ROTATIONAL POSITIONING A method for rotating posterior babies during labour
Problems associated with persistent posterior positioning Prolonged labour 12% for posterior vs. 1.7% 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% SOURCES: Ponkey, S., et al, Persistent fetal occiput posterior position: obstetric outcomes, Obstetrics and Gynecology, 101 (5), May 2003, pp 915-920 Fitzpatrick, M., et al, Influence of persistent occiput posterior position on delivery outcome, Obstetrics and Gynecology, 98 (6), Dec 2001, pp 1027-1031
Our findings 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 Babies that were ROA before labour appeared to have the highest level of intervention, especially caesareans 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
Malrotation as a cause for malpositioning 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
Causes of posterior positioning Our findings from research and anecdotal evidence: 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 Placental location: increased incidence with anterior placental sites
Dextrorotation considering clockwise movement We saw a link between babies turning in a clockwise direction from ROA and slow labours 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 Resulted in high number of caesarean births
Dextrorotation why clockwise? Everything in nature has a tendency to move in a clockwise direction 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
Needed a different approach Developed a way of encouraging ROA, ROL and ROP babies to rotate more effectively Used gravity and various positions to encourage rotation Had a significant impact on intervention rates
Rotational Positioning - Assumptions 1. Most babies that become posterior begin labour at ROA 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
Rotational Positioning - ROA 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
Rotational Positioning - ROL WHAT YOU SEE Contractions become inconsistent & may space out Mother may start to feel pain or pressure in right hip, or right thigh If mother stands, can clearly observe right hip bulging Mother may need to urinate as bladder is compressed by baby as it rotates
Rotational Positioning - ROL WHAT TO ENCOURAGE Mother to lie on right lateral Apply firm pressure to back of right hip Use heat packs to relieve discomfort at back of right hip Look for bulge behind right hip to indicate rotation occurring If mother wants to be upright, apply strong counterpressure to right hip
Rotational Positioning DIRECT POSTERIOR 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
Rotational Positioning DIRECT POSTERIOR WHAT YOU SEE If woman lies on her back, you may notice a dip near, or just below, the umbilicus
Rotational Positioning DIRECT POSTERIOR 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
Rotational Positioning DIRECT POSTERIOR WHAT TO ENCOURAGE Mother to move to left lateral Apply strong pressure to lower back Use heat packs to relieve discomfort in lower back Look for fetal movement moving towards the right abdomen and back pain moving towards the left back to indicate progress
Rotational Positioning DIRECT POSTERIOR If woman has had an epidural: Encourage a switch from right lateral to left lateral Look for line extending from top of buttocks to indicate baby moving under the sacrum
Rotational Positioning - LOL WHAT YOU SEE As baby begins to rotate past left hip, back pain becomes less constant Left hip seen to be bulging if mother is upright Contractions become more regular Look for bulge behind left hip to indicate progress, then hip returns to normal as rotation occurs
Rotational Positioning - LOL 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
Rotational Positioning - SUMMARY Picture the baby trying to rotate and use gravity to assist 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 Avoid ROM and oxytocics where possible