le Ray, C., Serres, P., Schmitz, T., Cabrol, D., & Goffinet, F. (2007). Manual rotation in occiput posterior or transverse positions: risk factors and consequences on the cesarean delivery rate. Obstetrics & Gynecology110(4), 873-879.

Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005). Changes in fetal position during labor and their association with epidural analgesia.Obstetrics & Gynecology105(5, Part 1), 974-982.

Reichman, O., Gdansky, E., Latinsky, B., Labi, S., & Samueloff, A. (2008). Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section. European Journal of Obstetrics & Gynecology and Reproductive Biology136(1), 25-28.

Shaffer, B. L., Cheng, Y. W., Vargas, J. E., & Caughey, A. B. (2011). Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. Journal of Maternal-Fetal and Neonatal Medicine24(1), 65-72.

Simkin, P. (2010). The fetal occiput posterior position: state of the science and a new perspective. Birth37(1), 61-71.

Stremler, R., Hodnett, E., Petryshen, P., Stevens, B., Weston, J., & Willan, A. R. (2005). Randomized Controlled Trial of Hands‐and‐Knees Positioning for Occipitoposterior Position in Labor. Birth32(4), 243-251.

Recommended resource: The fetal occiput posterior position: state of the science and a new perspective http://www.ncbi.nlm.nih.gov/pubmed?term=simkin%202010%20posterior by Penny Simkin.


Babies, Cesarean Birth, Epidural Analgesia, Guest Posts, Maternity Care, Medical Interventions, Research , , , , , , , ,

  1. avatar
    | #1

    So, I guess the question remains, is there anything a woman can do to prevent OP? For example, chiropractic or other prenatal care? My second was definitely solidly OP, and my first may have been, but I didn’t know to ask the question at the time. I am possibly going to have a 3rd, and would like to try for a VBA2C and want to know if I should even be able to get my hopes up? I know that I would be in for a potentially long labor, as I had with #2, and due to his position, I didn’t progress adequately (days of prodromal labor before I wore out and ended up with the section)…

  2. | #2

    Great article! Just another reason to avoid artificially ruptured membranes. I would love it if there were more research on how to prevent premature ruptured membranes at term, since I’ve had quite a few friends with a persistent posterior baby in that scenario, as well.

  3. | #3

    Thank you for this article! The one question that comes to mind is: were the manual rotations primarily done on women who had epidurals, without, or both? I just wonder how effective we can be in an out-of-hospital context with this skill.

  4. | #4

    “Take home: Prenatal positioning and exercises aimed at preventing OP in labor don’t work. Women should not be advised to do them because they may wrongly blame themselves for not practicing or not practicing enough should they end up with a difficult labor or an operative delivery due to persistent OP.”

    I honestly don’t think this is valid commentary as it relates to prenatal preparation. The ‘exercise’ tested began in week 37 and was practiced for a total of 20 minutes a day. It by no means proves that educating women about the importance of her lifestyle habits: sitting and standing postures, general activity levels (of lack thereof) is redundant. In my view the design of the experiment is limited and its findings are, unsurprisingly, limited also. Until there is concrete evidence to show that correcting poor mechanics and encouraging more movement during pregnancy (during the entire pregnancy, not just for 20mins a day from week 37) does nothing to improve a woman’s chance of a well-positioned baby, I will continue to believe that our sedentary lifestyle, coupled with poor postural habits and lack of regular exercise contributes enormously to the issue of persistent OP babies.

    No woman should ever be led to believe that a technique or position or ‘lifestyle’ change will be fail-safe preparation for a well-positioned baby, that approach would be utterly irresponsible. But to avoid educating a woman about how her ‘lifestyle’ may affect her baby’s ability to position itself favorably, in case she then blames herself for an OP baby, is worse.

    It’s maddening when conclusions are drawn from experiments of limited design, it closes a door before it’s even been opened.

  5. | #5

    First, Those of us who feel we’ve observed positive results using maternal positioning and activity when posterior position is (or appears to be) making labor more difficult have a much more versatile approach then just using hands/knees and side-lying positions. We also use the rebozo, lunges, pelvic tilts, belly lifts, walking, and on and on until something (or everything combined) works. So we can read your research as indication that half-hearted efforts may not succeed, not that no effort succeeds.
    Second — re the study that compared rocking in the hands/knees position with daily walking. Because the results were the same, someone concluded that neither activity had an affect??? You could as easily conclude that both activities had an effect. Both are excellent prescriptions for helping a baby shift into a favorable position. A real test would have included women doing both and women doing neither.
    But — I think the warning is well taken that we need to keep studying and paying attention and meanwhile be very careful not to overestimate and overpromote our ability to influence fetal postion and be very careful not to set women up to feel that an issue with fetal position during labor represents a failrue on their part.

  6. avatar
    Amy Milton
    | #6

    My concern with the manual rotations is damage to the baby’s spine. There is only one sentence that addresses potential delivery injury to the baby at “similar rates.” I’m glad the rate of injury is not increased, but is the type of injury any different?

  7. | #7

    My second was OP and asynclitic, and he was born that way (all 9 pounds, 9 ounces of him). I had no back pain, which may have cued us into why it was taking so long during the second stage (pushed for 90 minutes). I had no medications at all, including pain meds. My midwife was unable to tell his position until he started emerging. My third baby was also OP, but I got up and lunged and he immediately rotated, dropped, and was born in the next contraction (he had a nuchal arm and was only 8 pounds, 2 ounces). As a CBE and doula, I always talk about OFP, and I weigh that with, “Even doing those exercises and being aware of your positioning, some babies will still show up OP during labor,” and then we go over ways to not only cope with back labor, but ways to help a baby move into a better position if baby is suspected to be OP, like Miles Circuit, lunging, and being more active during labor/before an epidural.

  8. avatar
    Amy Bauer
    | #8

    Great article and review. On my unit (L&D), we encounter OP babies all too often. It’s helpful to see a bit of research on the issue of maternal position to influence the position of the baby in labor. I have found manual rotation (performed by the trained, experienced person!) to be effective in turning an OP baby around, but the experience can be overwhelming for some women – particularly those who do not have epidural anesthesia on board. Extra support from the labor support team is essential when manual rotation is employed…

  9. | #9

    If the problem is prolonged prodromal labor, I recommend Penny Simkin’s advice (I don’t have a source, but I know I got this from her long ago): alternate periods where you try activities to stimulate more effective labor and/or rotate the baby–and in early labor, as I suggested in this blog post, pelvic rocking on hands and knees could help–with periods when you use strategies to help you rest and relax (ex. warm tub baths, massage, music) with periods when you use distraction strategies (ex. window shop, watch a movie, play a video game). I also think it’s worth talking to a chiropractor. I’m not aware of any studies, but chiropractic manipulation should fall into the category of “can’t hurt, might help.” You might also spend some time strategizing about how you might handle the psychological aspects of another VBAC labor given your discouraging experiences. For example, would it help, or not, to consider whether there were emotional barriers or fears that might have gotten in your way, and if so, how might you resolve them? Would it help, or not, to set time limits for yourself? What support will you need from your labor companions if this next labor is also slow? Come to that, what support will your partner need? It doesn’t sound as if you got far enough along for manual rotation, but if I were you, I’d want to be sure my birth attendant knew how to do this in case I did and I needed it. The best you can do for yourself is prepare as well as you can and stay in the driver’s seat when it comes to making decisions. The rest isn’t within your control.

  10. avatar
    Birthy Mom
    | #10

    My third baby was OP and lead to a lengthy birth. I believe if I had been in a hospital I would have had a c-section. My midwife did try to manually rotate the baby when I was about 8cm dilated, but I couldn’t hold still long enough for her to really give it a good go. Eventually we walked with wide lunges. After a few minutes of this, I felt my son rotate and began pushing

  11. | #11

    @Sunita & Amy
    (Sunita wondered whether manual rotation could be done outside of the hospital and Amy implied that it was painful, that is, it could be overwhelming without an epidural.)
    I can speak from personal experience that at least as performed by the obstetrician who did it on me 35 yrs ago and of observation of the same ob performing it on one of my doula clients that it was no big deal. On me, it was no more uncomfortable than a vaginal check, and my client did not seem distressed or complain. I wonder if technique makes a difference. (BTW, it worked in both cases, and the baby was born shortly thereafter.)

  12. | #12

    @ Only Sometimes Clever
    Schaffer et al. (2011) reported on rates of 5-minute Apgar < 7, pH – 12, shoulder dystocia, delivery trauma as a composite of skull fracture, Erbs palsy, facial nerve palsy, clavicle fracture, and intracranial hemorrhage as well as on the incidence of each type of delivery trauma separately. The only outcome that achieved a statistically significant difference was 5-minute Apgar < 7, and that favored manual rotation (1.8% among 731 women having manual rotation vs. 3.7% among 2527 women expectantly managed.

  13. | #13

    The point I was making was that whether exercise or maternal positioning during pregnancy worked or didn’t work at shifting babies to OA was irrelevant since research has shown that babies who are OA when labor begins don’t necessarily stay that way.

  14. | #14

    @Judy Gabriel
    “First, Those of us who feel we’ve observed positive results using maternal positioning and activity when posterior position is (or appears to be) making labor more difficult have a much more versatile approach then just using hands/knees and side-lying positions. We also use the rebozo, lunges, pelvic tilts, belly lifts, walking, and on and on until something (or everything combined) works. So we can read your research as indication that half-hearted efforts may not succeed, not that no effort succeeds.”
    I think the elephant in the room is epidural analgesia, especially early epidurals. In the study that performed serial ultrasounds, almost all of the women eventually had an epidural. Now, while the study shows that babies can go from OA to OP in labor, thereby explaining why prenatal exercise didn’t work, the unanswered question is what role epidurals play in that, or, for that matter, the other interventions (continuous EFM, IVs, IV oxytocin) that tend to limit mobility, in fostering rotation from OA to OP? And what role do epidurals and these interventions play in limiting options for positioning and activities that might shift an OP baby to OA?

  15. | #15

    @Amy Milton
    I responded to “Only Sometimes Clever” with the detailed neonatal outcomes from the Shaffer study.

  16. avatar
    Judi Tinkelenberg CNM
    | #16

    For many years, I tried to have women “do things” to prevent posterior positions in labor. In my experience, doing some positions helped during labor and, as I have done manual rotations (in and out of hospital)for over 30 years, that is a successful technique quite often. When I evaluated the studies, especially the Australian study that did ultrasounds during labor and discovered that most if not all babies rotate positions frequently during labor AND that OP positioning WAS NOT related to back pain for most of these women, I stopped recommending “correct postures and exercises in pregnancy” to prevent OP babies. What I realized I was doing was frightening women about the “dreaded OP baby” when these rotations appear to be necessary for a baby to navigate the difficult planes of female human pelves. I will recommend Webster’s Chiropractic technique to many women,especially if they had difficult first labors. Also, I only do rotations if the labor is prolonged or difficult. I catch many babies who come out OP and do just fine. I had “issues” about posterior babies because had them. Both of my daughters have had them (I did have to correct one acsynclitic, deflexed, OP grandkid and one delivered OP and easily). I think this study is really helpful and maybe, we allneed to reevaluate the whole “OP babies are bad” issue!!!

  17. avatar
    | #17

    spinningbabies.com – Easier Childbirth Through Fetal Positioning
    Check out this website, better yet attend one of Gail Tully’s AMAZING workshops about exercises, activities and techniques that may assist occiput posterior babies.

  18. | #18

    This article shows that No matter what the turn out of the birth girls need to think “I did everything I could, NOT “I didn’t do enough.”

  19. avatar
    Margaret Lipton CNM
    | #19

    The research Henci linked to on the effect of epidural on fetal position at delivery was published back in 2005 and I remember reading it at the time. It’s flatly stated conclusion answers the question of how to prevent the problematic persistently posterior baby, ie the one who won’t deliver vaginally, either in the direct OP or, as we used to say, by “spinning on the perineum”. Epidural analgesia is associated with a 12.9% rate of persistent posterior at delivery; occiput posterior position without epidural was present in 3.3%. This is a statistically significant effect specific to receiving epidural analgesia, a predominantly elective medical intervention P=.002. However, the full impact of this effect is only seen when we look at the correlation between persistent posterior position and cesarean delivery. In the study disclaiming any reduction in persistent OP with maternal positioning in labor, the OP rate among women who had cesareans was 71.9% in the positioning group and 89.1% in the control group. In women with spontaneous vaginal deliveries the OP rate was 5.8 and 2.8 respectively. http://www.ncbi.nlm.nih.gov/pubmed/23107610
    Take home: women who receive epidural analgesia, are, regardless of their babies’ position at the beginning of labor, 4 times more likely to have a cesarean rate between 71.9% and 89.1% ( ie a persistently OP baby ) than women who do not !

  20. | #20

    Sharon gave me the go-ahead to do a blog post on the relationship between epidural analgesia and persistent posterior. Stay tuned.

  21. | #21

    The author of Rotational Positioning TM Nikki Macfarlane, director of Childbirth International, maintains that the babies who start labor as ROA (right occiput anterior), during labor rotate in clockwise direction. For successful delivery, the baby has to rotate all the way through the posterior and left transverse to the front again. If ‘hands and knees” position alone is used for a ROA baby, gravity prevents the clockwise rotation, and this leads to persistent posterior, and even higher rate of Cesarean than for the babies who start in a posterior position.

  22. | #22

    After reading this and the engaging comments I headed straight to uptodate.com. I read the review by Argani and Satin (2012) entitled “Managment of the fetus in occiput posterior position” which also references many of the studies and reviews you reference here. In the study “Intrapartum sonography and persistent occiput posterior postion: a study of 408 deliveries”, Gardberg, Laakkonen, Salvevaara conclude from their study of fetal positioning at onset and during labor that in their study “In most cases, persistent occiput posterior position develops through a malrotation and only in little more than one-third of cases through absence of rotation from an initially OP position”. Argnai and Satin (2012) surmise that “these data suggest that pelvic musculature relaxation associated with epidural analgesia leads to malposititonig of the fetal head, and this is an important mechanism for OP position at delivery.” I am glad to hear that you will be doing a follow-up about epidurals and OP position.

    The conclusion of this study and your statement is definitely a trigger for me and most likely others. Information on OP babies and fetal rotation including body movement and positioning in pregnancy, Gail Tully’s spinnning babies, use of Rebozo and bellydancing, lunges and stair stepping, and Dance for your Birth have been passed on through workshops, apprenticeships, doula/midwifery/nurse practices, books, videos and websites for quite some time. So is all of this old wives tales? It has me wondering the history of this knowledge passed on over time? From what did all of this arise? Is it that none of this works or that all of this does “work” because babies ARE spinning and moving during pregnancy, and as reported in this study and others, during labor. Is it just that doing these activities or not does not predict position of the baby at time of birth and there are other factors involved but all of this is still important although not a “treatment” for fetal OP position. How are we to bring this information to new parents? If a woman lies completely still in labor (which is unethical to study) with and without epidural do babies rotate and to what extent and positions? Gail Tully calls for more research on Balance and Movement along with Gravity.

    Of the studies and reviews I read about maternal hands and knees position in labor and during pregnancy none said that this promoted rotation. In childbirth classes, leaning forward positions and pelvic movement is encouraged. Is this then a baseless recommendation? It seems that to promote a lifestyle of movment and pelvic rotation and tilting, and sitting with knees lower than the hips is good basic body ergonomics. Is there any benefit to labor physiology and fetal positioning (an easier/safer birth) if women embody a lifestyle of good body alignment and movement during pregnancy and on labor day? I agree the terminology of promising an easier birth and a “solution” to OP position may set women up for self-blame. And ancient eastern spiritual practices include some of the same body posturing in their teaching that we offer modern women to assist with an easier labor and birth.

    I wonder, in practical terms, if an epidural does cause malrotation and/or prevent OP to OA rotation independent of maternal positioning (because women with an epidural can use sidelying, upright in bed and hands and knees in bed), how can we support women in labor, even more, to cope with the nature of labor with a baby in OP position. We talk about constant support, changing up support persons, use of water, back pressure and positions that relieve the sacrum of added pressure and promote rotation and the use of drugs and/or epidural.

  23. | #23

    @ Christy
    I agree with everything you’re saying about mobility in labor, including the problematic effect of epidurals. Even apart from specific recommendations, when not hampered by being tethered to equipment, few women who don’t have epidurals are content to lie on their backs. I know this from my own observation as a doula and, indeed, from my own experiences in labor. Women tend instinctively to seek positions and activiities that feel more comfortable. They sway from foot to foot, they lean forward and pelvic rock, they wriggle their hips. I don’t think it is coincidental that these are the very things that can coax the baby into a favorable position for birth. I just don’t think that positioning and special activities in pregnancy are effective first, because you may get the baby into an OA position, but it doesn’t “stick” and second, because absent an epidural, almost all babies will eventually position as OA in labor. I definitely think it worthwhile to engage in positioning and activities designed to foster rotation once labor begins because as I wrote, it can’t hurt and it may help.

  24. avatar
    Sally Westbury
    | #24

    I am a woman who birth all 3 babies posterior. The first I was a 21 year old nurse. Working, walking, swimming at the beach every day, walking up and down sand dunes to get to the beach too. My baby was still posterior.

    Ina May Gasgin said at a conference, in Geelong Australia, when asked about posterior babies. Well….. when we started we did not know about posterior babies, we just knew it took some women longer to have their babies.

    So although as a midwife, of 25 years practice, I encourage optimal foetal positioning, good posture… blah blah blah.. in the end if that is the way the baby needs to be… then we need to understand that some babies take time.

    One of the most successful pieces of information that I share with women is understanding pre-labour.

    For a first time mother (or first time labour if VBAC). You are NOT IN LABOUR unless you have contraction every 5 minutes, regularly, and the contraction is lasting 60 seconds or more. Before that you are in prelabour and you should not be involved in active labour practices but should be resting, eating, drinking and ignoring it as much as you can.

    My first baby was born at home after 24 hours labour thanks to the non intervention and support of my amazing team of family, friends and health care providers. An event I am eternally grateful for.

    Let us not set women up for failure. When we talk about optimal foetal positioning we should also tell them that many, many women birth posterior babies….. but it just takes a little longer.. and it’s not the end of the world.

    Good family histories are also important. My mother had 6 babies… when I hear her stores… posterior for sure. My 2 sisters also had posterior positioned babies. Sigh… it’s our pelvis shape and no amount of optimal foetal positioning is going to change the shape of my pelvis. BUT if I had a care giver who told me that if my baby was not in a optimal position my birth was going to be difficult and that I might end up with a C/S then maybe I would not have had the courage and confidence to birth at home or the courage and confidence for the long journey to an amazing powerful birth that changed my life.

  25. | #25

    I love this reply, thanks for taking the time to share it, Sally! It speaks to many of the things I feel and share with my students and doula clients. Thank you!

  26. | #26

    Interesting article. Though I have to agree with Linzi’s comment, we have to be careful about throwing the baby out with the bathwater, so to speak, when it comes to teaching prenatal techniques for baby positioning. Certainly mothers can and do help their babies turn into a more optimal position prenatally AND during labour, and positioning techniques can help. Of course, like this article mentions, there are many other factors….positioning exercise only being part of the picture.

  27. | #27

    I agree with Sally as well. I think one helpful thing we can do is point out that it is *normal* for labors with an OP baby to take longer. Ditto for bigger babies and VBAC labors. Impatience and undue anxiety, whether on the part of women or their careproviders, is a major obstacle to physiologic labor and birth. In most cases, time is the laboring woman’s friend, not her enemy.

  28. | #28

    I have appreciated reading this article but I believe it’s v v limited in its inclusions and conclusion – I believe a huge chunk called ’emotional navigation of the birth process’ is missing – the emotional overlay of a woman’s inner world that informs the physical plays a huge roles
    – when we allow a woman to move through her emotional landscape in birth without undue pressure that it must look a certain way I wonder how things would be different – in my teaching of bellydancebirth which I wholly recommend in pregnancy their is a great emphasis on this aspect in my teachings – empower a woman and trust in her decision making with gentle guidance – we cannot under estimate this and I agree some babies take longer to move through that passage of time and some mummas require this time too – when we analyse everything to the enth degree we leave no room for mystery aNd often birth unfolds in this mystery – ps we have a beautiful bellydancebirth movement to lift the ischial spine creating room – a gentle suggestion – loves to All x

  29. avatar
    Katie B.
    | #29

    How is this study ethical?

  30. | #30

    When I published my book “The Doula Guide to Birth” in 2009, I too quoted the 2005 study by Lieberman, stating that babies rotate all through labor (I called that section of my book “Back Labor: The Good News.”) Although at that time I did not recommend prenatal exercises for fetal positioning, I have since come to change my mind. As Henci postulates, once a baby has descended into the pelvis, rotation may be less likely to occur. Prenatally, if a baby rotates into a favorable position AND descends, this baby may be more likely to stay in position and be born more readily. (I believe this happened with my first birth in 2010 — I did Latin dancing with intense pelvic movements throughout my pregnancy. At 30 weeks my baby was LOA and low in my pelvis, and stayed that way until delivery, which went quickly.) It is good to see that researchers are taking interest in fetal positioning — now we just need to have some more complete and well-designed studies on the topic.

  31. | #31

    Hi! I’ve been reading your blog for some time now and finally got the
    bravery to go ahead and give you a shout out from Atascocita
    Texas! Just wanted to tell you keep up the great job!

  32. avatar
    | #32

    Hi there, I love this site! I am 5 weeks post partum and had a persistent Left OP baby born via C-Section after 24 hours of labor. I waited until 7cm to get the epidural (wanted one after my water broke as back pain was excruciating). Going into my pregnancy (first time mom) I had no idea about OP babies. I wish I knew before hand so that I could have done more to try and get him in a more optimal position for delivery. I was dilated to 9.5++ and stuck there for over 2 hours. I ended up developing a fever (maybe from the epidural) ? and had nothing left to give as my back labor was immense. Nothing could have prepared me for that pain. I just keep playing it back if I only could have done more etc. but baby and I are healthy and I am thankful for that. Maybe I will try for a VBAC if we get to have one more.

  33. avatar
    | #33

    Sorry I can’t buy your or anyones crap about exercise and pregnancy.I was incredibly active.Almost all my children were born either breach transverse or in a veil.It has more to do with pelvic floor stamina and pelvic size than exercise in most women.Then again I only had a slow labor with the first.The rest were normal or fast[no not abnormally fast as in placenta previa].Have a pelvimetry.I think that is the right name and am spelling it correctly.It will show if you are small in the pelvis.It can give you a heads up that you may have the same problem in the future.

  34. | #34

    Dear Henci,
    Current maternal positioning studies in pregnancy and labor observe the types of maternal positions common in hospitals today. OK, in many areas hands and knees or kneeling over a birth ball are not common, but among the doula community this would be a common maternal position. Which side to assume is a rather passive approach to encouraging fetal rotation.

    What is not studied are the exercises and labor positions and techniques that either (or both) attend to the soft tissues of birthing (not just the pelvic floor or perineum) or opening the pelvic diameters at the pelvic level (station) of the baby’s head. The anecdotal evidence seems to be there. I’d love a researcher to team up with me on these topics. I’m posting this in hopes that such a researcher is reading your excellent column. I agree that we must reflect on the research results, but also if we only learn and then teach from current research we’ll practice in a cul-de-sac.

    I do believe that Lieberman’s 2005 data held a key to occiput right and occiput left differences but wasn’t tracked and so the conclusion was random. The percentage of OA babies rotating to the OP was very small compared to to OP babies rotating to the OA or remaining OP (30%). Yet the study concluded a perspective of pointlessness in being proactive with fetal positioning at labor onset. I think something important was missed in the data.

    You shine your brilliance on current research, Henci, and this is a treasure for our fields of birth. I am uplifted by your work. I also have a lifetime of experience outside the institution and daily emails telling me another, perhaps parallel, reality. Being outside the institutional walls means that research has been outside my ability for a long time. I hope to look into some of the newer “People’s Science” approaches to track actual outcomes and see if my perception is simply reporting errors (perhaps people tell me the successes and seldom the failures?). I do know we can get a large percentage of late third trimester babies in transverse lie (who don’t have placenta over the cervix) to move head down in 48 hours. That’s worth studying.

    Thank you for all you do. You make me a better activist.
    -Gail Tully, “The Spinning Babies Lady” SpinningBabies.com

  35. | #35

    Thank you for the great literature review, Henci. Over the years, I too have been interested to see the positive results of the manual rotation studies. I would like to see more care providers trained in this technique, as well as participating in larger and better-designed studies in possible positional interventions in labor.

    In addition, I would echo the others that have suggested chiropractic care as another alternative before labor for resolving persistent malposition issues. The research on the Webster Technique (which addresses mostly sacrum issues) and the Bagnell Technique (which addresses both sacrum and pubic symphysis issues) is sadly limited to a few small case series and case reports, but a number of women report having good success in resolving malposition issues with these techniques.

    Although it is only anecdotal, a number of women with prior cesareans for malpositioned babies have gone on to have VBACs with well-positioned babies after having seen a chiropractor trained in either the Webster or Bagnell Techniques. In my observation, this seems especially useful in women with a history of car accidents or significant falls, and in those who experience significant back or pubic pain in pregnancy.

    We need more and better-designed research into these techniques, but until we have that, it’s important that people know about women’s positive anecdotal experience with well-trained pregnancy chiropractors. It’s definitely not successful all the time, but it can be another tool in the toolkit when needed.

  36. avatar
    OP Mom
    | #36

    I recently delivered an OP baby with a midwife and am an example of a delivery that proceeded smoothly without major intervention (for which I am extremely grateful.) The position was discovered when I entered the hospital fully dialated; I had mistaken back labor and irregular contractions for false/early labor. There were several factors present when I arrived: very advanced stage of labor, the coard was loosely wrapped around babys neck, I have a very open pelvis, and I had an adamant goal of a natural vaginal birth. In addition to personal reasons for desiring a “natural” birth, a prior spinal fusion made me a poor candidate for an epidural or spinal block.
    Immediately after entering the L&D room, Midwife ruptured my water and coached me through a quick pushing process, assisting as baby descended. Baby suffered no ill effects whatsoever. I had a medical team experienced in such deliveries and am grateful that I was not rushed for a c-section, as is typical in my region. As an aside, the contractions and birth were much more painful than my prior OA birth.

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