Optimal foetal positioning?

[newbie1]

I see that this gets mentioned frequently. I have tried unsuccesfully to search for a study that confirms its benefits. Does anyone here know of any? I mean a well designed study, not just someone's opinion.

I am geniunely interested to know if it actually works.

[reAllytee]

If you google 'spinning babies' you will find an awesome website that offers lots of info on it all.

I cant offer any studies but possibly the above website can lead the way !

All the midwives ive had in both pregnancies have talked about it so it cant be something that doesnt work iykwim.

[becca74]

www.spinningbabies.com

From: http://www.homebirth.org.uk/ofp.htm#proof

<H2>Is there any proof that this works?

Midwives and mothers who have learned about, and used, Optimal Foetal Positioning techniques are convinced that it works. There is a wealth of anecdotal evidence in favour of it. However, there have not been many trials or studies on the subject so far, because they would be extremely difficult to organise. Practising techniques to turn a posterior baby can take a lot of commitment on the part of the mother, which could not be assumed in a randomised trial. There would also be ethical problems with a trial - would mothers in the control group be told not to adopt upright or forward-leaning postures? Or would they simply not be told that taking care with their posture could lead to an easier labour?
Stremler et al study on hands-and-knees in OP labours

The most recent research on using hands-and-knees position in labour, where the baby is known to be OP, has supported OFP theory. Stremler and colleagues confirmed that babies were OP by ultrasound, then asked the women concerned to spend at least 30 minutes out of an hour on hands-and-knees while labouring. The baby's position was checked after an hour. Twice as many babies had turned OA at the end of that hour in the hands-and-knees group, as in the control group. However, because of the small numbers involved this did not reach statistical significance. I think most of us would be prepared to take a chance on that! What did reach statistical significance, however, was the women's experience of back pain; the hands-and-knees group experienced significant reductions in persistent back pain than the control group.
BMJ article on hands-and-knees in late pregnancy

A study published in the British Medical Journal January 2004 found that just going on hands-and-knees in late pregnancy (but not labour) was not enough to stop you having a posterior baby at birth. This is probably because many babies (approx two thirds) who are OP in labour, have only turned OP during labour. Therefore it's not what you do before labour which is important, so much as what you do during labour. The reference is:
Azar Kariminia, Marie E Chamberlain, John Keogh, and Agnes Shea
Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth
BMJ, Jan 2004; 10.1136/bmj.37942.594456.44
The Kariminia et al study (above) did not really look at OFP techniques in the way a committed woman might practise them - women in the study were asked to go on hands and knees and do pelvic rocks for just 10 minutes, twice a day. It did not look at whether babies were posterior or anterior at the start of labour - only at their position at the end of labour. It did not look at the position or movements of the mothers in labour, and the study didn't include any advice to women on labour positioning. Finally, it did not note whether the babies who were OP at the end of labour, had started labour OP, or had started labour OA and had turned OP during labour. So what it tells us is that a token, brief attempt at OFP techniques from 37 weeks onwards, is not on its own going to do very much for the average woman. I don't think many OFP supporters would disagree with that! It's a great shame that the study did not look at the positions the babies were in at the start of labour, or the positions of the mothers during labour. I imagine that the briefness of the OFP exercises was probably because the motivation came from the researchers, not the mothers; if they'd asked women to commit to a more comprehensive exercise and positioning package, fewer women would have complied.
There is an interesting letter from three UK midwives criticising the study, on the BMJ website. They say:

"The use of hands and knees posturing, otherwise referred to as the 'all fours posture', is widely used by midwives. It is surprising that Kariminia et al (2004) refer to it as an intervention based on personal belief (1). The use of the all fours posture has long been supported by the laws of physics and physiology (2). The law of gravity states that all objects are drawn towards the earth, and that the acceleration of movement is dependent on the mass and the availability of space. If this is applied to the fetus where the mother has adopted the all fours posture the heaviest poles of the fetus (the trunk and the occiput) would be drawn towards the earth, and into an anterior position. Such movement would be hindered only in two cases; [1] if the mass (the fetus) was not heavy enough to exert a force of acceleration or [2] if there was no available space into which the mass (fetus) could move. It appears that such principles were not considered by the authors for the intervention used in their study. Firstly, by implementing the intervention at 37 weeks, the availability of space was restricted. Midwifery practice advocates such intervention at 34-35 weeks when more space is available. Secondly the intervention was not implemented when the fetus was in an active state, which would have encouraged further movement of an already moving object. Another very important principle that was neglected related to the specific nature of the associated rocking with the all-fours posture. If 'rocking' equates to swaying of the pelvis from side to side this would exert only a frictional force which, solely, would not be of great benefit. If, however, posturing included movement of the maternal trunk backwards and forwards whilst on all fours this would both increase the available space at the pelvic inlet and along with gravitational and buoyancy forces will encourage frictional movement (3). As the mother moves her trunk forward, her spine is encouraged to move away whilst the maternal symphasis drops down, thus increasing the available space in the pelvic inlet and allowing the fetus more room to rotate to an anterior position.

If the study intervention did not consider any of these vital principles, it is hardly surprising that the result of the trial was negative. At best what the authors can claim is that their particular form of maternal posturing was both ineffective at decreasing the incidence of occiput-posterior position at birth and painful to the study participants. It cannot by any means be concluded that appropriate hands and knees exercise should be discontinued as a way of changing fetal position. No doubt further research is required, but it would be a mistake to use this study alone as a rationale for dismissing maternal posturing as a potentially effective means of changing fetal position. "

Aishah Bibi, Registered Midwife

Bernadette Earley, Registered Midwife

Sara Webb, Registered Midwife

Birmingham Women's Healthcare NHS Trust

References

(1) Kariminia et al (2004) Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. British Medical Journal 2004(328) pp.490-493

(2) Barnum C G (1915) The effect of gravitation on the presentation and position of the fetus. Journal of the American Medical Association. 64 pp.498-502 (3) Sears F W & Zemansky M W (1960) College Physics (3rd Edition) Addison-Wesley Publishing Company, Reading, Mass.

There has been one other small study [4] which looked at the short-term effects of mothers adopting a hands-and-knees position, compared to sitting, when their baby was in a lateral or posterior position. Mothers were asked to go on hands and knees, or to sit, for a short period of time, and the position of the baby was noted ten minutes afterwards. The study found that babies were far less likely to remain posterior after mothers had been on hands and knees.
This could be very useful for women whose babies are in the posterior position when they go into labour. However, since the babies' positions were only assessed for ten minutes after one session on hands and knees, this study doesn't tell us very much about the longer-term effects of alterations in the mother's posture. You can read the abstract in the Cochrane Pregnancy and Childbirth Database.
Some good evidence for the effectiveness of the theory comes from its author's own practice. When Jean Sutton was appointed Principal Nurse Midwife at a maternity unit in New Zealand, she emphasised antenatal education on foetal positioning. The transfer rate from maternity unit to hospital fell from 30% to 5 % and the forceps delivery rate fell from 3-4 per month, to 2-4 per year, over a period of several years [2].
Perhaps the most valuable aspect of OFP theory is that it gives you a set of tools to use if you find your baby has turned OP during labour. Remember that many babies are OA at the start of labour, but may turn OP as the labour progresses - thought to be more likely if the mother is lying back or sitting back, and if she has an epidural. If you can move, you can do something about it.

</H2>

[becca74]

On a related note, I homebirthed my biggest baby on my hands and knees, needing no stitches, and he took a while to get his shoulders and hips through. My instincts told me to get in that position because I could feel that in the sitting/leaning against bed position was doing sweet FA to get him out of my body. I literally felt him wriggle and kick as he moved down when I flipped over, as I'd given him more space to do so.

Without using OFP to get him out, I would have been c/sec'd a 3rd time *shudders*

[newbie1]

Becca,

Thanks for the reply. I have previously read the BMJ study.
I think on the effectiveness of OFP, much more research is needed before drawing conclusion. I don't think anecdotal evidence is enough to base recmmedation on, though OFP itself is simple and harmless.

[fai firinne]

How did you find it, Newbie? When you do the OFP exercises, what do you feel happening in your body?
During your personal experience of pregnancy, labour and birth, what did you find to be helpful?

Science is one thing, but the intangibles of birth, the things that can't be measured and evaluated, also play a significant role in successful birthing.

You see the same balance in athletic endeavour.

[newbie1]

Julia,

i never did it.
Personal experience often affects our opinion, and it often clouds our judgement.

[AM]

I'm a little confused as to your motivation on this forum. What is your background, from what angle are you coming from? You seem to be very pro intervention, and anti women sharing knowledge between them and finding things which work.

Yes, carefully controlled studies are bloody wonderful when they exist, but they are not the be all and end all, if many women have anecdotally found something to be very useful, and as you stated does no harm, I see nothing wrong with that?

Women sharing experiences has been the way huge amounts of information has been disseminated for thousands of years, and I feel it is still very relevant today, despite the existance of studies. The two things can quite happily exist side by side, they in fact fill two quite different needs in women.

Are you male or female, I still haven't worked this out.

[fai firinne]

Newbie1, when maternity care is determined without the systematic collecting and collating of women's experience, through their feedback and subjective, anectodal, personal experience of birth, but is primarily determined by what is presumed to be 'scientific method' and largely by those who have 'never done it' the results are going to be inadequate and insufficient in meeting the needs of birthing population and their infants. Of course we can play the game of "duelling research studies" till the cows come home, but until the subjective, anectodal voice of women's own experience is taken seriously, good judgement in birthing practices will be seriously clouded. The personal experience of women is discounted as being 'not scientific' and we overlook this to our peril.

Not only must optimal care be a healthy balance between the science and art of birth, but we need to be aware that much of what passes for standard maternity care in our hospitals (and what is taught in our midwifery and medical colleges and hospitals) is in fact not evidence-based, and not best practice. Not only that, but when trying to prove that a certain habitual practice is in fact "evidence-based" according to the latest studies, you get back to playing 'duelling research studies' again.

Meanwhile, so long as the collective, subjective voice of birthing women is dismissed, scientific method alone will continue to fail in moving us towards safe, satisfying, wholesome maternity care. It is possible, it's been done in other countries, and as the WHO points out, occurs where there is a balance between the art and science of birth, the midwifery/social holisitic model and excellent obstetric practice in the small minority of cases where this is called upon.

Can you tell us about your own personal experience of giving birth, please? I think that will help us to understand where you are coming from.

[newbie1]

Julie & Apprenticemomma,

I agree with some of your thoughts, but why is that when I post a different view, I get my background, my motive, and my personal experience questioned?
I have a medical backgroud, as you have probably guessed, if you really want to know. I just don't want that to affect how my posts are received. My opinion is just that, an opinion only. BTW, I have no intention of stopping women sharing informations, i am under no illusion that i have such power. If you disagree with my opinion feel free to do so, but I don't think questioning my motive etc is called for. After all, I don't do that to you.

I started this thread as I see that OFP is often promoted as the best thing since sliced bread, yet there is not a single study that demonstrated its effectiveness in reducing the C/S and instrumental delivery rate. Doe it mean it doesn't work? Not necessarily. Did I say it shouldn't be used? Not at all, as I have said it seems to be easy to do and harmless. I just don't think whenever a labour ended in C/S it is suggested that had the care provider encouraged OFP that things would have been different.

I take your point that some obstetric practices are not evidence-based. Obstetric used to be one of the least evidence-based specialty. This has been slowly changing over the last 20 years with more evidence supporting some of the interventions frequently carried out. Yet during this time, there has been plenty of criticism on the medicalisaton of birth, stating that it takes away women's right. This ignores the fact that the newer generations of obstetricians and researcher on women health and obstetrics are if fact more often than not, women.
It also seems that, some members here who are against intervention, do so simply because of the belief that nature always works best, and thus should not be interfered with. When it comes to science, they would embrace the studies that support their views (eg evidence against the routine use of electronic fetal monitoring), yet would disregard those that are against their view (eg induction for posterm pregnancy, routine use of oxytocics in third stage, induction for rupture of membrane, and the list goes on). It is very easy to say that I refused intervention against the dr's advice and I gave birth naturally without problem, so the Dr must be wrong. Most of the time, pregnancy is problem free regardless of what you do, and often intervention needs to be carried out on many women to prevent one potential bad outcome/improve the outcome. Thus using anecdotal evidence/personal experience is particularly unreliable in obstetrics, as any potential difference in outcomes may not be evident unless large scale study is carried out.

Research is analysed on its merits, not on the personal experience of its resechers. Otherwise, cancer researchers would need to have suffered cancer themselve to be able to produce relevant studies? And men can't treat women and women can't treat men?

Just my opinion.