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The Childbirth Educator’s Role in The Cesarean Epidemic: 10 Steps You Can Take Now!

April 29th, 2014 by avatar

As Cesarean Awareness Month (April 2014) comes to a close, I wanted to share ten things that childbirth educators can do in their childbirth classes to support families to avoid unneeded cesareans, help families to have a cesarean birth that is respectful and family centered and support families who give birth by cesarean, (planned or unplanned) both during the birth, in the postpartum period and when planning future births.

1. Birth plan exercises

Have your birth planning/birth choices activity include preferences for a cesarean birth.  Allow parents the option to select items such as delayed cord clamping, skin to skin in the operating room, delaying newborn weights and measurements, and more.  While these may not be available options in all areas, encouraging discussion amongst families and their health care providers is a good place to start.  Additionally, consider role playing a cesarean section in class and discuss ways to make the procedure family friendly.  Remember to suggest ways that the partner and other support people can best support mother and baby during the surgery. Consider sharing “The natural caesarean: a woman-centred technique” video so families can explore options for a family friendly cesarean birth.

2. Access teaching resources on the Lamaze International website

Lamaze International offers some great teaching resources on cesareans for educators on their website and for families on the Lamaze International parent site.  There are two infographics that cover the topic of cesarean sections; “Avoiding the First Cesarean” and “What’s the Deal with Cesareans.”  You might consider showing the brand new infographic video to your families in class. At only 3 minutes long, it does a great interactive job of highlighting important information. In addition to using these materials in class, encourage families to explore them more thoroughly at home.

3.  Provide current statistics

Access and share statistics about national and provincial or state cesarean rates and VBAC rates, along with local rates for facilities and providers if available.  Help your families to understand the difference between overall cesarean rates and primary cesarean rates and why facilities caring for high risk mothers or babies might have higher rates.  Make sure that you are providing the most current information available, and update your figures when new numbers are released. Encourage discussion in class with families who are considering changing birth location or providers if they feel so inclined.

4. Encourage the use of birth doulas

The addition of trained labor support has been shown to reduce common interventions and cesareans. (Hodnett, 2012)  Take some time during class to share how doulas can help support both the laboring woman and her partner and team.  Provide resources for families to locate doulas (DONA.org and DoulaMatch.net are two such lists that come to mind) and briefly share information on questions to ask a doula during an interview, so the families are prepared.

cam two ribbon5.   Share current best practice information

Be sure that the information in your classes is current, accurate and based on best practices and evidence.  Know the sources of the information you cover.  Make sure it is up to date and verifiable.  Have a short list of favorite online resources to share with families, including Lamaze International’s Giving Birth with Confidence blog- written specifically for parents.  Utilize the references that make up the Six Healthy Birth Practices, there is a citation sheet for all six of the birth practices.

6. Support the midwifery model of care

Share information in your classes about the midwifery model of care, which has been shown to be an appropriate choice for healthy, low risk women.  Let your class families know how to find a midwife by using the search functions on the American College of Nurse-Midwives website and information on finding a midwife on the Citizens for Midwifery website.

7. Have meaningful class reunions

If your childbirth class includes a reunion, create a space for all the families to share their stories, both the vaginal births and the cesarean births.  Honor the work that the families did to birth their babies and celebrate their intention and teamwork.  Highlight their shining moments and let them know that you recognize how hard they worked.  Model excellent listening skills and support all the families as they share their birth stories.

8. Provide support group information

Make sure that all families that leave your class have been given resources for a support group for women who birth by cesarean section.  Access the International Cesarean Awareness Network (ICAN) to find the nearest local ICAN chapter website or Facebook group. Or refer the families to the main ICAN Facebook page.  VBACFacts.com also has a large peer to peer support network active on Facebook as well.

9.  Share postpartum resources

Families that birth by cesarean section might find themselves needing additional support from professionals during the postpartum period.  Be sure that they have resources to find lactation consultants, mental health counselors, postpartum doulas, physical therapists and other professionals that might be useful for healing emotionally and physically from a cesarean section.  In the throes of postpartum hormones, exhaustion, sleep deprivation and physical recovery, having to hunt down appropriate professionals can be a daunting task for any new families, never mind a mother recovering from surgery with a newborn.

10.  Offer a cesarean only class

Some families know they will be needing a cesarean for maternal or infant health circumstances and are hesitant about taking the standard childbirth class, feeling like they won’t fit in.  While they may not be needing the coping skills or comfort techniques and pushing positions that you cover in the typical childbirth class, they do need information about the cesarean procedure, pain medication options, recovery, breastfeeding and newborn care/procedures and informed consent and refusal information, among other things.  Having a class designed with their needs in mind can help them to make choices that feel good to them and participate in the community building that is such an important part of childbirth classes.

Don’t underestimate the role of the childbirth educator (you!) to offer evidence based information, appropriate resources, respectful dialogue along with skills and techniques to help women to have the best birth possible, avoid a cesarean that is not needed and recover and heal  while feeling supported with options for future births.  Thank you for all you do to help women to avoid cesareans or if needed, have the best cesarean possible.

References

Hodnett, E. D., S. Gates, et al. (2012). “Continuous support for women during childbirth.” Cochrane database of systematic reviews: CD003766.

Cesarean Birth, Childbirth Education, Giving Birth with Confidence, Healthy Birth Practices, Lamaze International, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, Practice Guidelines, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

Lamaze International Webinar- Six is the New Four: A Review of the Safe Prevention of the Primary Cesarean Delivery Consensus Report

March 24th, 2014 by avatar

Lamaze International is delighted to be offering a continuing education opportunity for all interested professionals.  ”Six is the New Four: A Review of the Safe Prevention of the Primary Cesarean Delivery Consensus Report” is being facilitated by Richard Waldman, M.D. and Peggy DeZinno, BSN, RN, LCCE from OB-Consult on Tuesday, April 8th, 2014 at 4 PM EDT.

A few weeks ago, Science & Sensibility’s Judith Lothian highlighted and reviewed the just released joint ACOG/SMFM report “Safe Prevention of the Primary Cesarean Delivery” and many agreed it was a game changer.  Many of the recommendations listed in the report appeared to be shifting away from current, but outdated practices and encouraging more evidence based care that promotes patience, expectant management and acknowledges that protocols need to be changed if there is to be a reduction in cesareans, particularly that primary (first) cesarean.
In this upcoming webinar, Dr. Richard Waldman and Peggy DeZinno will discuss the gap between current practice and the opinion paper’s recommendations.  What will it take to get us there?  What needs to change and where are the challenges?
Dr. Waldman is the former president of the American Congress of Obstetricians and Gynecologists and a keynote speaker at the 2013 Lamaze International Annual Conference that was held in New Orleans, LA.  You can read an interview I did with Dr. Waldman last summer and also read his article, “Birth as the Ultimate Collaboration” that he wrote for Science & Sensibility in advance of his keynote presentation.
Co-presenter Peggy DeZinno, BSN, RN, LCCE provides OB-Gyn-specific risk management services at OB- Consult. She has over 35 years of experience in the healthcare industry, specifically as a coordinator and instructor of women’s health and education programs.
At the end of this webinar, learners will be able to:
  • List two reasons why the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine developed a Consensus for the safe prevention of primary Cesarean Delivery.
  • Describe the definition and management of abnormally progressing first-stage labor.
  • Describe the definition and management of abnormal second-stage labor
  • Discuss the role of continuous labor support in decreasing primary Cesarean births.

Participants in the full hour of the webinar will be able to receive 1.0 Lamaze Contact Hour and 1.0 Nursing Contact Hour after completion of a post-webinar evaluation. Lamaze International is an approved provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation.

This webinar and the associated continuing education hour is provide free as a benefit of Lamaze International membership.  Non-Lamaze members are invited to participate for the reasonable fee of $20, which includes the continuing ed contact hour.  Register for the webinar now to reserve your place at this exciting event scheduled for April 8th, 2014 ag 4:00 PM EDT.

ACOG, Childbirth Education, Continuing Education, Evidence Based Medicine, Maternal Quality Improvement, New Research, Webinars , , , , , , ,

Whether Women Have Cesareans Is Mostly Arbitrary

March 21st, 2013 by avatar

 Regular contributor Henci Goer, author of several books including Optimal Care in Childbirth as well as the expert on Lamaze International’s “Ask Henci” site, takes a look at a recent study that examines the wide divergence in cesarean rates amongst U.S. hospitals.  Read Henci’s take and see what she concludes might be behind this rate variability. – Sharon Muza, Community Manager, Science & Sensibility

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© Patti Ramos Photography

If any doubt remained that the likelihood of cesarean depends mostly on care provider philosophy and practices, a study of variation in cesarean rates in U.S. hospitals has laid it to rest. Investigators plotted cesarean surgery rates during 2009 by their percentile at 593 U.S. hospitals with at least 100 deliveries, comprising 817,318 women in all (Kozhimanni 2013). Rates ranged from 7% to 70%, a 10-fold variation.

Thinking that hospital factors might explain some of the variation, the investigators compared rates according to hospital size, whether the hospital was a teaching hospital, and whether it was rural. None had any effect. Average cesarean rates were similar to the overall average rate regardless of hospital characteristics.

Variation in population characteristics likewise could explain variation in cesarean rates. Accordingly, investigators looked at a more homogeneous low-risk subset of women who were at term (37 weeks or more), carrying one head-down baby, and who had no prior cesareans. This, they reasoned, should reduce the variation in rates. Wrong again. The range widened. Rates among low-risk women ranged from a little over 2% to nearly 37%, a 15-fold variation instead of a 10-fold one.

The investigators stopped with expressing concern over the large variation in cesarean rates, writing: “There is an urgent need to address maternity care quality in general and rising cesarean rates and variation in practice patterns in particular” (p. 531), but their data tell us something more: few hospitals had anything close to reasonable rates.

The mean cesarean rate among women overall was 33%. The World Health Organization holds that cesarean rates should not exceed 15% because research shows that as cesarean rates rise above this threshold, they necessarily are performed in less clear cut situations, and the risks of the surgery begin to outweigh its benefits. Beyond 15%, maternal and neonatal morbidity and mortality rise in parallel with further increase. Only 2 of the 593 hospitals had cesarean rates of 15% or less. Indeed, only 21 hospitals had rates of 20% or less.

In the low-risk population, the mean cesarean rate was 12%. The recent analysis of 18,084 women planning birth center births gives us a fix on whether this is a reasonable rate for low-risk women (Stapleton 2013). Of the 14,881 women admitted in labor to the 79 participating birth centers, 6% delivered by cesarean, and perinatal outcomes were equivalent to those in similar women planning hospital birth. Only 23 of the 593 hospitals had a cesarean rate of 6% or less in their low-risk cohort.

To be fair, the low-risk hospital dataset wasn’t able to identify women with problems that would increase their likelihood of cesarean but who would have been excluded from birth center care. The birth center data, however, provides a handle on the possible effect on cesarean rate. Six percent of women planning birth at the birth center were risked out because of pre-eclampsia, non-reassuring fetal testing, postdates, or prelabor rupture of membranes and no labor. Let us assume that these problems occurred at the same rate in the low-risk hospital population. Let us further assume that all women with these problems ended up with a cesarean, which is highly unlikely. Those assumptions would boost the birth center baseline cesarean rate of 6% by another 6% or to 12% for the low-risk hospital population. Even making this extreme assumption, 271 hospitals, nearly half, had rates greater than 12%.

What’s the take-home? Practitioners with appropriate cesarean rates are thin on the ground. Women need to seek out care providers whose judgment on when a cesarean is indicated can be trusted. (I should add that they are likely to have better luck with a midwife, but it isn’t a sure thing.) Women free of medical or obstetrical risk factors may wish to plan to birth in a free-standing birth center or at home because while individual practitioners’ rates may vary within institutions, a high hospital rate—true of nearly all of them—creates a cesarean–friendly culture.

How would you use this research study when teaching classes or working with clients or patients?  Do you think that women do enough research and investigation when selecting a provider and a birth facility? Please share your thoughts. – SM

References

Kozhimannil, K. B., Law, M. R., & Virnig, B. A. (2013). Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues. Health Aff (Millwood), 32(3), 527-535. doi: 10.1377/hlthaff.2012.1030 http://www.ncbi.nlm.nih.gov/pubmed/23459732

Stapleton, S. R., Osborne, C., & Illuzzi, J. (2013). Outcomes of care in birth centers: demonstration of a durable model. J Midwifery Womens Health, 58(1), 3-14. doi: 10.1111/jmwh.12003 http://www.ncbi.nlm.nih.gov/pubmed/23363029

 

 

 

 

 

 

Cesarean Birth, Guest Posts, informed Consent, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Push for Your Baby, Research , , , , , ,

Consider the Source: An Interview with Cara Osborne, SD, MSN, CNM, co-author of The National Birth Center Study II

January 31st, 2013 by avatar

http://flic.kr/p/v7Wse

The Journal of Midwifery and Women’s Health has just published the results of the National Birth Center Study II. As the name suggests, this is the second time researchers have undertaken a multi-site study of U.S. birth centers to understand the process and outcomes of care in these settings. The first appeared in the New England Journal of Medicine in 1989, and concluded that “birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women, particularly those who have previously had children, and that such care leads to relatively few cesarean sections.”

The current study describes birth centers as a “durable model” of care because, again, outcomes were excellent. 

Here are the key findings of the National Birth Center Study II:

  • Of more than 15,000 women eligible for birth center care when labor started, 93% had spontaneous vaginal births, and 6% had cesareans.
  • 16% of women transferred during labor, and approximately 2.5% of mothers or newborns required transfer to the hospital after birth. Emergent transfer before or after birth was required for 1.9% of women in labor or for their newborns. Most women who transferred in labor had vaginal births.
  • There were no maternal deaths. The intrapartum stillbirth rate was 0.47/1000, and the neonatal mortality rate was 0.40/1000 excluding anomalies.

I had an opportunity to interview one of the study authors, Cara Osborne, SD, MSN, CNM. Dr. Osborne is an Assistant Professor at the University of Arkansas School of Nursing, a perinatal epidemiologist, and co-founder of Maternity Centers of America. I asked her what the study findings mean for women and families and what it will take to scale up the birth center model and expand access.

AR: Thanks for participating in this interview. First and foremost, what should expectant parents know about this study?

CO: The take away messages from this study for expectant parents are that birth center care is safe and minimizes the likelihood that their baby will need to be born by cesarean, and that if hospital care becomes necessary, that transfer is very unlikely (1.9%) to be an emergency.

(Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth has prepared an excellent summary that appears at the American Association of Birth Centers web site with more about the study findings and their implications for women and families.)

The study is based on the AABC Uniform Data Set. What are the strengths and limitations of the UDS? 

CO: The UDS data were collected prospectively, which means women were enrolled in the study before the outcome of the pregnancy was known. This is an important strength because it means that the ultimate outcome could not bias the data that were collected during the pregnancy. Also, the UDS is used across dozens of birth centers, so it also enables us to get much more data than would be possible from a single birth center site.

Cara Osborne, SD, MSN, CNM

A primary limitation is that the UDS does not capture information that describes the family’s experience of birth center care, which makes correlating the clinical findings with experiential information impossible. Also, the UDS isn’t used by physicians practicing in hospitals, so we could not compare our findings to typical hospital-based care.

AR: The first National Birth Center Study reported outcomes of births from 1985 to 1987. Even though this study took place two decades later, the results are strikingly similar. If we’ve known for decades that birth centers are safe and effective, and they provide high quality care without costly hospital overhead, why isn’t there one in every community?

CO: You’re right, the results were very similar. For example the c-section rate in birth centers remained stable, going from 4% in the first study to 6% in the current study, while the national c-section rate during the same period has increased dramatically from 18% to 33%. We’ve known all along that greater use of birth centers could curb or reverse this trend, but there are several obstacles that have prevented a broad expansion of the model. They fall into three categories: systems obstacles, business obstacles, and professional obstacles.

Systems obstacles:

  • Hospitals have been predominant place of birth in the U.S. for so long that associated processes such as payment by commercial insurers and state Medicaid, the filing of birth certificates, and administration of state required newborn screening tests have all been developed based on hospital timelines and protocols. Therefore, changing the place of birth requires changes in all the associated systems as well, which can be difficult.

Business obstacles:

  • The skill set that it takes to be a good care provider and the skill set that it takes to start and run an efficient business have very little overlap, and it’s the rare provider that has both.
  • It takes a considerable capital investment to get a birth center up and running, and that’s not something most providers can access.
  • Equitable reimbursement for provider fees to midwives and facility fees to birth centers from commercial insurers and state Medicaid plans has not been available in most areas of the U.S., so the return on investment has been low.

Professional obstacles: 

  • Many physicians have opposed the independent practice of midwives while also refusing to enter in to collaborative practice agreements, which are required for midwives to provide intrapartum care in many states.
  • Birth center regulations in many states require that a physician be the medical director of the center, and recruiting physicians to fill this role can be difficult.
  • Hospitals have seen birth centers as competition and thus have not offered access to referral and transport.

AR: You are part of an effort to change things so that we do one day have a birth center in every community. Can you tell us about that effort, and why you think you will succeed?

CO: My co-founder Shannon Bedore and I formed Maternity Centers of America (MCA) in order to create a vehicle for addressing the barriers described above. As you pointed out, birth centers are a good thing and there should be more, so we built MCA to bring together professionals from a variety of backgrounds including business, real estate, construction, and health policy to look at the big picture of how maternity care works and find new ways to make birth centers a part of the healthcare system. If our efforts are successful, I believe that this broad range of perspectives will be the reason.

Credit: Center for Birth http://centerforbirth.com

As our first step, we established a demonstration site in northwest Arkansas which will allow us to try new management strategies and find ways to leverage technology while staying true to the birth center model of care. From this flagship site, we hope to develop a replicable, scalable model for the development of birth centers around the U.S. This is not a new idea, nor one that only we are working to implement. Our colleagues at New Birth Company in Kansas City and at the Minnesota Birth Center in Minneapolis are also building replicable birth center models. Each of us has a slightly different approach, and all of us need to succeed in order to or build enough scale to have measureable impact on national outcomes.

AR: The American Association of Birth Centers and the American College of Nurse-Midwives are hosting a congressional briefing next month in Washington to share the study results. Why does this study matter to policy makers?

CO: This study is of particular interest to policy makers because of both its content and its timing. Maternity care makes up the largest proportion of the national hospital bill from a single condition, and a large proportion (45%) of that is paid by government programs. A recent report from the consumer advocacy organization Childbirth Connection entitled The Cost of Having a Baby in the United States highlights the striking cost of U.S. maternity care and its inverse relationship with clinical outcomes. The report showed that almost two-thirds (59-66% depending on payer and type of birth) of the total costs of maternity care went to cover facility fees charged by hospitals. Birth centers charge facility fees too, but they are a fraction of the typical hospital fee. In addition, c-sections cost commercial payers $19,000 more than vaginal births, and they cost Medicaid programs $9,500 more than vaginal births. Multiplied by the estimated number of excess cesareans in the United States, this means about $5 billion dollars could be saved each year by improving our ability to safely get babies born vaginally.

The low value of maternity care is coming into sharper focus for policy makers at the moment due to the implementation of the Patient Protection and Affordable Care Act, which adds maternity care to the list of essential health benefits and increases the number of pregnancies that will be covered by the government through the expansion of state Medicaid programs. As policymakers attempt to realign costs and outcomes, they are looking for strategies that address the “triple aim” of healthcare championed by Don Berwick and his colleagues: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Birth centers are a viable, evidenced-based option for meeting all three aims, which is rare, particularly in maternity care. 

Are you surprised by the results of this new study?  Will  you share this information with your clients and students?  Do you think this study will have an impact on the choices that women make about their birth location? Do you believe that more birth centers can help solve many of the problems facing birthing women and maternity care today? Share your thoughts in our comment section. I’d like to hear from you.- Sharon Muza, Community Manager.

Cesarean Birth, Evidence Based Medicine, Guest Posts, Healthcare Reform, Home Birth, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Research, Uncategorized , , , , , , , ,

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

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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.

http://flic.kr/p/9Rs7mL

 

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.


 

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