Friday, May 29, 2009

Yes, I've seen the new Institute of Medicine guidelines on how much weight "obese" women are supposed to gain (or more accurately, not gain) during pregnancy. (See Yahoo "health" news.) Wanted to reassure you all that I will be commenting on it soon.

But first I have to put top priority on some mom stuff, some end-of-the-school-year activities and big events that need my more immediate attention, and then I'll get to this. Sometimes blogging has to take a back seat to real life, but wanted to reassure you that I'm aware of this story and have plans to discuss it.

In the meantime, feel free to talk among yourselves about the new guidelines. What do you think of them, how do they make you feel, what are your concerns, are they realistic, what do you think the practical application of the guidelines will be in clinical practice?

I'll publish comments frequently until I have time to blog more fully about this, but in the meantime, let's start some dialogue on the topic.

What do you think about the new IOM guidelines?

Monday, May 25, 2009

Holiday Fluff: No. 1 Ladies' Detective Agency

Although I'm busy like crazy right now, trying to get through end-of-the-school-year activities, I did find time recently while I was doing laundry to watch a new TV series. Now I'm a big fan and I have to spread the word!

The series is called "The No. 1 Ladies' Detective Agency" and it's on HBO. They just finished the first run of the series but it will get repeated soon so if you haven't seen it yet, put it on your "record" list ASAP.

The series stars Jill Scott, an American singer and actress. She is a woman of size. Huzzah!

The thing that's most refreshing about the series is that this well-rounded woman is portrayed as a completely well-rounded human being too. How often is a woman of size allowed to be more than a one-note caricature on TV? Yet this character is. She's smart, she's sassy, she's vulnerable, she's assertive, she makes mistakes, she falls in love, she solves cases, and oh yeah, she's funny too.

I haven't yet seen the first couple of episodes in the series because I only heard about it partway through its run. I set my DVR to record the rest of the series, but I was so busy I didn't get to watch it for quite some time. In fact, I almost deleted it, thinking I'd never get around to it anyhow......but thank goodness I took a chance and peeked at it while folding some laundry one night! I quickly got hooked.

It's not a laugh-out-loud, smile-a-minute series. It's quirky and atmospheric, and the humor is more chuckle-y and character-driven. It also has some sad moments and a little romance thrown in for good measure too. It's just charming overall, and was definitely quite enjoyable. Even my husband got hooked after a while, despite initially thinking he wouldn't care for it.

Jill Scott, the star, was pregnant for the filming, so there's even a well-rounded mama connection!! How cool is that!

I was watching her in the series before I knew she was pregnant and just had a little inkling of something, that little intuition I get sometimes when people are pregnant. It was just the way her body was shaped and the way she moved, I think....kinda rang a memory bell for me. I shrugged it off at the time but now that I know she was pregnant during the filming, I get a little chuckle out of it. My "babydar" is still going strong!

The good news is that she had her baby last month. What a lovely gift for her after experiencing years of infertility, and what a note of hope to other women who have been through the infertility rollercoaster too. Congratulations to her on her new son!

I should note that the series is not perfectly fat-friendly. There are a few remarks here and there about "overeating" or vague insults about her shape from others, and they did pad her some for the role.........but the director and author were adamant about having a woman of size (what they call a "traditional build") in the role, and for the most part, she is treated with real respect and portrayed as a woman of beauty.

And she really is beautiful in the role, too. Look at her picture there. What a gorgeous woman.

There are also occasional people of size in other characters as well. Usually, on the rare occasion there is a fat person in a movie or series, he/she is the token fat person, rather than having a cast full of people of varying sizes to represent the diverse spectrum in most societies. So that diversity of size among multiple characters in this series was refreshing too.

The show is based on a book series by Alexander McCall Smith, and the action takes place in Botswana. Others have said that it stays very true to the culture of Botswana and is very respectful of its people. It is a fascinating and gentle introduction to this very inviting culture and definitely makes you want to learn more about it.

The series has quite a pedigree of famous people. The two-hour series pilot was directed by the late Anthony Minghella (Oscar winner for "The English Patient"); it was co-produced by the late Sydney Pollack ("Out of Africa") and co-written by Richard Curtis ("Four Weddings and A Funeral"). Famous guest stars in the show include CCH Pounder ("ER" and "The Shield") and Idris Elba ("The Wire" and "The Office").

The lead in the show is Jill Scott, a Grammy Award-winning singer, poet, and actress. She plays Precious Ramotswe, a woman who ends an abusive marriage, then takes an inheritance from her father and turns it into a detective agency, supposedly the first in Botswana. Although she is a detective and the show features some mysteries, they are refreshingly less graphic than the usual "CSI" style fare and feature some unique African twists to the stories.

The secondary lead in the show is Anika Noni Rose, from "Dreamgirls." She is a Tony-award winning actress who is set to become Disney's first black animated princess character later this year. She plays Grace Makutsi, the secretary and aspiring detective at the agency. Her character is more stiff; the actress seems to be playing it for laughs and it doesn't work at first glance. But as the series progresses on, the character begins to "click" and her mannerisms become more quirky and humorous and gives some genuine chuckles later on.

I've read reviews that say that the pilot drags a bit and that the series doesn't really hit its stride until about halfway through. Since that's about when I really started watching, I can't say. All I know is that the last several episodes were really charming and if you start from the beginning of the series, it may behoove you to stick with it for a few episodes if it doesn't "spark" for you at first.

I look forward to catching the rest of the episodes soon and I really hope that HBO will make more in the future. It's certainly a series worth continuing.

*According to the HBO website, it looks like the series is scheduled to repeat next weekend, starting on May 30th and 31st. Be sure to set it to record if you get HBO. Definitely worth catching.

Sunday, May 17, 2009

Going in the Wrong Direction

The Los Angeles Times actually had a pretty decent article recently about the strong rise in childbirth-related healthcare costs, and declining U.S. childbirth outcomes. You can read it here.

Even if you are not pregnant or will not ever have children, this is an important article to read because the topic affects your bottom line....your pocketbook.

The article makes the important point that our increasing use of interventions like induction and cesarean sections are driving up our healthcare costs enormously while not improving outcomes. Indeed, some outcomes are actually going downhill.

Childbirth often is held up in healthcare reform debates as an example of how the intensive and expensive U.S. brand of medicine has failed to deliver better results and may, in fact, be doing more harm than good.

"We're going in the wrong direction," said Dr. Roger A. Rosenblatt, a University of Washington professor of family medicine who has written about what he calls the "perinatal paradox," in which more intervention, such as cesareans, is linked with declining outcomes, such as neonatal intensive care admissions. Maternity care, he said, "is a microcosm of the entire medical enterprise."

Too Many Cesareans

The article discusses how the rising cesarean rate in particular is driving up healthcare costs and resulting in poorer outcomes.

Once reserved for cases in which the life of the baby or mother was in danger, the cesarean is now routine. The most common operation in the U.S., it is performed in 31% of births, up from 4.5% in 1965.

With that surge has come an explosion in medical bills, an increase in complications -- and a reconsideration of the cesarean as a sometimes unnecessary risk.

One of the more interesting points the article made was how much depends on your choice of birthplace. You really shouldn't just choose the hospital closest to you. Your chances of interventions like a cesarean varies dramatically, depending on which hospital you go to.

Among California hospitals, cesareans range from 16% to 62% of births. Such variation means a lot of women are getting unnecessary cesareans, Main said. "There's no justification for that kind of variation." [emphasis mine]
Of course, you can decrease your risk for cesareans even more by choosing an out-of-hospital birth, which more and more women are recognizing as a reasonable alternative (and which has been endorsed by the Royal College of Obstetricians and Gynaecologists in the U.K. as a reasonable choice for women with uncomplicated pregnancies).

Or you can select a hospital care provider who follows the midwifery model of care, which emphasizes proactive prevention of problems, de-emphasizes use of interventions such as inductions, individualizes care based on each woman's needs, and sees labor and birth as a normal physiological process instead of a disaster waiting to happen.

Some doctors follow tenets of the midwifery model of care, and not all midwives follow the midwifery model. You can't always tell a provider's philosophy by their title or degree, so it's not simply a matter of choosing always choosing a midwife, and of course, some women have complications or special needs that necessitate seeing a doctor.

But if you ask careful questions and choose a provider that practices from the midwifery model, whatever their title, chances are much higher of you avoiding unneeded interventions and having a spontaneous vaginal birth.

Too Little Support For VBAC

The article also discusses how doctors frequently limit women's access to Vaginal Birth After Cesarean, or VBAC.

The International Cesarean Awareness Network (ICAN) did a telephone survey this year of virtually all the hospitals in the United States and found that nearly half did not permit VBACs, either by outright policy ban or because no doctors at the hospital would take a VBAC.

In fact, even in the hospitals that in theory "permitted" VBACs, few actually had many VBACs occur, which means that their "support" for VBACs was mostly theoretical and in reality, most mothers were talked out of a VBAC.

Based on the comments ICAN received in the survey, they estimated that only about 10% of hospitals contacted were truly VBAC-supportive, where women would actually have a reasonably good chance of having a VBAC. That's the apalling state of VBAC in this country today.

Consider the healthcare implications of this. If the rate of cesareans in first-time mothers is strongly increasing, and if most doctors do not support VBAC anymore, that means that nearly all those mothers will be having repeat cesareans for any subsequent children. It doesn't take long for that to really add up.....and for the related costs to add up too.

The lack of access to VBAC for most women means that a lot of unnecessary repeat cesareans are being performed all over the U.S., and that's another reason why our healthcare costs are spiraling completely out of control.

Even when there are no complications, the hospital stay for a cesarean is twice as long, and the costs for all the services needed are higher. Add in complications such as wound infections, blood clots, hemorrhage, and breathing issues for the baby (all of which are higher with a cesarean), and all these cesareans are really costing a lot. As the article notes:

Because spending on the average uncomplicated cesarean for all patients runs about $4,500, nearly twice as much as a comparable vaginal birth, cesareans account for a disproportionate amount (45%) of delivery costs. (Among privately insured patients, uncomplicated cesareans run about $13,000.)
So not only does the rising primary cesarean rate cost our healthcare system dearly, the fact that few hospitals currently support VBACs will continue to cause a rebound effect, driving the cesarean rate (and our healthcare costs) even higher in years to come.

Too Many Early Deliveries

Another important point the article made is the trend to deliver babies earlier and earlier.

The average pregnancy lasts between 38-42 weeks, with 40 weeks being considered the official "due date." But the length of the average pregnancy has declined, according to the article, and is now just 39 weeks.

Yet early delivery often creates problems with babies that just aren't quite ready to be out in the world yet. Babies born even just a little too early can have trouble with their breathing, with maintaining a stable blood sugar, with nursing effectively, and with neonatal jaundice. This means they often go to the Neonatal Intensive Care Unit (NICU), and that drives up healthcare costs. From the article:

In an analysis of its claims, United[Healthcare Services Inc.] found that 48% of newborns admitted to neonatal intensive care units were from scheduled deliveries, many of them before 39 weeks.
One of the best ways to start reducing maternity costs is to decrease the rate of early inductions and cesareans. This should start from the top-down, from institutional policies, but until those institutions really start reforming their practices, it can start with mothers refusing early interventions that are not truly medically necessary. Even better, it can start with women refusing to choose a provider likely to order such early interventions.

The Burden of Rising Maternity Costs

Rising maternity costs are taking up an increasing proportion of the already over-bloated healthcare budget in the U.S., and will only continue to rise as the rates of interventions like cesareans go up. In an increasingly stressed economy, this makes no sense.

Pregnancy is the most expensive condition for both private insurers and Medicaid, according to a 2008 report by the Childbirth Connection, a New York think tank.

"The financial toll of maternity care on private [insurers]/employers and Medicaid/taxpayers is especially large," the report said. "Maternity care thus plays a considerable role in escalating healthcare costs, which increasingly threaten the financial stability of families, employers, and federal and state budgets."
It is time for some healthcare reform, and one of the first places to start is in the maternity care system and the skyrocketing rates of inductions and cesareans.

Even if you never plan to have children, pressing for childbirth reform is in your own best interest because of the ultimate impact of an out-of-control cesarean rate on healthcare costs that you will have to help shoulder.

It's time to press for institutional change, for policies that strongly discourage early delivery, for policies that discourage induction for convenience or for "soft" indications, for policies that strongly discourage unnecessary cesareans, and to demand that hospitals honor women's right to access VBACs.

And for those who plan to have children, we as consumers can drive this maternity care reform by voting with our feet.

We can demand that hospitals and doctors be required to report their cesarean rates to the public, we can boycott hospitals and doctors with high cesarean rates (and let them know why we are not choosing them), we can refuse to allow early and unnecessary interventions, and we can choose a provider that follows the midwifery model of care to lessen our risks of costly procedures like inductions and cesareans.

Childbirth care and outcomes are indeed going in the wrong direction in many ways, and it's up to all of us to help change that trend.

Wednesday, May 13, 2009

Care Providers vs. "Scare" Providers

Far too many doctors and other healthcare professionals have decided to become "Scare Providers" instead of "Care Providers." This seems to be particularly true for fat women in the realm of pregnancy and childbirth.

I am hearing more and more stories lately about doctors telling fat women that they will never have a healthy pregnancy, that if they dare to become pregnant at their size they will probably die, that their baby will die, or that they will never have a healthy baby.

This kind of bullying is not the experience of all fat women, mind, but I am hearing this kind of story much more often than I used to. The risks around pregnancy in women of size has become SO hyped now that some doctors are totally distorting the actual risks way out of proportion, trying to scare fat women away from having babies at all.

The Newest Story for the "Scare Providers Hall of Shame"

A mother from a support group for women of size recently wrote about her experience going to a Reproductive Endocrinologist (RE). She gave me permission to share it here.

She is 29 years old, "overweight," and has been trying to get pregnant for 2 years without success. She saw an OB, who determined that she has a blocked tube and doesn't ovulate regularly. They did lab work and counseling to discuss her risk factors and to work out a healthy, sane proactive plan for having a healthy pregnancy. Then her OB sent her to her local RE for help in getting pregnant.

The RE took one look at her size and started interrogating her. In the end, he refused to help her, telling her it would be "unethical" to assist them with pregnancy because of her size.

He also told them that if they were to get pregnant somehow, "The baby would only have a 5% chance of survival." FIVE PERCENT.

Then he told them that he would be writing a letter to her doctors so they would quit wasting his time with cases such as hers anymore.

Now, I have no idea where that doctor got that "5% chance of survival" bullshit. I've read a LOT of medical studies on "obesity" and pregnancy, and I have NEVER seen any number like that in ANY study.

It was purely and totally a scare tactic number, pulled out of his behind and not based on any real research. Bottom line, it was designed to bully and frighten this woman out of having a baby.

Fortunately, she didn't buy into this bullshit at all, but how many fat women have been told crap like this (or read scary online "information" articles and media releases) and are intimidated out of having children?

Other Stories in the Hall of Shame

This is just the latest story of fat bias mistreatment. You'd think I'd get used to reading these by now, but my blood starts boiling every time I read these things.

I've documented other stories like this on my blog before, but it was early in the history of the blog and few people had found me then, so pardon me for a little repetition. Let me hit some of the "highlights" for you.

First, there's the story of the woman who emailed me last year about "Suicide By Pregnancy." An OB at a prestigious university medical school told her that if she chose to continue her pregnancy, she would almost surely die. Here's a quote:
He told me that I wasn't going to make it alive through my pregnancy and that they would "have to take drastic measures to try save me before they would even attempt to save my baby" etc.

He kept saying I shouldn't have gotten pregnant, that I had in a sense, committed suicide! He told me that my heart was going to give out, or that I was going to stroke out while attempting to push my LARGE baby out, therefore I was going to have a c-section. He told me that I was going to have massive blood clots in my legs and severe pre-eclampsia.

I left his office completely panicked and in tears. I was shaking so bad I could hardly walk and all he did was look at me and said in a cold voice with no emotion at all, "It's really scary, isn't it."
Or there's Gina Marie's story, where she was induced early because of a suspected big baby, which resulted in a cesarean, as inducing early for a big baby often does. (Of course, they blamed the c-section on her obesity instead of on inducing for macrosomia, naturally.)

Just before the cesarean, the OB pressured her to agree to tie her tubes so she wouldn't have any more pregnancies. When she would not agree, they implied she would not survive the surgery, asked if she was an organ donor, and wanted to know what funeral home to use.

Then they used a classical incision in the cesarean (a huge up-down incision, which is usually used only when a baby needs to come out as FAST as possible, which was not true here), and told her that if she dared have another pregnancy, her uterus would "explode."

In other words, they found a way to punish her and scare her out of another pregnancy, despite her not agreeing to let them tie her tubes.

After the surgery, they took turns coming into her room and yelling at her about losing weight:
Not only did I need to diet, but if I did not do so, I would be dead before ten years, because women my size don't live past 40. My child would never love me because he would be so ashamed to have a fat mama. Fat women are bad mothers who can't keep up with their children, and their children suffer for it. By obstinately continuing to be fat, I would show myself to be an unfit mother.
Then of course, there are the fat women who are pressured to terminate their pregnancies, simply because they are fat. The implication is that the baby of a fat woman could never be healthy, that pregnancy at larger sizes is so dangerous that the pregnancy must be aborted in order for the woman to survive, or that the baby would die in a fat pregnancy anyhow so you might as well abort sooner than later.

As one woman recounted:
I also was told I could not have kids. Then when I got pregnant I was told by various doctors for various reasons that I should abort.
This is the latest tactic in the obesity hysteridemic------extreme medical bullying.

A New Form of Medical Bullying

Medical bullying has been around for "obese" people for a long, long time, but it only seems to be getting worse now with all the hype about obesity.

Fat women have been having babies for years too, but the risks of obesity and pregnancy are so hyped nowadays in the media and the medical literature that doctors have a hugely exaggerated sense of risk with it.

Because of this, they feel justified in a nearly 50% cesarean rate for "morbidly obese" women (or more; that study was only on first-time mothers); in preventing fat women from having access to reproductive technology (as is happening in the UK); in pressuring women of size to not get pregnant unless they get to a "normal" BMI first (which, given the long-term failure rate of dieting, basically means that very few will ever have babies); or in scaring fat women out of trying to conceive at all or into terminating their pregnancies.

Basically, they are trying to emotionally manipulate fat women out of pregnancy (or further pregnancies) by any means they can.

I've said it before but it bears repeating.....this kind of over-the-top BULLYING is a total exaggeration of the risks, and basically amounts to trying to scare women of size out of having babies rather than giving them reasonable counseling about possible risks and ways to mitigate those risks.

It is a unique and insidious form of eugenics and IT MUST STOP.

*If you have a story of fat-biased treatment that you encountered during pregnancy or birth, please feel free to email it to me at kmom at plus-size-pregnancy dot org. It's very important that we document these kinds of incidents.

Friday, May 8, 2009

Friday Fluff: Attn Firefly/Serenity Fans!

Okay, I really didn't want to interrupt my fetal malposition series for something non-sequiturish and fluffy, but what the heck. It's Friday and I'm going to see the new Star Trek movie tonight. Geekdom SO trumps continuity.

If you are a Firefly/Serenity browncoat (or Nathan Fillion) fan at all, you have got to check out these comics. Too funny!!!

Be sure to read the whole series. Here's the link to the first in the series.

Here's part 2.

Wednesday, May 6, 2009

How Fetal Position Can Affect Labor

We've been talking about how fetal position can affect a woman's belly shape. Today, we start discussing how it can affect labor.

As a reminder of what we discussed last time, remember that an Anterior baby (Occiput Anterior, or OA) means the baby is head-down; the back of the baby's head is towards mom's belly and the baby is facing towards mom's back.


A Posterior baby (Occiput Posterior, or OP) means that the baby is also head down BUT the back of the its head is towards mom's back and baby is facing towards mom's front. Other names for the OP position include "stargazer" or "sunny side up" because the baby seems to be looking "up" at the sky when mom is lying down.


Why Fetal Position is Relevant

Question: Why be concerned about the position of the baby before birth?

Answer: Because the anterior position (facing mom's back) is generally an easier position for birth. A posterior baby (facing mom's belly) is generally a harder position for birth and the cause behind many cesareans these days.

But why is that? Well, there are a number of factors that are at work here.

Speed and Ease of Labor

Generally speaking, anterior babies are born more quickly and easily than posterior babies.

Labor with an anterior baby is usually less painful and progresses smoothly (as long as the baby is lined up well and does not get a hand or arm in the way!).

Labor with persistently posterior babies tends to be slower and more painful, and more prone to stall partway through labor. (More on that below.)

"Fit" Problems

With an anterior baby, the diameter of the baby's head that presents through the pelvis is smaller because the angle is different. The chin is usually tucked down so the smallest possible diameter of the crown of the head presents at the cervix. This then applies nice even pressure on the cervix so it usually dilates reasonably fast and easily.

The angle of presentation of the baby's head is different with a posterior baby, so the diameter of the head that must fit through first is larger. Furthermore, an OP baby often does not tuck his chin to his chest as much (sometimes called a "military" position), and its de-flexed head makes an even bigger diameter to fit through.

Some sources state that the average OA baby's head diameter is about 9.5 cm, compared to 11.5 cm for the same baby if he is OP and de-flexed. Two centimeters doesn't sound like a lot, but it's around 20% of the total diameter of the baby's head, which is significant. And that 20% can make a lot of difference in how quickly and easily the baby fits through the pelvis. (See the pictures below.)

In addition, the "fit" of the baby's head in mom's pelvis is trickier with an OP baby and there's not as much room for error. If the baby is a little out of alignment in an anterior position, he can usually still fit through. If he is a little out of alignment in a posterior position, the same baby may not "fit" as well.

Molding Issues

Because the OP baby's head enters in a larger diameter and is often deflexed, it has to mold more.

"Molding" is where the bones of the baby's head slide over each other, like the metal plates of a vegetable steamer that fold in. This helps to make the head smaller and helps it fit through more easily. It's one of nature's ways to ensure that babies of diverse sizes can fit through pelvi of diverse shapes and sizes.

Molding is natural and no big deal, but there's quite a bit more molding needed with a posterior baby and that takes a lot of time. Alas, hospitals are notoriously impatient with "slow" labors.

Slower Dilation and Labor Dystocia

Because the pressure on the cervix with an posterior baby tends to be more uneven, dilation also tends to be slower and more uneven.

Furthermore, because the presenting diameter of the head is larger and needs more time to mold, a posterior labor often stalls out or slooooows down for a while in the middle of labor. This slowing/stalling is called "labor dystocia" and usually happens at about 4-7 cm.

Even though she is still only about partway through labor, during labor dystocia the mother may be showing classic signs of "transition" (the last part of labor) like shaking, intense pain, a premature urge to push, exhaustion, or wanting to give up.

If the baby needs to do extensive molding, this labor dystocia stage may go on for quite some time and can be very discouraging and tiring. As a result, a lot of women request epidurals (or even cesareans) at this point---often out of sheer exhaustion.

More Interventions

Because the posterior labor tends to be slower and may stall for a while, medical interventions are often used to compensate. Hospitals often try to speed things up by artificially strengthening contractions with drugs (pitocin augmentation) or by breaking the mother's water.

It should be noted that sometimes this does work just fine and may be better than doing nothing.......but sometimes it permanently jams the baby into a bad position that he can't get out of. His head gets stuck in that position, the pitocin augmentation keeps ramming him into the pelvis at a bad angle, and the pitocin may start reducing the amount of oxygen getting to him. As a result, he may go into fetal distress.

Also, once the mother's waters are broken, the cushion of fluid is lost. Labor usually becomes much more painful for the mother, the lack of cushioning fluid makes it more difficult for baby to rotate OA, and the baby has less protection, making him more vulnerable to fetal distress and infection. Many cesareans are done at this point because the baby is not tolerating labor well.

Furthermore, because of the uneven pressure on the cervix, there is often a cervical "lip" left near the end of dilation. Care providers often manually push this out of the way, over the baby's head----another quite painful intervention common to posterior labors.

It's no wonder that many moms with posterior babies are ready to call it quits before the baby is even born.

Back Labor

Labor with an OP baby tends to be more painful and difficult. The back of the baby's head tends to hit against the mother's sacrum, making labor more painful and concentrated in the back and pelvis (and sometimes the hips, if the baby tries to rotate to anterior). Back labor and OP positioning are not always connected, but they are frequent companions.

Requests for pain relief are more common with posterior babies because of the combination of back labor, labor augmentation drugs, breaking the mother's bag of waters, and the sheer exhaustion of a long hard labor. Many, many moms with persistently posterior babies end up with epidurals, even those who strongly desired natural childbirth beforehand.

Sometimes the epidural will help ease the pain from an OP labor enough to relax the muscles and help the baby turn anterior. However, because an epidural partially paralyzes the muscles of the uterus that help maneuver the baby through the pelvis, sometimes the epidural makes it even more difficult for the baby to turn anterior. So while sometimes an epidural can help in an OP labor, sometimes it's just another step along the way to a cesarean.

Ironically, the pain relief from epidurals tends to be less effective with an OP baby. There is often a need for frequent re-dosing of the epidural, and pain relief can be spotty, with "windows" of sensation. No one is quite sure why this happens, but it probably results from a lack of uniform distribution of epidural meds because of the pressure from the baby's head against the mother's spinal column.

Inadequate pain relief during a long, hard labor is another reason why mothers and hospital staff may be more quick to move to a cesarean. No one likes to suffer (or to watch others suffer), and a cesarean may seem like the most compassionate thing to do at that point....the best way "out" of a tough situation.

However, the spotty pain relief associated with epidurals in OP labors may make them less than 100% effective for the surgery there are no easy answers here.

Long Pushing Stages

Eventually, given enough time (or enough pitocin augmentation), many mothers of OP babies will dilate fully and begin pushing------only to have pushing go nowhere.

A long, painful pushing stage that goes on for hours is a classic sign of a posterior baby. The baby simply doesn't "fit" well in that position, or hasn't molded enough yet to get through.

However, with enough time and molding (or some creative pushing positions), some OP babies will finally "fit" through, hit the resistance of the mother's pelvic floor, and rotate to anterior. They are usually born very quickly after turning to OA.

Some babies remain persistently OP and are born face-up, but often to an exhausted mother and caregiver. They may have avoided a cesarean, but often at a price, because mothers of vaginally-born persistent OP babies tend to have more instrumental deliveries (low forceps or vacuum extractor), more episiotomies, and more (and more severe) perineal tears.

The good news is that they don't have the surgical recovery of a cesarean, nor a scar on their uterus that puts future pregnancies at risk----but it's still not usually an easy birth.

A better choice would be to find a way to prevent the OP position or to turn the baby to OA while in labor so that it could be born more easily, without the collateral damage from either a surgical birth or a rough vaginal one.

Illustrations of the Difference in "Fit"

Below are pictures of anatomical models of a fetal head and a woman's pelvis. In one picture, the baby is anterior (facing mom's back); in the next picture, the baby is posterior (facing mom's front).

Please note, it's the same fetal head model and the same pelvis model, but look how much more room there is around the baby's head when the baby is anterior.

Anterior fetal head
in woman's pelvis

Posterior fetal head
in woman's pelvis

Look one more time for good measure. Notice how much more room there is for the baby's head in the anterior position? Same baby, same head, same mother's pelvis.....but a different "fit" because of the baby's position and the flexion (tucking) of its head.

[Note for the curious: The lines drawn on baby model's head are "suture lines," where the plates of the baby's head bones come together. The diamond shape is the fontanelle or "soft spot" near the front of baby's head. Feeling for the shape of these suture lines is one way midwives and doctors figure out the baby's position during labor.]

Not All Posterior Labors Are Equal

It has to be noted that not all posterior births are difficult. Some women have easy OP births. They tell the story of how their posterior baby "flew out" and wonder why other posterior moms can't birth their babies so easily.

Well, it's because not all posterior labors are created equal.

Some posterior babies are relatively small and have their chins tucked nicely down; these labors take a little while longer than anterior labors on average but tend to be born vaginally. It's the big baby whose head is de-flexed and who is persistently posterior through all of labor that tends to have the most difficult labor and birth.

Many posterior babies flip to anterior partway through labor, once their heads have molded enough to get into the pelvis. These babies may have a slow start to labor, but labor usually progresses quickly once the baby rotates to OA.

Whether you've had a baby before can make a difference. Mothers who have given birth before (multips) tend to have more spontaneous OP vaginal births (no cesareans, forceps or vacuum extractors) than first-time mothers (primips). One Irish study showed that only 29% of primips had a spontaneous vaginal birth with an OP baby, while 55% of the multips had one. (Mind, that still means that even the multips had a 45% rate of major interventions with OP babies, which is still quite high.) Other research has found similar results.

Some posterior births happen when the baby begins labor anterior but then flips posterior partway through labor. Some research shows this can be associated with epidurals; the partial paralysis of the muscles in the area may make it more difficult for the baby to turn properly during its journey through the pelvis. However, a flip at this late stage (when it's already partway into the pelvis) usually means that even an OP baby comes out fairly efficiently and a vaginal birth is common.

It's the persistently posterior baby----one who is posterior from the beginning of labor and remains so consistently throughout, and especially one who is big and whose head is de-flexed----these are the posterior labors that tend to be long, hard, and painful.

That's not to say that a persistent posterior cannot be born vaginally. Of course not! A persistently posterior position is not an impossible position for birth.....but it often needs more time and patience and support from caregivers.

Unfortunately, because of economics and "standard of care" procedures, time and patience for longer posterior labors can be in short supply in hospitals. Therefore, the cesarean rate associated with persistently posterior babies can be quite high.

Research on Persistent Posterior Positioning

Here is a 2003 study that compared the effect of persistent posterior (OP) and anterior (OA) positioning on labor outcomes. There are several other studies like this available as well.

You can see that on average, OP babies had longer labors, longer pushing phases, and more than five times the cesarean rate.

Labor longer than 12 hours
OA: 26.2%
OP: 49.7%

Length of pushing greater than 2 hours
OA: 18.1%
OP: 53.3%

Cesarean delivery
OA: 6.6%
OP: 37.7%

(Ponkey et al. Persistent fetal occiput posterior position: obstetric outcomes. Obstet Gynecol 2003.)

In addition, some studies find that persistent posterior positions are harder on the babies, with more NICU stays or longer hospital stays, more signs of stress, and sometimes lower Apgar scores at birth.


So you can see, persistent posterior positioning DOES affect labor and birth. It tends to create longer, harder and more painful labors, long pushing phases, and results in a much higher rate of cesareans. It also can be more stressful on the baby.

Posterior positions that occur partway into labor, posterior babies that rotate to OA during labor, posterior babies in multips, or posterior babies that tend to be small and/or with well-tucked heads.......these OP babies don't usually cause as many problems and have a good chance at a normal vaginal birth.

But babies that stay persistently posterior from before labor and throughout labor....these are associated with a lot more difficulties in labor and birth, especially when the baby is big and/or its head is de-flexed. They have a much higher risk for birth via cesarean, forceps, or vacuum extractor.

So now the question arises......What, if anything, should we do to try and prevent persistent OP babies? Is there any effective way to prevent or turn persistent OP babies?

Or is persistent OP positioning simply another variation of normal in labor, and all that is needed is a little more time and patience?

(Ahhh, the $64,000 question!!)

Tune in next time.......that's another post in the series!!