April 14, 2004
Volume 6, Issue 8
Midwifery Today E-News
“Occiput Posterior Presentation”
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In This Week’s Issue:

Quote of the Week

"Be kind and say a prayer for those of us who came before you, as we honor those who lit our path."

Cynthia Jaffe

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The Art of Midwifery

I am a huge believer in slippery elm for treating vaginal yeast—it cured me after a year of chronic yeast. I make a paste of slippery elm powder, to the consistency of pie crust, and insert it using a vaginal applicator (like you get with over-the-counter remedies). Or, you can roll it into a ball and insert it. It may stay in for as long as 5–7 days. After the ball comes out it is followed by white frothy material. When my OB checked me he said I had "the healthiest-looking vagina he had seen in a long time."

Mary, Midwifery Today Forums

ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.

News Flashes

Comparative statistics for persistent occiput posterior (OP) fetal position and occiput anterior (OA) include:

Labor longer than 12 hours49.7%26.2%0 to 6 1-minute Apgar12.4%7.1%
Length of stage 2 greater than 2 hours53.3%18.1%7 to 10 1-minute Apgar87.6%92.9%
Spontaneous delivery37.7%83.9%0 to 6 5-minute Apgar0.6%0.9%
Assisted vaginal delivery24.6%9.4%7 to 10 5-minute Apgar99.4%99.2%
Cesarean delivery37.7%6.6%Shoulder dystocia0.8%2.1%
Third- or fourth-degree tear18.2%6.7%Nuchal cord8.6%21.6%

Persistent fetal occiput posterior position: obstetric outcomes. Obstet Gynecol 2003; 101:917

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Homeopathy for Occiput Posterior Presentation

Homeopathic medicine, along with comfort measures such as counterpressure, hydrotherapy, and positioning, are very positive means of helping a baby move into the most desirable position for birth and result in more-effective contractions with a shorter and a less painful labour for the mother. Homeopathic remedies are easy to administer and act quickly and dynamically to alleviate back pain. They should be given in the following manner:

  1. Use a 200C potency of the appropriate remedy.
  2. Tip the remedy pellets into the lid of the container and place directly into the woman's mouth; avoid touching them with your hands.
  3. Use a 1:10 time frame to assess the effectiveness of your remedy. If the woman has been experiencing back labour for three hours you should begin to see a change in the location of the pain within 18 to 20 minutes. If the remedy does not seem to be reacting in your time frame, you may want to continue observing and talking to your client until another remedy picture is clear to you.
  4. Administering an incorrect remedy will do no harm; the result will be that there is no effect.

Several remedies can be quite effective in alleviating the pain of back labour. They may cause the baby to shift positions or even turn from a posterior presentation.

Kali Carbonicum (potash)

  • Pains in the lumbar region
  • Very severe pain in the back, feels as if her back would break
  • Desires constant pressure on back
  • Pain may pass from the back through the gluteal muscles with cutting pain in abdomen
  • Extremely chilly to the point of trembling
  • Touchy mentally and physically
  • Worse 2–4 am
  • Posterior presentations

Gelsemium (yellow jasmine). This remedy is for a woman who is about to begin pushing but the baby appears to ascend rather than descend with each contraction.

  • Pains from the uterus up the back or extending to the back and hips
  • Nervous chills up the back
  • Baby appears to ascend rather than descend with each contraction
  • May lose her dilation during a pelvic exam
  • Weakness
  • Dullness—heavy eyelids, flushed, puffy face
  • Drowsy and listless—sleepy when she should be pushing
  • Performance anxiety—may be feeling pressured to perform

Excerpted from "Homeopathic Remedies for Back Labour and Posterior Presentation," by Piper Martin, DS Hom. Med., Midwifery Today, Issue 58

To be continued next issue [Issue 6:9].

Order Midwifery Today, Issue 58.

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Web Site Update

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Forum Talk

Do you have experience with a woman becoming pregnant with an IUD in place? I have had one for two and a half years with no problems, check the strings as advised, etc. but as I usually get serious PMS I thought it odd this month when I didn't and suspected that I might be pregnant, which I am. I immediately, gently removed the IUD with only minimal spotting for less than one day and have been fine since (three days ago). Other than cramping, bleeding, fever, is there anything else that I should be looking for or concerned about? How unusual is this? If I get past the beginning of the pregnancy would there be any further concern about the pregnancy related to the IUD use?


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Question of the Week

Q: I am a student midwife and doula who has been hired to support a young mom with bipolar disorder. She is due in a few months and has an open-adoption plan for the baby (her second baby, second open adoption). I am currently researching bipolar disorder in pregnancy and have found a lot of information about risks/benefits of drug treatment in pregnancy but very little about the effects of pregnancy hormones on bipolar disorder and what I might expect or watch out for, and when, as her pregnancy progresses. I have heard that if the mom is off medication during pregnancy, the hormonal changes in very late pregnancy are likely to trigger a bipolar episode even if the mom's pregnancy had previously been relatively free from mood disorder symptoms. Does anyone have suggestions for where I can find out more about this aspect of pregnancy with bipolar disorder?

— Anon.

SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.

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Question of the Week Responses

Q: I am currently 32.5 weeks pregnant with my third child. My first baby was anterior. My second baby was persistently posterior. He turned *just* before delivery. Both births were unmedicated. My baby is currently posterior—at around the same time my son became posterior. I tried acupuncture, water exercise, yoga, pelvic rocking and tilting, hands and knees, etc. with my son. I have been doing the same things this time with the addition of chiropractic (and I have not done acupuncture yet). I am planning a homebirth this time and am very anxious about repeating my 2.5 day excruciating posterior labor. I am also very familiar with Pauline Scott's new book [Sit Up and Take Notice: Positioning Yourself for a Better Birth]. Are there any suggestions that would be helpful for me? Or is there anything else I have not tried yet?

— Robin

A: I highly recommend the Pink Kit, which is a little like optimal maternal positioning—it helps you get to know your body, especially your pelvis, and has great ideas for loosening up any tight areas and positions for helping you in labour. It is enlightening and empowering. See www.birthingbetter.com for more information and to order the kit.

— Sarah J Buckley, Anstead, Queensland, Australia

A: We must realize that babies in utero feel everything emotionally that the mother does and that they also come with their own "set of baggage." Something I have had great success with when it comes to getting babies to turn is guided relaxation and visualization. Getting the mother into a highly relaxed state and then having her acknowledge her anxieties and fears allows her to let them go. Then she takes herself into her womb (with her mind's eye) while still in this relaxed state, and she is able to see her baby and sense its environment. She then communicates her love to the baby, gives reassurance to the baby, and asks the baby, "If it will not hurt you to do so, please turn facing my back" (or head down, or whatever you need the baby to do). I have observed the baby moving and shifting while the mother is communicating, and often the babies turn that night. It can also be very helpful to ask the baby what it needs from you. I have found that you can do many exercises to assist, but the key thing is connecting to the baby and being able to reassure him/her with your peace. And when you do this, you are also reaffiming to yourself your faith in the birth process. In Robin's case, the baby could very likely be picking up on her apprehension about having another long back labor.

— Abbie Thomas, CD (DONA), CLD

A: Our doula group recently had a chiropractor come speak to us about the Webster technique. We usually associate this technique with helping breech babies find a better position, but the principles of alleviating uterine constraint by realigning the sacrum and thereby restoring balance to the ligaments also have implications for women whose labors tend to be long and less than effective, or for malpositions other than breech presentation. You might check with your chiropractor to see if he/she is trained in the Webster technique, and if not, switch to one who is. Check this link for one in your area: www.icpa4kids.com/find_pediatric_chiropractor.htm

— Ana M. Hill, CD, CLD

A: Have you tried the pressure point on the outer sides of the pinkie toes? If not, have someone apply pressure to the outer side of the joint at the base of your pinkie toes. Make sure the pressure is even on both sides. This technique has been shown to help turn a baby. I had a 10-pound posterior baby girl at home; what saved me was envisioning her coming down anterior.

— Alicia

A: I am a homebirth CNM and am very adamant about trying to turn the baby to an anterior position prior to labor. In addition to hands and knees, I ask my patients to have their partner or support person encourage the baby to turn using the following exercise (first you must know from your midwife what position the baby is in currently): Thoroughly oil your belly; while on hands and knees, have a helper (H) reach across your belly from beneath and draw the baby toward H in the direction of pulling the back of the baby in their direction. For example, if the baby's back is more on your left, H will pull from your left to right in an attempt to bring the back to the anterior position.

Stair walking can be an effective exercise to turn a posterior baby. In addition, I suggest placing one foot on a chair or couch and lunging, with the leg corresponding to the baby's back being the one on the chair. Finally, if the baby persists OP in labor, I massage the uterus during contractions with lots of oil, beginning at the pubis with both fists, bringing my fists up to the fundus, sort of lifting the baby out of the pelvis. This is very uncomfortable, but the tradeoff is a much shorter labor if the baby turns on its own without encouragement. For pain relief, I use sterile water papules to relieve back labor. Very effective and easy to do at home.

— Anon.

A: Here are a few articles you may want to check out: www.homebirth.org.uk/ofp.htm
www.doulanotes.com/halta.htm My first child was posterior, and I found the most comfortable position was standing with my forearm against the wall and my forehead resting on my forearm. This position allowed my belly to hang, removing pressure from my back, and helped the baby descend. Waterbirth might also lessen your pain.

— Erika

A: I highly recommend Jean Sutton's book Optimal Feotal Positioning. She is a New Zealand midwife. I empathize with the back labour and hope this helps. Have a great birth!

— Patricia Vanier, St. Albert Alberta, Canada

[Editor's Note: To order a copy of Understanding and Teaching Optimal Foetal Positioning by Jean Sutton and Pauline Scott, go to www.midwiferytoday.com/products/OFP.htm]

A: Be sure to check out www.spinningbabies.com to help with positioning. I've also had good luck helping babies turn in labor by having the mom get into an exaggerated 3/4 over side-lying position. You can also put ice down near the baby's face while mom is doing knee chest. Lastly, doing pelvic lifts during contractions with a rebozo can help the baby turn.

— Wendy Kogler, LCCE, CD (DONA)

A: Have you tried "diaphragmatic release"? It is very simple, and I have personally seen success with the two woman I've had try it with their posterior babies. They each only had to do it a couple times over a 24–48 hour period, and their babies turned beautifully. It seems to be a wonderful little technique.

— Diana Efsits

[Editor's Note: For a step-by-step description of the diaphragmatic release technique, plus references, see "Posterior No More!" in Midwifery Today Issue 63.]

[To order this issue of Midwifery Today print magazine, go to www.midwiferytoday.com/products/MT63.htm]

A: I too had a posterior home/waterbirth with baby 3, and with all the research I did I knew how to tell if this was the case. I didn't know until she was out that she was sunnyside up. The reason? I didn't have one second of back labor pains! I just did what my body told me at each contraction. I was on the floor with knees spread as wide as they could go and leaned on pillows or just hands, rocking/swaying hips. And I must say the water was a very big factor! So soothing. I concentrated on keeping belly lower than spine, hammocking baby into belly rather then lying back with baby on the backbone. It just felt good that way. She was born from beginning to end in less than 4 hours and weighed 8 lbs, 8 oz, 21 1/4", 14" head and 15" ribs, not a tear and really no "pain."

— Anon.

Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.

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Question of the Quarter for Midwifery Today Print Magazine

We hope you'll take a minute to consider the Question of the Quarter for Issue 70 of Midwifery Today. In fact, if you send us a response and we use it, we will send you a free copy of the next issue. Responses are subject to editing for space and style. Try to keep the word count at less than 400. E-mail responses, along with your mailing address, to: mgeditor@midwiferytoday.com.

Theme for Issue No. 70: Hands-on Care
Question of the Quarter: : What does hands-on care mean to you? What do you think it should involve? What are its advantages?
Deadline for submission: April 28, 2004.

Question of the Quarter is a feature of Midwifery Today magazine, E-News's parent publication. Responses will be printed in Midwifery Today magazine. Subscribe.

Write to us! (See writer's guidelines.) We love hearing from you!


When I read Valerie's question [E-News Issue 6:7], the first question that came to mind is whether her son is regularly seeing a chiropractor. Although his symptoms and conditions sound severe, sometime chiropractic care can help diminish their effects. The following might be worth sharing:

Fetal heart fails to signal cerebral palsy risk
Society for Gynecologic Investigation Annual Meeting: Houston, Texas; March, 2004
US researchers have found evidence to suggest that fetal heart monitoring is not useful in detecting the white matter brain injury that precedes cerebral palsy (CP). White brain matter injury can occur during labor if the fetus does not receive an adequate supply of oxygen from the mother's blood. Consequently, since the 1960s, doctors have believed that fetal heart monitoring could identify babies experiencing such hypoxia, and allow them to intervene. Noting, however, that the incidence of CP has not fallen within the last 40 years, researchers from the Johns Hopkins University in Baltimore, Maryland, compared fetal heart monitoring data for 40 babies born with white brain matter injury and 40 who were not. Data were analyzed for the final hour to delivery in cesarean sections, and in the last hour of the first stage of labor during vaginal deliveries. Finding no difference between the two groups in any of the heart parameters studied, lead author Dr. Jayne Althaus said at the annual meeting of the Society for Gynecologic Investigation in Houston, Texas, that "electronic fetal monitoring really can't tell us the status of the baby's brain." If the fetal monitoring that we currently have doesn't help us identify those babies who are later diagnosed with these brain lesions, then we need to explore other options," she concluded.

Sandy, Redwood City, CA

Regarding E-News Issue 6:5 Art of Midwifery: Pregnant or nursing women, as well as infants under age one, should never ingest honey due to the botulism spores/increased risk of SIDS.

Gail Neuman, RNC CPHW SNP, Tustin, CA

Miscarriage and pregnancy loss are very difficult emotionally on families. It is something that is uncontrollable, sometimes unanswerable and usually unpreventable. This gives way to feeling out of control, losing trust in one's body, and a general feeling of helplessness that sometimes cannot be overcome. Of all care providers, the midwife should be most in tune with the lasting effects of loss during pregnancy, and yet the emotional issues surrounding miscarriage are rarely handled properly if at all, even by midwifery care.

Recently I was blessed to attend the birth of a 15-week baby. The mother was a midwifery patient and had presented in the office the evening before with spotting. Fetal heart tones were attempted for 20 minutes without success. The midwife sent her home to rest, with a promise to make an ultrasound appointment for the next day (she did not want this mom to sit in the ER for hours waiting).

The following morning the mom experienced primary SROM, was transported to the emergency room, and on her exit from the vehicle experienced secondary SROM. She was taken into ER, triaged, and placed in a temporary cot. Her husband and I spent the next 1.5 hours tending to her as not a nurse or provider would bother with her until she was in a room.

I got her water, wiped her face, helped her when she vomited, changed her soaked and stained pants, and explained the bleeding that had begun. I also expressed twice to the nursing staff that she was bleeding, chilled, that she was afraid. The standard response was "I'm sorry but there is nothing I can do." The midwife had not called ahead to the ER nor come to see her patient.

Once mom was in a room, the ER OB/GYN did a pelvic exam, found the baby in the vaginal canal, and placed him in an emesis basin. She was then handed over to the cover OB for the midwifery practice. She experienced a retained placenta and required a D&C and an overnight stay. Meanwhile the midwife had been informed by the OB of the mother's loss. She did not come to the hospital. The mother went home the next day, dealing with a heavy loss. The midwife did not call.

The mother took her experience to the hospital board and has in the works a city-wide policy change for the four local birthing hospitals that all pregnancy-related concerns be handled through Labor and Delivery, not the ER. But she blames her treatment on the lack of support from her primary care provider, the midwifery practice.

The standard answer, "There is nothing that can be done," is the wrong answer. A woman/family experiencing loss can be helped by love, compassion, service. Just because you cannot stop the loss does not mean the job is over. The focus is often on completing the miscarriage, getting it over with. Many times the process is handled mechanically so the mother does not have to go through the trauma. What is missed is the heart. Grieving must be accepted for pregnancy loss the same as grieving over death is accepted. The midwife should have the resources and ability to acknowledge this process and help the healing that is to happen along the way.

For anyone reading this who has experienced a pregnancy loss, you count, your baby counts, and your feelings count. You deserved better if you did not get it and should expect better always.

Chantel Haynes, pregnancy and birth assistant, Mokena IL

The trends of our times keep nudging us toward a technological world that grabs hold of our personal and collective fears and pocketbooks. And yet, the times also take us through trends that develop us all in evolutionary paths we can't begin to understand. How shall midwifery survive for those who wish to experience their own humanity in deep and perennial ways? Perhaps by continuing to share in forums like the ones you offer. Thank you for your work.

Patricia Kay, CNM, Olympia, WA

Editor's Note: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.

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What is the ecology of childbirth? Find out at the International Congress of the Ecology of Childbirth - A Celebration of Life, Rio de Janeiro, Brazil, May 27–30, 2004. For more information or to register: www.partoecologico.com.br

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