‘Please don’t forget maternal position, the obstetric bed was probably the worst invention in the history of childbirth, turning women into passive patients who expected that there was nothing they could do to reduce their pain. MJ’
If you haven’t read my first blog post yet – the story behind the Campaign – click here. The second blog post focused on the research we so need into fetal positioning techniques to prove they are safe and effective. Believing in them because so many people have used them to great effect does not clinical evidence make… Click here to read about research ideas.
It has now been two weeks since the launch of the MakeBirthEasierCampaignUK and support has continued to grow. After I published my second blog post, it had 400 views in one day. I don’t know if that is good in the world of blogging for a second post but I thought it was pretty fantastic! The Campaign message – fetal positioning techniques, such as those on SpinningBabies.com, to be included in the standard training curriculum for all midwives for use as part of routine care – seems to be making its way around the world at a steady pace, reaching many countries including the UK, USA, Australia and as far afield as Bermuda and the Philippines!
I have had many supportive comments, “I love what you are wanting to achieve and yesterday I shared on both my FB page and website. It is a massive project and you will face many many challenges…” and some very constructive advice and suggestions which I will be covering below.
Move Mummy to Help Baby
Thank you to Margaret Jowitt for your comment ‘Please don’t forget maternal position, the obstetric bed was probably the worst invention in the history of childbirth, turning women into passive patients who expected that there was nothing they could do to reduce their pain.’
You have inspired the blog this week!
Firstly, I may not have been clear in one vital part of my explanations of fetal positioning techniques. Fetal positioning can be improved by ‘maternal positioning’ and posture. The techniques on SpinningBabies.com use ‘maternal positioning’ in order to achieve optimal ‘fetal position’. Move mummy and this can help baby to move.
Secondly, to the obstetric bed. The obstetric bed is great for the care provider who has a better view of, and access to, ‘proceedings’. ‘Proceedings’ for the labouring mum in this position however are far from ‘better’. Lying on ones back, particularly with legs up in stirrups, is the worst position! The medical term for this is the lithotomy position and it is a common position used for medical examinations and surgeries involving the lower abdomen and pelvic area. References to the position have been found in some of the oldest known medical documents including versions of the Hippocratic Oath!
However popular it has been with obstetricians, the position is not conducive to a smooth labour as it constricts the birth canal, puts pressure on the coccyx, and does not allow the mother to move during the process, therefore increasing pain in labour. During labour, the position appears to cause compression of the main maternal blood vessels including the vena cava, thereby reducing the flow of blood to the infant which can cause severe problems for mum and baby.
The baby is pulled by gravity into the mum’s back rather than out and the birthing process is much less active. It becomes, as Margaret quite rightly put it – ‘passive’ birthing. This makes for much more effort on the mum’s part and, I’m to understand, considerably more discomfort. Passive birthing also often requires more invasive medical interventions, and is associated with increased trauma to both mum and baby.
Even the World Health Organization does not recommend the use of the lithotomy position for child birth, and states that ‘Giving birth in an upright position appears to be associated with several benefits, including reduction in the duration of the second stage of labour. Pending further confirmation of these benefits women should be allowed to choose their birthing position.’
My mum gave birth to three of us in the lithotomy position and has stated categorically that if she knew then the things that I have taught her about birthing and the role of movement and gravity in labour – she would never, ever, have given birth the way she did!
The strange thing is these days, that even though movement and remaining active is readily promoted by midwives antenatally, it is all too easy for a woman in labour to walk into the labour room and be guided directly to lying down on the bed. Why does this still happen? It is ingrained in us, by media and society in general, that a labouring woman is supposed to lie down on her back. ARGH!
Luckily I know a few midwives making efforts to turn this initial error on its head (pardon the pun). Some midwives are leading the labouring mum into the labour room but sitting on the bed themselves so the woman in labour could only sit on it and cannot lie down on it. They may even move the bed to one side of the room rather than it being a centre piece, so that space is made available for the mother to move around, maybe sit on a birthing ball, or put pillows on the floor for her knees so she can lean over the birth ball or against the side of the bed…
Hang on, did I say bed? Yes, okay, if we are a bit more inventive, there are some pretty good ways we can make use of the obstetric bed, it has to be said. The hospital bed has a back that raises up at an angle so mum can lean forwards over it while on her knees. Another rather smart use of the modern obstetric bed is that the lower section can be lowered in a kind of step fashion which is a fabulous shape for doing the classic Spinning Babies ‘Forward-Leaning-Inversion’!
Is All this Extra Training Really Going to be Used?
The other night I had a chat with an ex-midwife in her 70s who is very close to me. She is very supportive of this Campaign, yet still has her doubts about the practicalities of its use in certain settings and she played devil’s advocate with me to press home some points.
In the home birth setting or a small Birth Centre with enough midwives to go around, yes there may be plenty of time to spend with the labouring mum, one to one. In these situations a midwife can invest the time required to do fetal positioning techniques. Some take a few minutes and some, for example the ‘Abdominal Lift and Tuck’, need to be done through 10 contractions. Hmmm…alarm bells…10 erratic contractions for me with my back to back baby No2 took well over an hour – maybe even an hour and a half. Am I saying that a midwife needs to spend an hour and a half with a mum to do just one exercise?
Midwives Stretched to Limits
Now let’s look at a busy labour ward in September or October – notoriously the busiest months for number of births. This is the time when a midwife is popping in and out of the room and may be gone for what feels, to the labouring mum, like a million years. Where does she keep going? Why does she keep leaving the room?! Well, she has several other ladies at various stages of labour, with varying degrees of urgency to attend to. This is the reality. One to one care at this point is not what it feels like to the patient left with her hubby or relative or at times – alone. The midwife cannot leave a woman who is in the midst of actually delivering a baby or placenta to spend time with the lady who is experiencing a long labour with contractions which for one of several possible reasons, are not increasing in strength. Maybe this is due to stress of being without a midwife!
Whose fault is this? Let’s not go into that here but it is not usually the fault of the midwife, we can safely say that! She (or he), is stretched beyond sensible limits probably far too often and is trying her level best to get through the shift doing a great job of bringing babies safely into the world.
Maybe this failure to progress is due to a malpositioned baby. So let’s say the #MakeBirthEasierCampaignUK is entirely successful and midwives are now all being trained in fetal positioning techniques – where then is this trained up midwife? Why is she not on hand to come and spend that hour and a half with this lady to do an ‘Abdominal Lift and Tuck’? Because it takes too long and she is away tending to a more urgent labour! This was devil’s advocate talking.
My answer to this quandary is that actually, and I must make it abundantly clear here, it would NOT necessarily need to take an hour and a half of the midwife’s time to do the ‘Abdominal Lift and Tuck’. It could take a couple of minutes to explain how to do it to the mum, and guide her into the correct position for contraction number 1. Then the midwife could go and see her other patient/s leaving mum coping quite well with the other 9 contractions needed for the ‘Abdominal Lift and Tuck’. I did this exercise on my own without anyone to help me. I left my husband sleeping soundly in bed while I carried it out according to the instructions on the website.
May I add here that taking some form of action to actively improve the labour, immediately gives a feeling of empowerment, which is incredibly good for a birthing mum psychologically, and subsequently physically.
Again, another staple of Spinning Babies like the ‘Side-Lying Release’ – which in labour is held through 3 contractions – could take just a few minutes of the busy midwife’s time while she helps to position the mum on her side in the correct manner, gives instructions to the mum and birth partner (husband, relative, doula) and leaves them to continue after the first contraction.
These are possibilities. Depending upon the technique in question it could be fine to leave a lady doing an exercise without the midwife present throughout. After all, a birthing ball is readily accepted as something a mum can use without the attention of a midwife. Or should the mum go back to lying on her back on the bed…
Taking More Time to Create Time
The point I am trying to make (hopefully this is making some sense!) is that investing a few minutes, even on a busy labour ward, to use these fetal positioning techniques where appropriate (where a midwife assesses that it would be beneficial), can shorten and ease labours, and reduce the number of interventions, augmentations, assisted deliveries and csections. Mums (even very tired ones) could be motivated to do them to avoid these interventions and eventually, when the techniques become a routine, standard part of everyday midwifery, time will have been created – created by a reduction in the number of interventions – created by a reduction in the number of emergency csections – created by a reduction in the time each woman is in labour in the first place – a less busy labour ward. Even if it is just a bit less busy, and there are just a few less interventions, won’t this make a big difference in the number of women leaving the labour ward happier, having had an easier time and better outcome?
In fact, I wrote the above text last night, and tonight during my review, I have found information via the World Health Organisation as follows – ‘the potential to improve delivery outcomes; reduction in the duration of second stage of labour may help reduce overcrowding in labour wards and reduce the time health-care providers spend with each woman.’
It appears I may not be as daft as I look…I should run this by my friend the ex-midwife! The text is in particular regard to allowing women to deliver in an upright position, however, it refers directly to reduction in the duration of second stage of labour, which fetal positioning techniques help to achieve. This is what I am hoping will happen by implementing fetal positioning techniques across the UK. Fingers crossed midwives!
Something that would add a lot to the use of fetal positioning in labour, is the use of fetal positioning in pregnancy. If women are using these techniques to balance their uterus, ligaments and muscles before labour even starts, many malpositions and malpresentations could be prevented in the first place. Plus if fetal positioning techniques are then required during labour, women would already be familiar with the techniques and the time midwives need to spend guiding them during labour could be shortened even further. After all, midwives are not integral to the hypnobirthing process and are not required to be present to monitor that are they. If women are adequately and routinely prepared with fetal positioning knowledge and practice, they could possibly go ahead and do these exercises themselves with just reminders or pointers as to which exercise would be beneficial for whatever situation arises.
The Next Step
So two weeks in, what is the next step? My plan is progressing rather better than I anticipated…
Step 1: Generate interest and support from mums and the midwife community. This bit is continuing well and on Facebook and Twitter there are more and more liking and following each day. Today @MakeBirthEasier topped 100 followers on Twitter!
Step 2: Generate interest and support from the research community. Can I just put a BIG FAT TICK by this one as the Campaign has received keen interest to do some research!! Although it is not yet known if we can pursue this avenue, it is incredibly heartening to know that there are researchers out there who may have the means, and are eager to study the effect of maternal / fetal positioning techniques on birth outcomes. This is already a huge step for the #MakeBirthEasierCampaignUK in such a short time – there is still a very long way to go. With continued support to raise awareness about fetal positioning by sharing the campaign message we hope this first step becomes one of many. Totally buzzing with excitement at the possibilities!!
Step 3: Generate interest and support from the obstetric community. I have started to receive some support here which I believe to be crucial to these techniques being accepted into mainstream care.
Step 4: Generate interest and support from the medical press. I have begun tweeting the medical press and can tentatively say I have had a couple of journalists and editors follow @MakeBirthEasier.
Further Thoughts on Research
My last post set out some thoughts and ideas on research methodologies. I’m over the moon about the possibility that there is a researcher who may be able to set up a study at their facility. It is immense news! We can only keep our fingers crossed that there is a viable study to be pursued. We will have to wait and see if we can get approval!
This however is certainly not where we put our feet up – we cannot rest until our goal is achieved! There are many avenues to look down, many ways to gather evidence and many sources.
Here I shout out to anyone who could conduct case reports – where the experience of a few patients is written up as a paper. This can be the starting point for saying ‘this is something interesting and worth looking at further’.
From there we might be able to generate interest to do a cohort study, possibly supported by a maternity unit, where some parameters are set e.g. specify type of women included i.e. low risk pregnancies, with a baby which is known to be malpositioned (back-to-back etc.) or perhaps exhibiting some signs which may be due to a malpositioned baby such as contractions which slow down or stall or contractions with no progress. Then use the fetal positioning techniques with those women and record what happens.
It may be unrealistic to expect to generate direct evidence of the impact of fetal positioning techniques on labour outcomes, due to the number of compounding factors. However we would hope such studies could support a trend towards improved outcomes.
The way to start may be to find an interested midwife unit – one where ‘natural’ birth is actively promoted. Are there any head midwives reading this who are supportive of these ideas? If so, please do make yourselves known to me!
Thank you to a lovely friend of mine experienced in the world of trials and use of their data (you know who you are!) and also to Jackie, founder of Cherished Births, for this suggestion.
I mentioned this in my previous blog post – this is such a complex and dynamic issue. Any advice or guidance you clued up people out there (researchers, midwives, obstetricians, gynaecologists, scientists, anyone in the know!) can offer on any of these questions would be very welcome. All comments which have come my way so far have been valuable and I would like to thank all of you who have been in touch!
I also say this every blog post, but if I can use fetal positioning techniques myself for both my births with such impressive results (see my first blog post MakeBirthEasierCampaignUK dated 11 May 2015), imagine what trained midwives could achieve using them every day. Women in this country would have a better chance of an easier, uncomplicated, intervention free birth if midwives and other health care providers had training in fetal positioning techniques. To reach that goal, we need evidence and support.
This is a huge opportunity to invest in a more positive future for maternal care in the UK. I am hopeful that I have your support.
For health professionals and others interested in being part of this opportunity, please leave comments / advice / guidance / offers of funding / offers of research team & research facility (!!) on this blog page.
You can contact me via my page at https://www.facebook.com/MakeBirthEasier (particularly if you would like to message me privately)
The Campaign is also on Twitter @MakeBirthEasier, #MakeBirthEasierCampaignUK
Blog written by Alix Fernando
The content of this blog is not intended, and should not be read as constituting medical advice, diagnosis or treatment. Always consult your doctor, midwife or other qualified healthcare provider before making any changes to your birth plan or recommended routine.