ROTATIONAL POSITIONING
Prolonged labour – 12% for posterior vs. 1.7%
SOURCES:
Ponkey, S., et al, “Persistent fetal occiput posterior position: obstetric outcomes”, Obstetrics and Gynecology, 101 (5), May 2003, pp 915-920
Problems associated with persistent posterior positioning
Assisted delivery – 24.6% for posterior vs. 9.4% Caesarean delivery – 37.7% for posterior vs. 6.6%
Anal sphincter injury – seven times higher with posterior Augmentation – 48.9% for posterior vs. 36.8%
In line with research studies, we found that our clients who had posterior babies, even if they rotated to LOA, were more likely to have interventions
On analyzing these births we found that most of the babies in an ROA position at onset of labour, rotated to posterior as the mother entered active labour
Babies that were ROA before labour appeared to have the highest level of intervention, especially caesareans
Most posterior positions develop as a result of malrotation from an anterior position
-68% of persistent posterior start anterior
-32% of persistent posterior are posterior at onset of labour
SOURCES:
Gardberg, M., et al, “Intrapartum sonography and persistent occiput posterior position: a study of 408 deliveries”, Obstetrics and Gynecology, 91 (5), May 1998, pp 746-749
Our findings from research and anecdotal evidence:
Causes of posterior positioning
Dextrorotation: like other natural objects, the human body has a tendency to move in a clockwise direction
Muscular imbalance: psoas muscles and round ligaments can be tighter on one side than the other, pulling the uterus to one side
Posture: poor maternal posture and lack of forward movement (e.g. housework) increase the risk
Morphology: short stature and short waistedness increase the risk of posterior positioning
We saw a link between babies turning in a clockwise direction from ROA and slow labours
Dextrorotation – considering clockwise movement
By the time the baby reached the right hip, mothers were exhausted
Once back pain started they tended to opt for epidurals
Rupture of membranes, oxytocics and left lateral tended to cause increasing problems
Everything in nature has a tendency to move in a clockwise direction
Dextrorotation – why clockwise?
The human body also has a tendency to work in a clockwise direction
Uterine pacemakers lie on the left of the fundus, moving contractions in a slightly clockwise direction
Moving clockwise from ROA towards LOA protects the baby’s head, avoiding the symphysis pubis, which is not padded with as much ligament as the posterior of the pelvis
Developed a way of encouraging ROA, ROL and ROP babies to rotate more effectively
Needed a different approach
Used gravity and various positions to encourage rotation Had a significant impact on intervention rates
1. Most babies that become posterior begin labour at ROA
Rotational Positioning - Assumptions
2. Babies prefer to turn clockwise 3. Gravity aids rotation
4. The faster a baby rotates, the lower the incidence of complications
5. The baby will continue to turn until it finds a position where the head can comfortably descend through the pelvis
WHAT TO AVOID
Maternal exhaustion Rupture of membranes Lying on left lateral
All fours
Wait and see if baby rotates spontaneously to LOA across anterior of pelvis
Contractions become inconsistent & may space out
Mother may start to feel pain or pressure in right hip, or right thigh
WHAT YOU SEE
If mother stands, can clearly observe right hip bulging
Mother may need to urinate as bladder is compressed by baby as it rotates
WHAT TO ENCOURAGE
Mother to lie on right lateral
Look for bulge behind right hip to indicate rotation
Apply firm pressure to back of right hip
Use heat packs to relieve
discomfort at back of right hip If mother wants to be upright, apply strong counterpressure to right hip
WHAT YOU SEE
Back pain during contractions and possibly between contractions
Right hip moves back to normal position as baby rotates further Sacrum begins to move outwards Head may be found to be deflexed on vaginal examination
WHAT YOU SEE
If woman lies on her back, you may notice a dip near, or just below, the umbilicus
WHAT TO AVOID
Positions where mother is forward until after the baby has moved to LOP
Rupture of membranes
As the baby moves under the sacrum, you may feel the fetal
heartbeat behind the sacrum with your fingertips
WHAT TO ENCOURAGE
Mother to move to left lateral
Look for fetal movement moving towards the right abdomen and back pain moving towards the left back to indicate
Apply strong pressure to lower back
Use heat packs to relieve discomfort in lower back
If woman has had an epidural:
Encourage a switch from right lateral to left lateral
Rotational Positioning – DIRECT POSTERIOR
Look for line extending from top of buttocks to indicate baby moving under the sacrum
WHAT YOU SEE
As baby begins to rotate past left hip, back pain becomes less constant
Look for bulge behind left hip to
indicate progress, then hip returns to normal as rotation occurs
Left hip seen to be bulging if mother is upright
Contractions become more regular
WHAT TO ENCOURAGE
Mother to move to all fours
Provide firm massage on abdomen, stroking from left of mother’s abdomen towards the right
If another supporter present, continue to apply sacral counterpressure if any residual back pain present
Picture the baby trying to rotate and use gravity to assist
Rotational Positioning - SUMMARY
Explain progress to mother to encourage and provide motivation
Do not expect consistent rates of progress – throw away the curves!
Focus on rest and reserving energy, keep mother well hydrated and eating well
