LOP baby

[mothercat]

Just a quick poll about baby positions in those last few weeks.

Four of my last five births have had babies that were LOA for weeks before the due date and then a week or two before labor starts they back up and switch to LOP. You can feel the legs and arms in front. Where mom describes movement is all across the front. And, I trust my hands.
So quietly I'm worrying the baby will decide to go ROP and instead when labor actually starts baby is back to LOA and a relatively short labor follows.

First, how common is this?

Second, I'm assuming because the baby can easily change positions, and the labors are good, that mom has a pretty good sized inlet?

As you have probably guessed, I don't do pelvimetry. Know how to, just don't see it as useful as labor for determining if baby will come out.

[mwherbs]

there is one midwife I know of who does everything she can to keep babies moved and no where near the OP side of things- but talking with her graduated apprentices it seems that they have the same incidence of OP as the rest of us.
Babies spin around I think that there was a study published recently that said as much that a high percentage of babies that start in labor OA would move around ---- here is a study on rotation

Obstet Gynecol. 2005 May;105(5 Pt 1):974-82.

Comment in:
Obstet Gynecol. 2005 Sep;106(3):642; author reply 642.

Changes in fetal position during labor and their association with epidural
analgesia.

Lieberman E, Davidson K, Lee-Parritz A, Shearer E.

Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, and Boston Medical Center, Boston, Massachusetts, USA. [e-mail]

OBJECTIVE: To evaluate whether epidural analgesia is associated with a higher rate of abnormal fetal head position at delivery. METHODS: We conducted a prospective cohort study of 1,562 women to evaluate changes in fetal position during labor by using serial ultrasound examinations. Ultrasound examinations were performed at enrollment, epidural administration, 4 hours after the initial ultrasonography if epidural had not been administered, and late in labor (> 8 cm). Information about fetal head position at delivery was obtained from the provider. RESULTS: Regardless of fetal head position at enrollment (occiput transverse, occiput posterior, or occiput anterior), most fetuses were occiput anterior at delivery (enrollment position: occiput transverse 78%, occiput posterior 80%, occiput anterior 83%, P = .1). Final fetal position was established close to delivery. Of fetuses that were occiput posterior late in labor, only 20.7% were occiput posterior at delivery. Changes in fetal head position were common, and 36% of women had an occiput posterior fetus on at least one ultrasound examination. Women receiving epidural did not have more occiput
posterior fetuses at the enrollment (23.4% epidural versus 26.0 no epidural, P = .9) or the epidural/4-hour ultrasound examination (24.9% epidural, 28.3% no epidural), but did have more occiput posterior fetuses at delivery (12.9% epidural versus 3.3% no epidural, P = .002); the association remained in a multivariate model (adjusted odds ratio 4.0, 95% confidence interval 1.4-11.1). CONCLUSION: Fetal position changes are common during labor, with the final fetal position established close to delivery. Our demonstration of a strong association of epidural with fetal occiput posterior position at delivery represents a mechanism that may contribute to the lower rate of spontaneous vaginal delivery consistently observed with epidural.

PMID: 15863533 [PubMed - indexed for MEDLINE]

[mothercat]

Thank you for the study link. I had heard about the study itself but had no citation to find it.

So, although the focus seems to be on the effect an epidural has on OP babies, in truth the study showed that baby position is variable even during labor.

But this brings up another question. If babies have the ability to change their head position, how is it that so many seem to get wedged and just have a really hard time coming out? Other than breech, aren't asynclitic heads or deflexed heads the major causes of primary C/sec for FTP?

[mwherbs]

malposition/presenation which includes posterior- as a cause of c-section- those so you have malpositon causing rom-or those irritating prodromal labor contractions- a population that goes to the hospital too early- on an epidural too early not upright and ignoring the early labor and not moving around helping a baby to find the right position- and we know that epidural = more persistent posteriors/and resulting c-sections-- I think that asynclitic is in there doing some similar things-- and I do think it is harder to correct because once you have a neck out of wack and harder to tilt side to side-- neck muscles seem fairly strong front to back- but the side ones strain a bit-- - lax abdomal muscles so that babies entering the pelvis in the LOT -ROT -and try to hold flexion- chin to chest can end up with not exactly the crown entering the pelvis-- I think that lax muscles play a role in lack of flexion as well--no studies on this sorry--

so there is a recent study in the family practice journal
here is the abstract and a link so you can read full text free
http://www.aafp.org/afp/20070601/1671.html

Am Fam Physician. 2007 Jun 1;75(11):1671-8.

Dystocia in nulliparous women.

Shields SG, Ratcliffe SD, Fontaine P, Leeman L.

Dept of Family Medicine and Community Health, Family Health Center of Worchester,
University of Massachusetts, Massachusetts 01610, USA.
[e-mail]

Dystocia is common in nulliparous women and is responsible for more than 50 percent of primary cesarean deliveries. Because cesarean delivery rates continue to rise, physicians providing maternity care should be skilled in the diagnosis, management, and prevention of dystocia. If labor is not progressing, inadequate uterine contractions, fetal malposition, or cephalopelvic disproportion may be the cause. Before resorting to operative delivery for arrested labor, physicians should ensure that the patient has had adequate uterine contractions for four hours, using oxytocin infusion for augmentation as needed. For nulliparous women, high-dose oxytocin-infusion protocols for labor augmentation decrease the time to delivery compared with low-dose protocols without causing adverse outcomes. The second stage of labor can be permitted to continue for longer than traditional time limits if fetal monitoring is reassuring and there is progress in descent. Prevention of dystocia includes encouraging the use of trained labor support companions, deferring hospital admission until the active phase of labor when possible, avoiding elective labor induction before 41 weeks' gestation, and using
epidural analgesia judiciously.

PMID: 17575657 [PubMed - indexed for MEDLINE]

-----------------
PS
here is another study that goes with epidural and persistent OP-- not exactly on topic but good to have atleast 2 ; )

J Matern Fetal Neonatal Med. 2006 Sep;19(9):563-8.
Associated factors and outcomes of persistent occiput posterior position: A
retrospective cohort study from 1976 to 2001.
Cheng YW, Shaffer BL, Caughey AB.
Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94143, USA. [e-mail]
PMID: 16966125 [PubMed - indexed for MEDLINE]

[mothercat]

Thanks for the AAFP article. I read the whole thing and it was great.

Now if someone would just write a book that included all the info we use for preventing labor dystocias, it would be great. Maybe that should be the next one in the Midwifery Today series.

[blissful_maia]

There's a really fabulous article called "Optimal Foetal Positioning", I'm not sure where to find it online as I have a print copy, but you could look. It really helped my understanding about what causes malpositioning and/or dystocia, how to remedy and prevent it, etc.

[cathicog]

Maybe this is an elemental question, but what motivation would the docs have to prevent distocias, if it brings in more income for the hospital (and thier own pockets?) Just wondering here....

[sevenkids]

I don't think OP is a malpresentation.(asynclitism is another matter, it's those little crooked heads that cause the most trouble) I think OP is the way, for some babies and mamas, that the head and the pelvis will best fit. I don't recommend anything to turn them to OA before labour begins. If Mom is experiencing back pain then I suggest ways she can ease the ache in her back. Most of the time, no matter how many pelvic rocks and cat/cow excercises Mom does, the baby will turn back to OP when or before labour begins. I am convinced it is because baby fits the inlet best when in OP.

Sometimes labour with an OP baby will cause back pain and be prolonged until baby rotates to OA, and sometimes an OA labour will cause pubic/hip pain and be prolonged until baby rotates to OP. Have you ever seen a long-arc rotation when baby's head is on the perineum? It's pretty amazing to see!

I believe (and have seen many, many times) babies heads will naturally engage into the best position to fit in the pelvic inlet, and will rotate and turn as it navigates the bones and fits into the outlet. You can see this when you check FHT's and they keep changing location. It goes without saying that an upright, mobile mother will facilitate the process. Some pelvic shapes/bony structures do take longer for the baby to navigate, which is why some women always have longer labours and some women always have short ones. What is the optimal fetal position? The one that works! I've even seen a few births progress rapidly when the baby rotated to OT.

I see a lot of fear regarding OP babies, and that is not a good thing to go into labour with fear about the baby's position. It makes the labour more uncomfortable, and if the attendent is communicating her fears about OP, the mother is going to react on it. When I have a lady with an OP baby, I make sure she understands that it is just a position, it most likely is the way her baby fits best, and we have ways to help her if her back aches in labour. Most women will, instinctively, choose a position/s that eases the back ache and facilitate the birth, and will loudly ask for counter-pressure .

lax abdomal muscles so that babies entering the pelvis in the LOT -ROT -and try to hold flexion- chin to chest can end up with not exactly the crown entering the pelvis-- I think that lax muscles play a role in lack of flexion as well--no studies on this sorry--

YES! I'm a big fan of the maternity support belt, especially for multips. Not only do they ease the discomforts of late pregnancy by centering the baby's weight inside the pelvis instead of over the arch, but they sort of force a baby to tuck in it's chin and stay well-flexed. I've seen a lot less asynclitism and a lot less non-productive prodromal stuff since we've started recommending a nice, wide support belt. Plus, the ladies feel better and are more inclined to take a daily walk when their backs, hips, and bellies aren't aching and feeling pulled in all directions.

[blissful_maia]

Originally Posted by sevenkids

I I think OP is the way, for some babies and mamas, that the head and the pelvis will best fit.

This is a good point, I had one client who had pushed three babies out OP who were all in the 9-10lb range (last one was 10lbs8oz). It worked for her. However, I think for most women, I think the number is around 85 or 90%, their pelvises are shaped to best accommodate an OA baby. I think it's best to start off with an OA baby in most cases, if the baby is meant to come out OP, he or she will rotate and vice versa, most of the time. These babies are smart!

[mothercat]

I noticed a while ago that some women with a very wide pelvis, well it just doesn't much matter how that baby goes into the pelvis. Those babies are just going to come out in pretty short order. I started wondering about the whole "posterior causes back pain thing" when a good friend had her last one.
She was describing how the baby was OP and her labor had been 4 hours, the doc told her to go ahead and push when she was complete and she told him "No, the baby isn't ready yet." A contraction or two later baby suddenly spun around to OA and almost wasn't caught he came out so fast.
Her mom and 3 sisters all had babies the same way. All posterior, all short labors, no back pain.

I swear that small babies who are posterior or asynclitic are far more trouble than larger babies positioned the same. The small ones can get hands up next to the head, they have plenty of room with an "adequate" pelvis to fit their head in at a funky angle, that at birth causes problems. How many moms have you seen where they have a C/sec. for FTP and the real cause behind it is a small baby that may have had too much room. Is it any wonder that these moms then go on to have a usually easier vaginal birth with a bigger baby.

I have the book Optimal Fetal Positioning, but does anyone know if there is a specific book that lists all the tricks in one place for giving baby the best chance to choose the best postion for birth?

[mothercat]

Originally Posted by cathicog

Maybe this is an elemental question, but what motivation would the docs have to prevent distocias, if it brings in more income for the hospital (and thier own pockets?) Just wondering here....

The article about management that mwherbs provided is from the American Academy of Family Practice docs. They are not surgeons and have a C/sec. rate aroung 10-15%, a little worse than midwives and a lot better than most OB's.

From my understanding of billing, if they do a vaginal birth they get paid more than if they only first assist at a C/sec. So, the familiy docs actually have a financial incentive to have a lower C/sec and to do more vaginal births. Plus the few family docs I know who still do OB do it because they really believe in the natural process, especially if they are a DO.

[Charmie981]

I think _The Labor Progress Handbook_ is pretty good for having all of your tricks in one place.

OP is so facinating to me. When I was in the Philippines, I came to believe that there's no such thing as "malpresentation" unless baby isn't fitting through mom's pelvis. At the same time, I do try to encourage LOA because evidence says that's the easiest way for most babies to fit through most moms. I don't stress mom about it, though, and always tell her that if baby is still flip-flopping, I'm not at all worried about malpresentation. If baby is LOP or even ROA for a couple of weeks in a row in the last month, THEN we'll talk about encouraging a change (before labor). If it doesn't work, it doesn't work, though.

[sevenkids]

Originally Posted by blissful_maia

. However, I think for most women, I think the number is around 85 or 90%, their pelvises are shaped to best accommodate an OA baby.

About 50% of the white female population has a gynecoid pelvis, which favours OA positioning, and 25% have an anthropoid pelvis, which favours the OP position. The other 25% have android, platypelloid, or a combination.

50% of the AA population have an anthropoid pelvis, and 25% have a gynecoid.

So about half of all white women will have pelvises best suited to OA babies, and about half of all AA women will have pelvises best suited to OP babies.
Plus you have to consider the shape of the baby's head...(I swear, I always check out a Dad's head shape and size, it can often be more telling than pelvic shape.)

I think 80 or 90% of babies will be born OA, as the baby comes down and rotates to navigate the curve of carus, under the arch and outlet.

I swear that small babies who are posterior or asynclitic are far more trouble than larger babies positioned the same. The small ones can get hands up next to the head, they have plenty of room with an "adequate" pelvis to fit their head in at a funky angle, that at birth causes problems.

Oh, those little thumb-suckers! They work so hard to keep their fingers in their mouths! I'd guess about 99% of the time, when we get an asynclitic baby, it's because a little baby's busy sucking hands or fingers and got the head tilted to keep their hands in their mouths. And then, they shove their fingers in their mouths as soon as they're born.