Tuesday, July 5, 2011

Manual Rotation for Posterior or Tranverse Babies

This new study is just the latest in a series of studies that have shown that manual rotation lessens the need for cesarean during labor because of a malpositioned baby. 

In these studies, a persistent posterior baby (baby facing mom's tummy instead of her back) is turned manually to the generally-easier-to-birth anterior position (baby facing mom's back). The question has been whether such techniques improve outcomes. 

This study shows a dramatic improvement in outcomes with manual rotation.

This is a larger trial than many of the previous studies on manual rotation, which makes the findings even stronger.  This study is interesting in that it also includes manual rotation for transverse arrest (baby gets stuck facing sideways, usually as they are trying to rotate from posterior to anterior).  Not all manual rotation studies do.

Note that manual rotation is not without risks; there were more women in the rotation group with cervical lacerations, which is not fun.  However, balance that against less need for cesareans, fewer severe perineal lacerations, less hemorrhage, and less infection, and I'd say manual rotation wins, hands down.

But Should We Intervene for a "Malpositioned" Baby?

One of the controversies within the natural childbirth community these days is whether persistent posterior babies should be considered malpositions or just variations of normal, and whether we really need to intervene at all in such cases or just be more patient. 

Personally, I do believe that sometimes these positions are just a variation of normal and don't have to be a big deal.  Sometimes all that's needed is just a tincture of patience and time, and the "malpositioned" baby is born just fine.  Sometimes the baby's "malposition" is even actually needed because of a unique pelvic shape or some other factor we are not yet aware of.  So I agree─up to a point─with folks who tell pregnant women not to obsess too much over their baby's position or to feel that if they have a posterior baby that they are doomed to a cesarean etc. 

However, I think it's naive to believe that such positions are always benign and will always be born vaginally and without damage if just given enough time.  I think research is quite clear that OP labors are often harder and longer, and that there are often poorer outcomes for mother and baby

Yes, I do wish doctors would also study maternal repositioning and other less interventive alternatives so there were other options in the arsenal for a malpositioned baby.  I bet some of these babies would rotate just fine with other, less-invasive techniques, and then the more-invasive manual rotation could be used only when truly needed.   I also wish that care providers would be more patient in labors, because many positions will remedy themselves with a little extra time, or be born in that position just fine.

However, I don't believe that all malpositioned babies will be born safely "if just given enough time." Some babies and mothers will experience significant difficulties.  Many more will be subjected to forceps/vacuum extraction and cesarean deliveries, with all the associated risks. The question is whether these complications and operative deliveries could have been avoided if manual rotation had just been tried.

This new study compared manual rotation with expectant management─just waiting─and found that outcomes were significantly improved in the active intervention group.  Other studies have also found that prophylactic rotations improved outcomes. So perhaps "just waiting" is not always the best thing.

Remember, these malposition labors can sometimes be just HELL for both mother and baby. It's not always wise to wait to intervene until mother is exhausted and baby is in distress. Sometimes an earlier intervention like manual/digital rotation can be judicious and helpful. 

So while I want care providers to have more patience and use other, less invasive techniques first, I am thankful that manual rotation is in the arsenal too.  I think the results of these studies clearly show it should be learned by more care providers and applied when less-invasive techniques are not helping.

For the many many MANY of us out there who have had long hard labors and then cesareans for malpositioned babies, I say Hallelujah that care providers are re-learning this manual repositioning skill again.  About time! 

Huge thanks to the midwives and doctors who kept this technique alive when it went out of obstetric fashion.  I hope they are teaching others and spreading the word to more midwives and especially doctors.  Far too many women are being cut open because care providers don't know how to handle differences in fetal position. 

Manual repositioning can be a very valuable skill to have and will surely improve outcomes in many cases.  That doesn't mean it should be used too quickly or in place of less-interventive techniques, but that it clearly does have a place in the spectrum of options.

Shaffer BL, Cheng YW, Vargas JE, Caughey AB.  Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. J Matern Fetal Neonatal Med 2011 Jan;24(1):65-72. Epub 2010 Mar 30.   PMID: 20350240

Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Clinical and Policy Perinatal Research, University of California, San Francisco, CA 94143-0705, USA.


To examine mode of delivery and perinatal outcomes in women with occiput posterior (OP) or transverse (OT) position in the second stage of labour with a trial of manual rotation compared to expectant management.


A retrospective cohort study was designed to examine mode of delivery and perinatal morbidity in women who underwent a trial of manual rotation (n = 731) compared to expectant management (n = 2527) during the second stage of labour with the fetus in OP/OT position. Chi-square test was used to compare categorical outcomes and multivariable logistic regression models were used to control for potential confounders.


Compared to expectant management, women with manual rotation were less likely to have: caesarean delivery (CD) [adjusted odds ratio (aOR) 0.12; 95% confidence interval (CI) 0.09-0.16], severe perineal laceration [aOR 0.64; (0.47-0.88)], postpartum haemorrhage [aOR 0.75; (0.62-0.98)], and chorioamnionitis [aOR 0.68; (0.50-0.92)]. The number of rotations attempted to avert one CD was 4. In contrast, women who had a trial of rotation had an increased risk of cervical laceration [aOR 2.46; (1.1-5.4)].


Compared with expectant management, a trial of manual rotation with persistent fetal OP/OT position is associated with a reduction in CD and adverse maternal outcomes.


Anonymous said...

From a layperson's perspective, this issue dramatically illustrates the gulf between the medical and midwifery models of care. My midwife, who attended all three of my labors, matter-of-factly mentioned manual rotation as a tool in case my babies were posterior or transverse. She warned me that it was one of the most uncomfortable procedures she used, but it fit into her model. Her model assumed that the mother is formed in such a way that the fetus can come out, the fetus is formed in such a way that the mother can labor the fetus down, both members of the laboring pair have reliable reflexes that help them go about it, and the midwife is a spotter. Therefore, the first response to difficulty--whether ahead of time or on the scene--is to help the labor back on its normal course, then get out of the way.

I know I'm explaining the obvious. This is literally the first time I have ever stated it this way to myself. It was such a basic assumption that my midwife did not state it in so many words; she simply spoke as if I already knew. Of course we are capable. Of course fetuses are capable. Of course complications that require canceling the normal course of labor are extremely rare. Gravity works, labor works: well, duh.

Then I ran into the medical model, in which the first response to a labor going off script is CUT! Pregnant woman as ticking bomb, delivery room team as highly trained disposal squad. Go in there and get the baby out. Rescue! Save! Deliver! If this labor goes under 50 miles per hour, the mom will EXPLODE! Or perhaps a better metaphor would be labor as complex yet kludgy computer program that nobody but a highly trained specialist could possibly understand, so just get out of the way and let us work, honey. Of course, the assumption behind this meptahor is that the technicians get to revise the program as they see fit and nobody expects the machine to complain. No. I am not an IBM clone.

Jenny Islander

Regina530 said...

My first child was born face up. Labor was long (49 hours) and painful with mostly back labor pains. It's no picnic laboring thru the intense stages of labor with your baby's skull pressing on your spine with each contraction, and nothing but analgesics for pain.
That said, I would have had a much more difficult recovery if I had been talked into a csection. Of course, this was the mid 80s, and doctors actually tried to avoid surgery as much as possible. It's good to read that doctors are choosing to wait more now.

Cynthia Gabaldon, DC (Orlando, FL) said...

I am a chiropractor who routinely sees a baby turn from a malposition such as OP or even Breech with one or two Webster's adjustments. I've had midwives call me to labors and with a simple adjustment the baby turns IN LABOR within ten minutes. The difference for the mother is MEASURABLE and the labor progresses normally.

Cynthia Gabaldon, DC Orlando, FL

Elizabeth said...

I hope this makes it's way into more widespread use. I ended up being induced, and then having a c-section because my daughter was posterior. If it wasn't for your post on anterior vs posterior belly shapes I wouldn't have even known she was posterior. I had thought that the odd shape of my belly was due to me being fat when I noticed that my belly looked just like the posterior picture. I asked at my next appointment about it (I was having an u/s anyway), and was told that yes she was posterior, but that I didn't need to worry about it since almost all babies turn the right way. This was at about 32 weeks. Basically I was left on my own to deal with the malposition.

It turned out that her head was cocked sideways in addition to being posterior, and there were issues with her not being engaged when my water broke and meconium in the fluid, so maybe I'd of ended up with a c-section regardless. But I can't help but think that if someone, other than me with my internet tips, had attempted to get her to turn maybe I could have had the peaceful Hypnobabies birth I had planned, instead of having to worry about VBACS and possibly having reproductive choices taken away from me. The latter is more of a since my DH is in the military, there's no telling where we'll be living when we have another child. And if there's no hospital and/or ob/midwife practice that will attend VBACs, then I'll put off getting pregnant since I don't feel like that just because I let someone cut me open before that I have to have it happen again.

Anonymous said...

I personally have had one baby manually rotated, and it worked out fine. Another later was rotated by nurses having me do position changes and was born facing the normal way. My last baby did not rotate and the midwife tried to manually rotate her, but she kept going back. She was born OP with an asynclitic (spelling?) head. I have had problems with bowel movements ever since, but not to the extent I'd rather have a c-section. I wonder, when a baby will turn or can be turned, if it also helps with pelvic floor issues? (The midwife thinks the baby kept turning back because she actually had a tight cord and was having decels at the very end, I pushed her out so fast that even being baby #7 I tore...hadn't had a tear since baby #2. Again though rather this than a c-section).