27. Facilitation of related childbearing skills
optimal fetal positioning
Role and responsibilities of the midwife190
Having read this chapter the reader should be able to:
• discuss the evidence surrounding the use of optimum fetal positioning
• discuss the different positions and postures a woman can use during pregnancy to encourage the fetal occiput to rotate from a posterior to an anterior position
• discuss the different methods that may change the presentation from breech to cephalic
• identify some of the hazards associated with malpositions and malpresentations for the woman and baby.
Malposition and malpresentation in labour are associated with an increased risk of intervention during labour, instrumental and/or operative delivery and increased morbidity to the woman and baby. Reducing the incidence of malposition and malpresentation prior to labour could minimise the risks to both the woman and the baby. This chapter focuses on the use of different positions and alternative therapies used by the woman during pregnancy to encourage the fetus into an optimal fetal position.
Malposition of the occiput: occipitoposterior position
Approximately 10% of labours at term occur with an occipitoposterior (OP) position. Whereas many of these undergo a long rotation to become an occipitoanterior position during labour, a small number will persist in the posterior position. OP labour and deliveries are associated with a number of possible complications:
• higher presenting part with wider diameters that will take longer to negotiate the pelvis
• early rupture of membranes, increasing the risk of ascending infection
• cord prolapse
• uncoordinated uterine action leading to prolonged labour
• urinary retention
• premature urge to push
• increased risk of trauma to vagina and pelvic floor
• increased risk of instrumental and/or operative delivery, which may be associated with an increased blood loss
• abnormal moulding which may result in an unsettled baby and increase the risk of intracranial haemorrhage
• increased perinatal mortality and morbidity.
(Adapted from Lewis 2004)
Sutton & Scott (1996) strongly advocate using different positions and postures to encourage the fetus to rotate to a lateral or anterior position and so facilitate engagement from 34 weeks gestation onwards. They do caution women to discuss this with the health professional overseeing their pregnancy to ensure there are no contraindications to this.
The assumption behind their recommendations is to provide the fetus with room to rotate within the uterus and adopt a position that is more comfortable and better for delivery. The fetus will be able to adopt a more flexed position if in a lateral or anterior position; as the head flexes the engaging diameters will reduce and hence engagement is likely to occur earlier rather than later. Their advice centres on using upright and forward leaning postures regularly, particularly during Braxton Hicks contractions, as this is believed to assist the fetus to manoeuvre into the optimum position.
Favourable positions to adopt
• Use upright and forward leaning postures regularly (to create more space for the fetus to turn).
• To read, sit on a dining chair with elbows resting on the table, lean slightly forward and keep the knees apart.
• Sit on a dining chair facing the back, stretching and resting arms over the back of the chair.
• When sitting generally, make sure the knees are lower than the hips and keep the back straight by placing a small cushion over the small of the back for support.
• While watching television, kneel on the floor and lean over a large bean bag or cushion
• When driving, place a wedge cushion under the bottom.
• When swimming try to keep the abdomen forward; breast stroke is better for this than back stroke.
• When lying on one side, place a pillow between the legs with the top knee resting on the bed.
Positions to avoid
• Avoid relaxing in semi-reclining positions that cause the knees to be higher than the hips.
• If driving using bucket seats, have regular stops to change position and use a wedge cushion under the bottom.
• Do not sit with crossed legs or legs up.
• Do not squat in late pregnancy unless the fetus is no longer in the OP position as the head may be forced into the pelvis in the OP position.
Sutton & Scott’s (1996) work is not research based but they have strong anecdotal evidence to support their claims. This is an area that needs researching but at present does not appear to have any disadvantages for suitable women.
Another method that has been proposed since the 1950s is for the woman to adopt an ‘all-fours’ position, using knees and hands for support, used in conjunction with pelvic rocking. This method has been recommended over the years and used by many women without being researched as to its effectiveness. Hunter et al (2007) following a systematic review of the studies evaluating this intervention conclude that whilst adopting this position for 10 minutes twice a day resulted in a change in the position of the baby at the time, it had no effect on the position of the fetus at term, and thus do not recommend the hands–knees position as an intervention; however, use of this position during labour reduced the incidence of backache. Kariminia et al’s (2004) small study compared this intervention (for 10 minutes twice daily) with a control group who had to undertake walking each day from 37 weeks. They concluded that although the hands–knees posture combined with pelvic rocking exercises is a practice commonly used within midwifery to encourage rotation from the posterior to the anterior position, their results did not support this practice and recommended that in the absence of any beneficial effects, the practice should be discontinued. Encouraging rotation of the occiput from a posterior to an anterior position remains an area for further research.