Dear Jo, Liz, Andrea, Lynne and list It is non-informed consent to your management not to tell a woman she has an OP position during pregnancy ... Just as it is negligent not to tell her all of the possible ways she can deal with changing it during pregnancy and labour.
There is almost always a way a fetal OP position can be changed - dependent on where the challenge to it's turning presents. Jean Sutton has presented these ways very well in her "Optimal Fetal Positioning" book. If the challenge is ABOVE the brim and external to the uterus eg. strong abdominal muscles holding the baby tight against the mother's spinal column .. Then there is every likelyhood of the occiput turning towards the front once it hits the pelvic floor. (No problems except usually more lower back pain experienced during labour) The majority of posterior positions in primigravidas are due to their wonderful muscle tone. However, if the problem is above the brim and INTERNAL eg. Low lying anterior placenta the baby has a more difficult time gaining access to the pelvis and usually has to rock into it using an asynclitic mechanism. These babies usually present with very bruised scalp tissue and horrendous upward moulding (if they remain in the posterior position and deliver that way) and with backward moulding (similar to a brow if the placenta was low and to one side) and they had to spend a lot of time getting through the brim and then turned once they reached the level of the ischial spines. I had an example of the latter early yesterday morning with a client having her third baby. (The first two had birthed with normal mechanisms.) Kathryn commenced a labour that was sporadic all day Tuesday, and did not establish properly until late Tuesday night with the help of cualiphylum. She progressed slowly throughout the night, wanting to push prematurely and ending with a thick anterior lip that wouldn't budge for some hours despite side lying and trying just about every other position to open up her outlet. Her major complaint throughout was "my hips, my hips,...." Although abdominal examination revealed the occiput had finally disappeared into the brim just before sunrise, a repeat vaginal examination revealed lip still present and caput ++ with head still above the spines. The thought of an epidural was tempting as we were all sleep deprived at this time. There was a large fecal mass now evident in the rectum (not present earlier) so the advice was to try and sit on the toilet and evacuate it with the hope that it would provide a new space for the occiput to descend and rotate ... and after a few sips of warm lemon cordial and water to restore energy, a few pushes with contractions that evacuated the faecal mass,the head quickly followed. Oh, what a feeling!!! and not just for the mother! I also had another experience with a posterior (that remained that way) at home some years ago due to a low-lying anterior placenta. It was the second pregnancy. (First baby no problems, in fact a very easy birth). Linda's labour progressed slowly throughout the day, into the night and the next morning as well. Despite the pain, she persevered with her persistently posterior position, using the bath, the birthing ball, eventually reclining upright on a beanbag with exhaustion .. because of the knowledge of what would happen to her if we transferred to hospital (she was a midwife!). Linda's pain management skills were so powerful, she could literally rise above her contractions. She insisted that when the head finally crowned that she REST to recover the strength she knew she needed to let that huge presenting mass out. My trust in her almost wavered at that stage, but she reminded me that the FHS were still OK and that she knew what she was doing. In hindsight, she was allowing her external genitalia to stretch to adequately accommodate the diameters of that huge POP head. Eventually she got up on all fours and let her baby out slowly (no tearing at all) and I have never been so in awe of anyone as I was that morning Linda let her little baby boy out so gently. The upward moulding on that baby's head was so grotesque that he initially looked like an dwarf to me ... His swollen scalp and upwardly moulded head just looked so large in proportion to the rest of his body! Linda later went on to have a lovely birth in the water with her third baby, delivered her herself with her mother assisting the 'catch'. However, Linda had nightmares about pain for weeks when she viewed the video of her POP birth. I'll make a teaching package about posteriors with her and Kathryn soon and and I'll include their births in it ... before examples of successful posterior outcomes are lost the the students of tomorrow. Midwives will need to be stronger advocates for women as we move into an age where OP gets added to the list of reasons for doing an elective C/S. As midwives they need to be aware that they must be proficient in picking up the posterior position and monitoring it's descent into the pelvic brim ABDOMINALLY so they can support the woman making slow progress but more importantly that they don't miss the one that converts into a brow and obstructs. The converted brow is the only one that does need a CS and of course they DO OCCUR. I know Kathryn went pretty close to becoming a brow yesterday ... I hope the photographs of the baby's bruising and moulding show proof of that. Yours in best management of the OP i.e. Midwifery management Jan Robinson -- This mailing list is sponsored by ACE Graphics. Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe.
