Episode 118 - What is a posterior labour like?
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. And each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
Mel:
[0:24] Welcome everybody to today's episode of the great birth rebellion podcast today we're talking about what is it like to have a posterior labor obviously this conversation is going to be a rebellious one so it'll probably take a turn one that you weren't expecting a turn that it took that i wasn't expecting because i'm usually uber prepared was that i failed to explain what posterior labours or posterior position even means. So before we even get into this podcast episode, something that's important for you to know for people who aren't midwives or birth workers, it might not be common language to hear about posterior labours or posterior positioning or in the episode we call it OP which is a summarised definition of occipitoposteria which refers to the baby's position inside its mother's pelvis and inside its mother's tummy. So when we're talking about OP babies or posterior babies, what we're saying is that the baby is in a head down position in its mother's uterus.
Mel:
[1:35] And instead of facing what we would call anterior, occipital anterior, which means the back of the head is towards the mother's pubic bone or where your pubic hair would be.
Mel:
[1:49] That's the most common position for a baby to be in. But being in a posterior position means that the baby's, the back of the baby's head is positioned on the mother's back. So the baby's looking out towards its mother's pubic bone or pubic hair region. And we refer to those babies as posterior. So remembering if a baby's anterior, it'll come out looking at its mother's bum hole. If a baby is posterior and it is born in a posterior position it'll come out looking at its mother's clitoris or pubic pubic hair and we're talking about this today because posterior labors where the baby is facing outwards where the baby's back is lying on the mother's back okay i got that off my chest now we can get into the episode let's do it today i'm going to introduce Sarah Langford to you. I've invited her to the podcast because I believe her research is something to watch. She's a PhD student. That's the least of what she's doing. And we caught up at the Convergence of Rebellious Midwives conference. It just happened in our world. It happened a few days ago, which is why my voice is still a bit coarse. But as our listeners are listening to it, it was probably about a month ago. And Sarah told me about what she was working on. And I wanted to share it with you guys. So welcome Sarah.
Sarah:
[3:16] Thanks for having me.
Mel:
[3:18] I'd love if you could introduce yourself and then we can move into what you're working on.
Sarah:
[3:24] Sure. So, I always wonder where to start with my introductions. I guess I'm a PhD candidate at ACU in Melbourne. At the moment, ACU is the only university in my state of Victoria that offers the direct entry Bachelor of Midwifery. So, all the other courses in Victoria a few years ago scrapped it and everyone has to do the double degree of nursing and midwifery, which is really unfortunate because it's blocked a lot of women who would have wanted to become midwives but didn't want to do the nursing side of it. I was so lucky that I got into ACU. I mean, it meant traveling a bit further for uni rather than around the corner, but I got to have all of my placements with pregnant women, birthing women, postnatal women and their babies, which just made sense to me.
Mel:
[4:14] When did you finish your midwifery qualification?
Sarah:
[4:15] Uh 2020 was my last year of study so that was I got to see what things were like pre-covid as a student uh and then started my midwifery work in 2021 in January and I started in a private hospital so I did a year in a private hospital in Melbourne which was a great introduction
Sarah:
[4:39] To just caring for women and also becoming a little bit autonomous because in the private hospital you don't have doctors there. Like in the public hospitals, there's always doctors around that you can chat to and update, whereas in the private hospital you're having to call them to keep them updated and there's just a little bit more, you just feel a little bit more on your own. Like it just feels like a little bit more responsibility sometimes.
Sarah:
[5:05] But I did find that because I was fresh out of uni, there were a lot of skills I wasn't getting to consolidate because obviously the women have a relationship with their private obstetricians, so you don't really get to provide antenatal care. And it was also hard to get experience in the special care nursery. It was great for postnatal care. You were there when the women's milk came in and you had like five days to do postnatal education. So it wasn't this mad rush. And I really loved that aspect. But the birth side of things I found myself absorbing some fear and it really felt to me like I was an obstetric nurse not a midwife and and I would have women who would say oh I know that I am GBS positive but I really don't want the antibiotics so can you talk to my obstetrician for me and I was like oh my god I can't like it's gonna look like I've told you not to do it and that was eye-opening for me because even though they'd had continuity of carer they obviously hadn't felt safe enough to have these conversations at the time so when I got an opportunity to apply for a public hospital I jumped at it and I kind of worked between both for a few months but I've been at a public hospital since 2021 and we do around it's just below 5,000 births, I think, a year.
Sarah:
[6:31] And so I worked as a rotational midwife for a couple of years doing postnatal, birth suite and special care nursery. And then I wanted to get into doing the home visits and doing the antenatal clinic. And they're really competitive. Like it's really hard to get those jobs. And then the manager said to me, you want to end up in MGP, don't you? And I said, yeah, thinking later on, not like two years out of my degree. I figured you had to have five years experience and she's like just apply for that and if you get it then you'll get all the training you need to do those other things and so I applied for that thinking I didn't have a hope at all and I got in and so like in my third year out I was in MGP doing the whole spectrum and I love it everyone's like oh how do you go on call and it's great when i get a call it's because it's a it's a woman i know and we've been waiting to meet her baby and now's the time it's i much prefer that kind of stress over the stress of driving into work knowing i'm in a particular ward and thinking oh i hope i don't have this clinical situation today or that it's just like it's a different kind of stress but it suits me yeah
Mel:
[7:50] And i think it's ideal for us all to be working in MGP if we can. That's the continuity of midwifery carer for young players out there. And, you know, the research on MGP midwives is that they're actually way more satisfied in their work.
Sarah:
[8:06] I had heard that. And I also, one of the other ACU graduates who was quite a few years ahead of me, she actually went into MGP straight out of uni. Yeah. And she had been, every time I saw her, she was selling it. She was like, I know you want to, just come, just go for it. And she's like, you will feel so much better. There's better life work balance. And she was right. And I was surprised by that. So that's professional me. And then private me, which overlaps a lot. I'm a mom of five kids and I had them all at home. And three of them were posterior labors, which is where my interest in this comes from.
Mel:
[8:48] I didn't know that. I didn't know that your three babies were posterior.
Sarah:
[8:51] I sort of, I haven't mentioned it to the women I've interviewed so far for the research because I didn't want to step on their toes or... And I kind of, I was like, oh, do I say it in the podcast or not? Because I don't want participants to feel like I have a specific agenda. I just want it to be about them when I'm interviewing them. But yeah, it's kind of crucial to the story of who I am and how I got here. I remember at the first maternal child health nurse group with the other mums, the icebreaker question was share your birth story, which I thought was a fucking terrible idea. Like any midwife can tell you that's a bad idea like it's
Mel:
[9:35] A bad idea.
Sarah:
[9:36] And what happened in our group was the woman sitting directly next to me who spoke before me told the story of her horrendous 12-hour labor which ended in a cesarean because her baby was in a posterior position and babies in posterior positions can't be born vaginally and i'm sitting next to her like oh god what do i say now this woman really believes that that can't happen and now i'm gonna look like a smug asshole telling my story of how my baby was born in my lounge room vaginally after a posterior labor and i had i went on for three days and that's not everyone's jam i was just like how how are our stories so different with such different outcomes and that's always sat with me and then i went on to have five babies, two more were posterior and each of my posterior labours was distinct from each other. And one of them, I didn't know she was posterior until she came out and I saw she was face up. And I just feel like we have a lot of cultural assumptions about posterior labours that gets passed on to women and down from midwife to midwife.
Sarah:
[10:57] And I just didn't feel like that matched my experience. So that's why I wanted to know more about it. And so when I went to do the lit review and have a look at what's already been studied, I found there was nothing. There was nothing about women's experiences of posterior labour.
Mel:
[11:14] Can we step back a little one step? Yeah. Because we left off, you're in MGP.
Sarah:
[11:21] Yeah.
Mel:
[11:22] Can you, before you move on with like the lit review, i'd love to hear how you got into a phd.
Sarah:
[11:30] Oh yeah sure so well when i was studying my bachelor of midwifery i had this title come to me and it was nevertheless she persisted women's experiences of persistent occipital posterior labor and birth and i was like that's a banger like i want to do this And then I said, Sarah, you need to calm down. You're in second year. Probably you should actually get a Bachelor of Midwifery before you try to do a PhD in midwifery. And so, and like, that's not the title anymore. It's changed a bit since then. But I messaged, I knew Rachel Reid from going to conferences and I messaged her and I was like, this is what I want to do. What do you think? And she said, I really love it. I'll be your supervisor. Yeah. And then I was like, okay, great. It's all sorted. And I wanted to work as a midwife a bit first. And then it was 2022, I contacted her and said, oh, I'm ready now. And she said, I've left academia. Sorry.
Sarah:
[12:37] So I went on to what was then Twitter and I just posted, this is what I want to do. Any academic midwives out there want to supervise me. And I got an amazing response. Like I had my pick of just the best academic midwives around the country. I couldn't believe it. And so then I was going through all these responses and Googling different midwives' work and looking at what sort of research they'd done that I felt gelled really well. And there was a paper on plateaus in labour that Sarah Bays and Claire Davison had written together, and I think there were probably other researchers. But i i had come across davison and bays in other research so i felt like sarah and claire were a perfect fit so i approached them and they were both very happy to do it the lecturers move around and change unis and acu has this rule about having two um supervisors at the same uni and so that's how um kate dawson became my third supervisor amazing
Mel:
[13:42] Okay so we're in the phd.
Sarah:
[13:44] Yeah and
Mel:
[13:46] You've got to do a literature review and like a confirmation of candidature and all these things, right? To just prove that your idea is worth researching. Yeah, so you do the lit review. We're back on track for our story now. So you do the lit review and what did we find out?
Sarah:
[14:08] So I did a search first and it was like two searches in one. So I searched the terms occipital posterior, occipital posterior, and then also the term experiences, voices, perspectives, narratives, and labour. And it starts off with you have like hundreds or thousands of results and then you add more search terms to get what you want and so the first time I did this search I ended up with 12 sources at the end of it so 12 sources that were about op presentation in labor not pregnancy and women's experiences of labor and those none of them were about women's experiences none of them were talking to women they were care providers experiences and outcomes and management and then I went back and had to do another search I think at the end of the second search I had 491 papers in English and then I went through all those titles and abstracts to see what was actually about labor and childbirth so I went through all of that and found that all of the literature on posterior labour and birth can be divided into two categories, and that's management and outcomes. So there's a lot of particularly obstetric research about the outcomes of posterior labours
Sarah:
[15:36] And then it was like having two different topics in one and they just don't go together. There was nothing that went together. The only thing was Nigel Lee's work from 2015. So he had looked at back labour and that had come out of a previous study about sterile water injections. And in that study, only two of the women in that study who had back pain had a baby in a posterior position so at some point in that study he had said that care providers should consider factors other than fetal position for causing intrapartum back pain so it wasn't about posterior it was about back pain and something that the authors noted was that care providers will attribute back pain to op but they don't have any other explanation for it. And women were saying that the care providers would say, oh, your baby's probably posterior. But that was only the case for two of the women that they spoke to.
Sarah:
[16:42] Yeah. So that was sort of all I had to go on was that one study. So my lit review, I wrote what I could find about outcomes of posterior labor and management of posterior labor. And then I wrote about what's been studied in terms of women's experiences of labor and birth and trying to keep it as a focus on Australia because that's where the setting for my research. And so there's these studies about women's experiences of the interventions for OP labor, but not just their experiences of OP labor. So they'd been asked about their experiences of maternal positioning to rotate the baby and their experiences of manual rotation, but not just, hey, what's it like to birth a posterior baby? What does it feel like? So I felt like as care providers in a research discipline, we skipped ahead.
Sarah:
[17:38] We'd kind of missed the starting point. My research is, I'm using the methodology of narrative inquiry because my data is women's birth stories, which is something that I love. And I think it's such an important data set and I feel like it's undervalued. And also everything that we're taught about posterior labor as midwives and as pregnant and birthing women are stories they're not based on any kind of research or evidence they're just stories that are passed down or passed along and the authority of the knowledge is just care providers and it's it's a it's a cultural story that we pass along um and sarah bay is my supervisor has worked a lot with narrative inquiry um and that's a new methodology to me and i love how it challenges sort of hierarchical frameworks and something that it says is so for my study women who have had firsthand experience laboring with a baby in op position they're the experts it's called experiential authority and i just love that because women should be the experts recently
Mel:
[18:53] We spoke on the podcast about authoritative knowledge and how that usually lies with the socially accepted experts. So, you know, in our maternity world, that would be, the medical people so experiential authority you're saying places the authoritative narrative in the hands of the people who actually experienced it how novel.
Sarah:
[19:19] It doesn't it make a lot of sense as well like shouldn't that be where we start um and i feel really really privileged because at the moment my phd is listening to women tell their birth stories that's not work that's joy or you know connection sort of people say to me oh how do you you know work on call and do a PhD and be a single mom of so many kids and it's like what's your you time and it's literally the PhD at the moment because I get to um yeah I get to carve out this time to be one-on-one with women and hear their incredible stories and be able to see all of the power and all of the wisdom that she's shown throughout that experience.
Mel:
[20:04] But also what you'll be doing is, so it sounds like we as care providers have made all these assumptions about what a posterior labour is like, just based on information that we've collected ourselves and somehow categorised in our brain and then passed it on to the next person. But we haven't asked women yet. And this is what I was so shocked about when you said, hey Mel can I tell you about my PhD over you know we were over dinner and it was about posterior labor and he said no one has ever ever really in the history of any academic research thought to ask women what it feels like to have a posterior labor I mean of all the research we've ever done how did we miss that yeah because there's a virtually a research paper on everything and But... The other thing is that, also, by the way, for people listening, a literature review, because we're talking in PhD smack here.
Sarah:
[21:09] Yeah.
Mel:
[21:10] We get it. We're properly nerded. We are. We're properly nerded. But a literature review is quite a thorough systematic process by which we as researchers, we have to go through that actually to satisfy in our own minds that the idea we have is a viable one and that nobody's already done the work that we're thinking of doing. And then every now and then you catch a massive gap as you have. And it's very satisfying because you don't have to change your plans. Um so you are going to fill that gap quite a significant gap in really understanding being the first person to ask women what was it like.
Sarah:
[21:52] Yeah, it's very exciting. Like you, I was shocked. I thought there must be something. The other thing that's been really interesting is just looking at the studies of the outcomes because I thought in terms of just structuring my lit review, if you look at the outcome studies, then that kind of gives you a justification for the management studies. And obviously the outcome studies weren't incredibly positive for posterior labours. There were things, there's a lot of suggestion that posterior labours are associated with synthetic oxytocin use. They're associated with severe perennial trauma, increased NICU admissions, Mextane, Lycor, and less than seven Apgars at five minutes. There's other things. These studies are from 2003 2006 I think there's another one in 2000 they're associated with more um operative births both instrumental and cesarean and like that's that's not a happy story to tell someone and I think a lot about um
Sarah:
[23:04] What happens clinically in my practice when I meet a woman or I do an abdominal palpation and her baby's in an OP position and what to say. And I've had the situation where, like for me, I know that babies can come out OP. I know they're going to do most of their movement in labor. I'll talk a bit more about the research on that as well. But there is some cultural fear about it and another reason I'm doing the research is because I feel like it's only a matter of time before they pathologize the living hell out of posterior and recommend caesareans for all posteriors like they did for breech I'm just sort of I'm trying to cut it off at the pass some women will come into clinic and be like is my baby posterior at like 34 weeks or 36 weeks and like there's already that fear before they've got there so the the cultural stories that we tell about posterior are really negative. And so reading this research, I'm like, well, if these are the outcomes, of course the focus is going to be on management in terms of like clinical practice and also research. But as I read the studies and started to pull them apart, a lot of the studies on the outcomes of posterior labour, well, first of all, they're all studies that are conducted in hospital.
Sarah:
[24:24] Second of all, a lot of the women have epidurals and aren't able to have freedom of movement in these studies. So when we talk about the outcomes of posterior labor, a lot of the time what we're talking about is the outcomes of having a hospital labor with an epidural and an OP baby. So how much of that outcome had to do with the baby's position? How much of it had to do with the epidural? How much of it had to do with the care provider? That's the thing that I always come back to because I've had home births and I've experienced that model of care and then I've worked as a hospital midwife so I also experienced that model of care but from the other side and I know I have to come back to what are the hospital policies and I can advocate for a woman if she wants to go outside of those recommendations but I also have to make sure she knows these are the recommendations like that's just part of my responsibility as a midwife who works in the hospital. And so if you have a hospital policy that says a first-time mum can push for up to an hour or up to two hours and a multi-mum can push up to one hour. So that guideline, because they're not, well, they don't get treated like guidelines. They get treated as your set menu. So you get to an hour or two hours and now you're outside of what the hospital documents have said is normal. So now you're pathologized. So now...
Sarah:
[25:52] There's pressure. So obviously hospital policies and care providers are going to have an influence on the outcomes of a posterior labour.
Mel:
[26:01] It occurred to me as well when you were talking about how for women who are having posterior labours, increased risk of being offered or at least receiving synthetic oxytocin in order to speed up their labours. And part of that is the belief that when a baby's in a posterior position, that labor's going to go longer because the baby's got a longer rotation to do potentially, or the baby's working at coming out posterior. And that doesn't fit in with the medical timeframe of labor either, because, you know, it's supposed to progress in a particular way. And, you know, from experience, when you feel the cervix of a woman whose baby's posterior, it behaves a little bit differently, potentially, you know, obviously your researchers may discover something new but I think you're onto something in a sense that what we believe about posterior labours is that they're potentially more painful potentially go longer then that exposes women to, longer episodes of care with the maternity care provider and we know that the longer you're at hospital the more interventions you're going to get as well so yeah is that the reason why these babies and women have these kinds of outcomes or is posterior labor itself, problematic i'm using inverted commas.
Sarah:
[27:29] So um looking at there was a study in 2021 by levy et al and it was looking at the use of hands and knees position to help rotate babies and they didn't find that there was a statistically significant difference between the babies who rotated or didn't in the control and the experimental group and they concluded it seems time alone helps facilitate rotation from op or ot to an oa position and not the implementation of hands and knees posturing and i just thought yeah that's that was sort of my hunch the difference between the woman next to me and me is that I had all the time in the world providing my baby was you know coping and I was coping I wasn't
Sarah:
[28:15] On a clock my midwives could come and go and I got given that time for her to do a long rotation and I often think well what would that outcome have been if I had been at my local hospital like this lovely woman who I was sitting next to would I too have ended up going to theatre because of time constraints and my my secret dream why I'm doing this is I and this is ridiculous like this won't happen but like my dream is that my research will lead to the change in guidelines around time frames for labour and birth for posterior mums so that we don't put up SYNT and we don't have these extra interventions,
Sarah:
[29:01] Which is really hard for a hospital to facilitate. I completely appreciate that because I've also...
Mel:
[29:07] But only... I mean, it's not hard. It's only just hard because it goes against what they like. They like women to go in, labour, produce a baby and get out. So, I mean, potentially if the baby is diagnosed as being posterior, you could go, rightio, you get twice as long as everybody else.
Sarah:
[29:30] Or just go home. And I think the other thing that's really hard in practice is it comes back to also just our cultural fear around birth and women a lot of the women that I meet working in the system they want to have their babies in hospital that's where they feel safe and when they come in to be assessed it's a real kick in the ovaries to be told the best place for you right now is to go home because it doesn't feel like the best place for them they want a midwife they want support they don't feel safe they're scared of the pain they've already been doing it for a while and it just it's really demoralizing when the midwife says and I can appreciate that because I felt really demoralized and I was at home and didn't have to go anywhere and I feel like our education around expectations has a long way to go and that's I mean it's impossible because I've spoken to eight women so far and one woman yeah she spoke about how she wished the education about what to expect with posterior labour was better and I heard her experience of what the midwives had said to her in clinic and I thought oh god I've said that so many times and it's like in my desire to not freak a woman out and give her horror stories about what to expect with a posterior labour I've just kind of brushed over it and gone oh, yeah, it's posterior for now. That doesn't mean anything. Your baby will move a lot in labour. And that's not particularly empowering for a woman to hear, is it?
Mel:
[30:59] So as a woman who's had posterior labours, and are you getting a sense from these early interviews that women wanted detailed information during their pregnancy on what to expect if their baby was posterior? I mean, personally, I think I don't necessarily add it to my list of things that I'm going to talk to the women about of like, by the way, if your baby's posterior, here's what might happen.
Sarah:
[31:25] A bit different though, because you work in as a private midwife and you're going to be going to them at their homes, it's a little bit different. So in hospital, we have to do a lot of expectation management because we're dealing with policies and time frames. So I do talk a lot in clinic about just trying to normalize that you might come in and go home. And that might happen a couple of times because it's not something that people expect. They think that once they're going to hospital, they'll stay at a hospital. And when they go home, they're having going home with a baby. And that's infrequently the case with a first time mom and a posterior positioned baby. Yeah. So I was going to tell you about this study that just kind of blew my mind. I was reading it again this morning. It's an Icelandic study from 2021. and I cannot say the person's name. It's spelled H-J-A-R-T-A-R-D-O-T-T-I-R et al.
Sarah:
[32:23] So this is starting in 2021. It was only of 99 women, but I still got a bit excited about it. So with this study... They did vaginal exams at certain points throughout the labour to assess the baby's position to work out when OP babies turn and how common it is, which is not how common it is because they only had 99 participants. So the first vaginal exam they reported was at 4 centimetres and of the 99, 52 of them had OP babies. So that was, yes, that was at 4 centimetres and then they did it again at full dilation and at that stage it was 53 out of um 80 of the women so it was 66 percent were still posterior at full dilation so
Mel:
[33:13] Is this women who initially went into labor with a posterior baby 99 because it seems like a lot if there was 99 and then almost half Well, just over half.
Sarah:
[33:24] Okay. Nuller-pressed woman with a single fetus in kephalic presentation and spontaneous labour on set at greater than 37 weeks gestation. Okay. It doesn't say that they were, they didn't have to be posterior, but fetal head position and subsequent rotation were determined using both transabdominal and transperennial ultrasound. Just says catholic.
Mel:
[33:51] Okay.
Sarah:
[33:52] And then they said that throughout first stage, more than 50% of the babies in this study were in an OP position. So in their conclusion, they said the occipital posterior position was the most common fetal position throughout the active phase of first-stage labour. Occiput anterior only became the most frequent position at full dilatation and after the head had descended below the mid-pelvic plane. That, I feel, is really valuable information to be giving women in clinic, particularly those who have worries about posterior because this study, and I mean it's one study, it's Iceland, it's only 99 women, so, you know, asteroids everywhere. But this study suggests that actually OP is common in first stage.
Mel:
[34:39] But could it also be capturing a visual representation of the baby's rotation through the pelvis, throughout labour, and that at some point in your labour potentially your baby's going to be posterior if you were going to... Checking it the whole time.
Sarah:
[35:00] Maybe yeah well it there's this great quote from um mary cooper in a midwifery today article from 2015 and i just love it and it's one that i wish all women could hear in pregnancy and it's i believe it is normal in a baby's gestational life to be in transverse breech posterior LOA and ROA positions and of course it is the baby is living in a buoyant fluid environment and moving around and we know that your baby is breech until 30 weeks at least is a very normal thing and then they flip some of them and the same goes for being sideways for being posterior it's just it's all normal
Mel:
[35:50] Yeah, so, I mean, yeah, all normal except then the outcomes that you found were that babies who are posterior and their mothers end up with very different outcomes if the baby was diagnosed as being anterior.
Sarah:
[36:05] Yeah. So what do
Mel:
[36:06] We do about it?
Sarah:
[36:08] So the research around the intervention, so manual rotation is where the clinician rotates the baby from OP to OA with their hands so they can do it digitally with a sterile glove with their fingers, or they can do it with rotational forceps. The research does seem to suggest that with manual rotation, the rates of cesarean are reduced.
Mel:
[36:34] Oh yeah, I've had an experience of a client, we went in to hospital, her labour was going on and on and on and on, and she was so committed to a home birth, but by the end she was saying to us, take me to hospital now the baby is not going to come out and we took her to hospital and the baby was in a persistent op position and the obstetrician did this manual rotation I can only describe it as beautiful like poetry is she said it's okay the baby's posterior but I'm going to do a manual rotation and it will turn and then you'll push your baby out and so this was the information she gave to the woman and I'd been a private midwife for sort of 15 years at this point and never heard these kinds of words come out of somebody's mouth and I said to her well okay what would happen then if if the rotation doesn't work and she said no no it'll work.
Mel:
[37:39] I said, I realize you're confident, but you know, you're about to do something and if it doesn't work, it'd be good to know what would be the next steps if the baby doesn't rotate. And she's like, no, the baby will rotate. And I was like, how can you be sure? She's like, it just will. Okay. I mean, we could not get information out of her about what next. So the woman felt comfortable with that. And as the doctor explained, it happened. It took three contractions. So as you described, the obstetrician has to put their hand inside the woman's vagina and sort of cup the baby's head with their hand. And then during a contraction, you rotate the baby's head so that it's facing the other way, not posterior. So the back of its head is anterior so that when it comes out the baby's looking at its mom's bum hole and it happened she rotated the baby she said okay it's done you can push out your baby now and she did and I was like what did I just witness, and I know and also like how can you teach me how to do that because this is not the first time that I've brought a client into hospital for this reason.
Mel:
[39:03] So, yes, I mean, that is a case study of one, but if you're saying some of the research seems to indicate that with the behaviour of manual rotation we can reduce cesarean sections, That would be amazing.
Sarah:
[39:18] Wouldn't it? And I, yeah, when I have read about that, I think to myself, well, maybe not the forceps, but definitely the hands-on digital rotation. That could be a midwifery skill that we learn in our training. Absolutely.
Mel:
[39:34] But I don't think there's anything that would stop us from learning some of those more, I guess, invasive hands-on skills. I mean we enter a woman's vagina in order to release a shoulder or a posterior arm if the baby's having a shoulder dystocia so it's not foreign that we should be able to do things like that and you know you and I just attended a two-day breech workshop together where we learned all kinds of maneuvers that are completely within our scope now so I can't see why we wouldn't be taught manual rotation especially because I believe that actually obstetricians aren't utilizing it as much as they should and potentially I.
Sarah:
[40:17] Feel like that's the barrier I feel like it is a skill we could be learning from obstetricians but at least where I have worked so far and where I've been on placement so far it seems like the doctors have learned how to use the forceps and that's what they're comfortable with I haven't had an opportunity to see manual rotation digitally and in fact I haven't seen rotation with the forceps in the public hospital I've only seen that in the private hospital
Mel:
[40:46] Well even I think that um the skill of forceps is falling out of fashion too obstetricians are really de-skilling themselves and I've seen a rotation done with a vacuum before oh.
Sarah:
[40:58] Actually yes I've seen that in the private hospital as well
Mel:
[41:00] Yeah yeah, And I have heard a lecture from a researcher saying that manual rotation can be a midwifery skill, but the challenge is, like, can you imagine, I mean, if you're working in a public hospital and the baby is posterior and you just say to the woman, that's okay, we're going to do a manual rotation. I mean, midwives work is railroaded so often by obstetricians coming in to save the day that we don't often get a chance to practice more advanced skills like that because they're considered.
Sarah:
[41:35] There's also that um educational thing of see one do one under supervision and then teach one and that seems to be very deeply ingrained in obstetrics and because we don't i don't get to see it so i'm not going to get to the point where i get to do one i mean it's been really interesting to go from being a core midwife to being MGP. Like I feel now I have a much more sort of egalitarian relationship with the obstetricians where we're all on the same side and I don't know why that is. I just I felt more like as a core midwife you were sort of under suspicion and sometimes as an MGP midwife you're under even more suspicion. I feel like that whole cultural hierarchical thing gets in the way of really good care and really good skilling because we could be learning from each other.
Mel:
[42:27] Yeah. And in your opinion, having had three of your own posterior babies and also had a look at the outcomes and the management strategies, do you think posterior is a problem?
Sarah:
[42:43] In itself, no, absolutely not. Actually, I had a participant interview this morning and after we'd finished recording, she said to me that she feels like posterior is a bit like having a large baby. The risk factor is your care provider knowing.
Mel:
[43:02] Not dissimilar to breach, you know, that really the outcomes are dependent upon your clinician and their comfort levels.
Sarah:
[43:10] Yeah, and I think that's it. like I um it's like anything it can get abnormal if you know you start having a low fetal heart rate or you the woman you're caring for shows signs of actual labor obstruction not this imaginary failure to progress thing we made up based on time limits when the mom and baby are perfectly well but actual real obstruction where she's got blood in her urine she's got a temperature her heart rate's over 120 beats per minute those things i worry about those things those are things where i'm so glad to have my obstetricians around me to help get this baby out but before there's any of that it's just a it's just a normal thing it's not a problem it's not something we have to pathologize and um i just think we have a lot of work to do with uh communicating i mean with the general public not just the women who are pregnant about birth is not scary pregnancy is not a high risk condition it's a normal state of being for a female body and i feel like a lot of our our cultural fear comes back to that medical model which is based on a male and because we've got this patriarchal medical model that dates back hundreds of years um yeah they're they're scared of the unknown and
Mel:
[44:33] Even for me as a home birth midwife if we discover that the baby's posterior we kind of go okay let's do this like there is a little bit of a your heart sinks a little bit for that woman also a little bit for yourself because you know that it's going to be a hard slog for everybody it's not always the case you know I've been to births where the baby came out posterior and she hadn't mentioned a thing and the labour didn't look any different and afterwards don't we remember saying to her hey how did that feel she goes oh my back really hurt like she virtually said nothing through the whole labour it would hurt way more than the last.
Sarah:
[45:13] One I so hear you on that as the midwife and there have been so many handovers that I've been in where I've just been internally screaming because someone has handed over direct OP and everyone's gone and I just I just want to scream because I'm like it's like everyone gives up on the woman and the baby before they've even met them and I really hope that my research can help combat a bit of that negativity and I mean if nothing else I feel like a collection of posterior birth stories is going to come out of this and wouldn't it be great for everyone to hear different stories and positive stories and stories where they didn't know it was posterior and then hello, surprise, sunny side up. Beautiful because it's just birth. It's just like, you know, an anterior birth or a breech birth or a VBAC. It's just a birth and they're all unique.
Mel:
[46:11] You and I are on that page and, you know, when we were speaking at dinner I said, I wonder if you could speak to women who have had, both different types of positioning and they could actually compare their labours for each baby and how different they were you know you spoke about the outcomes for posterior babies and you said the other camp of literature that you came across was about management yeah.
Sarah:
[46:37] So a lot of it was about manual rotation digitally or with forceps and how it reduced caesareans the other thing was So they talk about how posterior position babies tend to have higher instrumental births, and also they tend to have higher rates of unsuccessful attempts at instrumental births and then going to Caesar. But there was a study in Australia, it was a randomised control trial, and it looked at manual rotation, and the authors were expecting that the outcome would be that manual rotation would reduce cesareans, and they actually found no difference. So that study stood out from other studies that suggest that there is a difference. It'll be in the references that I send you. The other things that they've looked at is different positions. So there's been a fair bit of looking at hands and knees position in labour. There's also a lot of research into pregnancy interventions, like just trying positions like hands and knees, because that I remember when I was having my first baby, the advice was get on your hands and knees and scrub the bathroom floor and scrub the kitchen floor and scrub, scrub, scrub.
Sarah:
[47:45] Um which is just such a disempowering thing and honestly as a feminist midwife you should never tell a woman to get on her knees and scrub but that's one of those cultural things that's been passed down to us and i mean i have read a bit of the pregnancy literature and it doesn't seem to make a difference and then the hands and knees position didn't make a difference to the rotation of the babies in labor but it did alleviate some of the back pain that participants felt and the conclusion tends to be let women move how they want is pretty much what comes out of it another position that's studied a fair bit is modified sims position which is what i write it down as in clinical practice when i'm and that's where you have a woman lying on her side the same side is where the fetal spine is if your baby's not direct op so left if it's left op um and the bottom leg is just like stretched out on the bed and then the top leg is uh at a 90 degree angle with your knee bent and being supported by a stirrup that's kind of the only time i use stirrups um and
Mel:
[48:57] I think the other way you can get a woman into that position is with the peanut ball.
Sarah:
[49:01] Yeah that hasn't been studied it's only been studied with them in the stirrup but it's i mean it's the same position and that position there's some studies that suggest it didn't make a difference but there's a couple of studies that did find a difference uh lou l-u-i-a-t-l in 2018 they did that one and they found that 87.6 percent rotated in the experimental group versus 65.7 in the control group and that the people who use modified sims had a 93.3% vaginal birth rate versus the control group that had 66.7% vaginal birth rate. So that to me, and that's such a non-invasive thing to do. Like it's a no-brainer. It's as long as the woman's comfortable, like I was caring for a woman and helping her get into that position. And she really hated it. It was really uncomfortable. She just needed to not be in that position. I was like, fine, well, I'm not going to force you to be in that position because that's not how I practice. That's not what the research says you should do either. Freedom of movement is what most of the research suggests, which is interesting considering so much of the research on outcomes has been of women with epidurals.
Mel:
[50:20] Yeah, well, and also that Sims positional, even with the peanut ball or the using the stirrup to hold that upper leg you could still apply that for women who have an epidural and you just rotate them every half hour or so so that the epidural stays balanced. You know, it's possible to do that.
Sarah:
[50:41] The other thing that hasn't been researched or it has been researched, like I think there was one study but it wasn't a random control trial and that's rebozo. So looking at the traditional Mexican technique of using a shawl around the woman's hips and shaking. So there's lots of opportunity to research that as an intervention in labour as well. I have done the Spinning Babies course with Fiona Hellenon in Melbourne.
Sarah:
[51:10] So that's the one where there's like the three balances and I talk about the three balances to the women in antenatal clinic. And so I will talk to women in pregnancy about just trying to ease tension. I'm like, I always say to women, listen to your body. It's going to tell you what you need. and being uncomfortable in pregnancy it comes with being pregnant but it's also your body talking to you and it's telling you i am tense here i need help releasing tension here so i always say to women if you're feeling uncomfortable in a particular area let's stretch it out and find different movements we can do because your baby will follow the path of least resistance so if we can the aim is to get your body free of tension so that you can have a comfortable pregnancy and hopefully a bit of a smoother birth so part of the spinning babies for releasing tension is they have side-lying releases which are quite similar to that modified sims position we were talking about before but they just also involve the shoulders being
Sarah:
[52:18] In line. So it's like shoulders and hips in line, knees in line. And then you can also put a jiggle into it. So you put your hand on the woman's thigh or glute and just give a gentle jiggle. And that helps with releasing the soft tissues. And the other one is the forward leaning inversion where knees are, and this is one time I love hospital beds because the woman can have their knees on one part of the bed, their forearms on the foot of the bed, and then I can lower the foot of the bed and their bum goes up in the air and it just sort of takes some pressure off pelvic bowl and then I usually get up on the bed behind them and put a towel around their bums and shake and just give a bit of a jiggle and some women find that really comforting I also will then after they've seen it get the partners to do it it always gets a lot of giggles and I love when there's laughter in a birth room I feel like laughter releases tension so the more laughter you can have in a birth space I'm all for it and I always say to the couples what gets the baby in gets the baby out and that always gets a big laugh especially when she's like upside down with her bum in the air and her partner's behind her jiggling away um yeah so we do that one a fair bit and I don't know how much research has been done on that particular intervention and that it would be interesting to see that what sort of role the jiggle plays.
Sarah:
[53:42] I feel like there is, I feel like Gail Tully who, you know, has the one who set up the Spinning Babies website has some research in the pipeline or positive results.
Mel:
[53:53] Well, Gail was on the podcast, you don't know it yet because it hasn't come out yet, but she will have been either one or two episodes before our one. Oh, okay, great.
Sarah:
[54:04] So we'll be able to hear about all that. So it's all used to listen to it.
Mel:
[54:09] Yes, well, basically if anybody's been listening to all the episodes, you will have heard from Gail Tully, and she gives some insight into the jiggle, and there is currently a research project going on with some of the spinning babies techniques.
Sarah:
[54:23] Fantastic.
Mel:
[54:24] Yes, you're on point.
Sarah:
[54:27] Also, when you're doing that sideline release or the modified sims where a woman's on her side, if she can reach up her top arm over and, like,
Sarah:
[54:36] Hold the bed, she gets a nice big stretch. Through her ribs and there's also there's usually a lot of tension in here and that tends to feel really good just releasing that and then the person doing the jiggle can just sort of hold hold at the hips and sort of separate the ribs from the bottom and and get a bit of release through there um there's this amazing midwife who works at my hospital and she has she used to do like exercise science and I can't remember her exact story but you should definitely have her on the podcast her name is gabby and her um clinic is called g.laurie body work for labor and so she does a lot of soft tissue release with women throughout pregnancy and preparing for birth and like all the women who have breech bubbers or have discomfort or have got to 41 weeks and they're birthing in the system we always recommend gabby because and she she talks a lot about like tension through the ribs because obviously everything's connected like obviously tension through your ribs is going to be affecting what's happening abdominally oh rebozo hasn't been studied spinning babies is in the pipeline models of care and care provider that's I mean this is my postdoc work I think is looking at how that impacts posterior labor and the other thing is timeframes like we said earlier timeframes is
Sarah:
[56:01] One of my things, I just, if we could not have timeframes and it just be about the clinical picture in front of us, I think we would dramatically reduce unnecessary interventions, birth trauma, our seizure rate, our job satisfaction for midwives. Like I think time constraints have a lot to answer for.
Mel:
[56:22] Yeah, I agree. A lot of the limitations that we put on labour mean that women who have posterior babies are not given a good enough chance to just wait for it to correct itself.
Sarah:
[56:34] It's that thing being a hospital midwife, just trying to keep women at home for as long as possible and I always talk to women about setting up your house as a birth centre and understanding that for some labours you are going to spend most of that labour, just the two of you in your own home. So start thinking about what you're nervous about, what you're comfortable with and what you're not comfortable with and talking to each other about it and setting up like a gym circuit around the house with like a football somewhere and something to hang from somewhere else and just thinking about all your strategies for managing at home and just setting up those expectations early. I had a woman about two weeks ago and her and her partner called me in the middle of the night and they're like we're just letting you know everything's okay. I'm like great call me back when you want to come in and they called back and it was interesting listening to their conversations like I could tell they'd really taken on board that information because I could hear them negotiating do you think we should go now do you want to wait half an hour and they're like we're going to wait an hour and then we'll let you know and then they called and they're like we're on our way in when she came in she was very obviously in second stage but in hospital you don't call it till there's head on view yeah
Mel:
[57:49] Oh we don't either at home where it's like i don't know i i can't say you're actually pushing out your baby until i see the top of your baby.
Sarah:
[57:57] So i just was supporting them and it was beautiful like they timed it so perfectly and she had this gorgeous water birth and she wasn't even sure she wanted at a water birth but yeah she had a gorgeous birth and I love those ones because I'm like I know I gave really good education I really prepared them well and I feel like expectation management is just so crucial and
Mel:
[58:24] Actually next week's episode is all about preparing for a posterior birth and it's not that you're going to have one but if you prepare for all possibilities then you might not get surprised if it happens and you're actually prepared and then if you use none of it you were still prepared and you didn't need it all.
Sarah:
[58:44] That's so great I feel like that is what women need I'm so glad you're doing that episode the things that we do are still useful no matter what position your baby's in
Mel:
[58:56] So next then, you need to just gather as many stories as you possibly can.
Sarah:
[59:03] So there's a little bit of debate about this between myself and my supervisors because they're like, you're going to hit saturation point really soon. You'll hit it before 20, aim for 20. And I'm like, I want all the stories. I want to hear all the stories. I want to have like this. And it's like that's not the thesis, but I just love the idea of having lots of posterior stories somewhere for women to access. A lot of the people that I've spoken to have been midwives themselves and so that kind of messes with the data because midwives have midwifery education when they come into the birth. So it would be good to hear from women who have had posterior labours who haven't had a midwifery background or midwifery education. And also just trying, for me, for it to be representative, I want to hear stories from women who have birthed in public hospital, private hospital, caseload or MGP, home birth, who have had shared care with a GP throughout pregnancy. Like I want to represent all the models of care. And so far I haven't got a representative sample yet. So, yeah, I do want to keep collecting.
Mel:
[1:00:11] Well, you might, if you need to get it from all of those areas, you might be able to interview 50 women. But good luck analysing all of that data because 20 is a lot. So we will put some details for the study in the show notes below. And if anybody listening either knows somebody who you think would be great to participate in the study or if you are somebody, then you can contact Sarah, tell her your story, and contribute to this massive gap in the research to help progress this work. Thanks so much for being here, Sarah. This is revolutionary, brand new research. We don't often get to say that because sometimes it feels like the research world is saturated, but you've found a gap and you're going to plug it with some big, hefty research. And then I do believe you will have your life's work cut out for you, writing and learning about posterior birth. Is there anything else that you feel like we haven't yet been able to address that you want to leave us with?
Sarah:
[1:01:12] No, I think I covered all of my dot points, but I'm very glad that my life's work is here and I've got my little, can you see that? That's my little posterior.
Mel:
[1:01:24] Posterior baby tattoo.
Sarah:
[1:01:25] So it's really great that this is my life's work because I've already inked it onto my body.
Mel:
[1:01:30] Yeah, right. Yeah, that's right.
Sarah:
[1:01:33] It's done.
Mel:
[1:01:33] Yeah. Self-fulfilling prophecy. Amazing. Thanks so much Sarah if anybody listening today wants to learn more have a look in the show notes and also Sarah has very generously provided her reference list that she's used to write her literature review which is where she's drawn her information from today so you can all have a look at that literature and go deeper if you're on the mailing list then you get access to all the resources that we use to make every single podcast episode thanks Sarah, To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
This transcript was produced by ai technology and may contain errors.
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