August 15, 2007
Volume 9, Issue 17
Midwifery Today E-News
“Posterior Position”
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In This Week’s Issue:

Quote of the Week

"Fear makes the wolf bigger than he is."

German Proverb

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The Art of Midwifery

[An] important remedy to consider when working with a woman who has had an experience with back labour is Aconite. Aconite has a special aspect to its mental/emotional realm; it addresses old fears that have become lodged in the body. This in homeopathic-speak is called: fear of the fright remains. It is specifically fear of the pain, and Aconite can be used for anyone who has a strong fear of the pain of labour. It works especially well with women who have had a very painful birth experience, such as a long posterior labour, and are facing their next birth. The fear of going through back labour again may terrify them in an acute way, i.e., they may have nightmares, panic attacks, weep when describing their previous labour, etc. In such a case give Aconite 200C during the pregnancy to lessen the intensity of the fear and hopefully to bring it into proportion for the time of the birth.

— Piper Martin, excerpted from "Homeopathic Tools for Occiput Posterior Position," Midwifery Today Issue 76

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Posterior Position and the Fetus Ejection Reflex

Two facts that were the basis of my empirical attitudes [regarding posterior position] have been authoritatively confirmed by published prospective studies.

The first fact is that worrying pregnant women about the position of their baby in the womb is useless. A large Australian randomized controlled trial involving 2547 pregnant women has eloquently demonstrated that hands and knees exercise with pelvic rocking from 37 weeks' gestation until the onset of labor does not reduce the incidence of persistent occiput posterior position at birth.

The second fact is that fetal position changes are common during labor, with the final position established close to delivery. This is the conclusion of a prospective study of 1562 women to evaluate changes in fetal position during labor by using serial ultrasound examination. Among babies who were posterior late in labor, only 20.7% appeared to be posterior at delivery. Finally, when the mother had no epidural, the overall rate of posterior position at delivery was only 3.3%, although this study was conducted in conventional departments of obstetrics, where the basic needs of birthing women could not easily be met. The rate was 12.9% in the epidural group.

When taking into account these two well-documented facts, focusing on the right question becomes easy: what factors can influence the rotation process during labor?

The answer is simple: The factors that can facilitate the rotation process are those that make a typical fetus ejection reflex possible.The passage toward the fetus ejection reflex is inhibited by any interference with the state of privacy. The ejection reflex does not occur in the presence of a birth attendant who behaves like a "coach," an observer, a helper, a guide or a "support person."

The fetus ejection reflex can be inhibited by a vaginal exam, by an eye-to-eye contact or by the imposition of a change of environment. It does not occur if the intellect of the laboring woman is stimulated by rational language (e.g., "Now you are at complete dilation; you must push"). It does not occur if the room is not warm enough or if the lights are bright. The best situation I know for a typical fetus ejection reflex is when no one is around but an experienced, low profile, silent, motherly midwife sitting in a corner and knitting.

The image of the "knitting midwife" should not be understood in a literal sense. Instead, it symbolizes the authentic midwife as a protective mother figure whose own level of adrenaline is maintained as low as possible. Noticeably, when the conditions for an ejection reflex are met, most birthing women find spontaneously complex and asymmetrical bending-forward postures that probably play an important part in facilitating the rotation of the baby's head.

Persistent posterior position at birth will become exceptionally rare on the day when the meaning of privacy is understood and authentic midwifery has been rediscovered.

— Michel Odent, MD, excerpted from "Occiput Posterior Position Should Be Exceptionally Rare at Birth," Midwifery Today Issue 76

Want the whole story? Midwifery Today Issue 76 has the complete article.

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Research to Remember

Researchers, in a review of data on Canadian-born infants in neonatal intensive care units (NICU), found that some ethnic disparities exist. (Mother's ethnicity of origin was used to determine the baby's race.)

The mortality rate for babies of South Asian (East Indian) origin was found to be more than three times that of Caucasian babies. Aboriginal males and East Asian females were found to have a significantly greater chance of surviving. All ethnic groups had "gestational age less than 29 weeks" as a significant risk factor, but only Caucasian babies showed "small for gestational age" as an important risk factor. Neonatal sepsis was the most important factor in mortality among African-American babies.

These are important questions, in light of the fact that premature births have increased in North America over the last 20 years.

Journal of Perinatology 27, 448–52, 2007

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A 46% drop in neural tube defects in babies born in Canada followed a 1998 requirement (with full implementation in 2000) that certain foods be fortified with folic acid, according to a New England Journal of Medicine report.

Physician's FirstWatch, July 12, 2007

Web Site Update

Read this article recently posted to our Web site:

Massage: Not Just for Mama—by Elizabeth Pantley
Baby massage has been practiced since ancient times. It can be as simple as a gentle rub with lotion after a bath or a more practiced infant massage. The benefits are many for both baby and parent.

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Question of the Week

Q: I am a hospital midwife in the UK and I occasionally see women admitted with symphysis pubis dysfunction pain so severe that it can only be controlled with opiates. When I was having my first baby in the US with an independent midwife, I remember discussions around the use of GLA (evening primrose oil) to ease this condition. Does anyone have any information on this, particularly on clinical trials that have been done to test its effectiveness?

Any help on this would be gratefully received!

— Elizabeth Pentz, RM

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

Question of the Week Responses

Q: My daughter's son is seven days old and she is breastfeeding him. He latches on and sucks well. Despite some soreness and bleeding of the nipples at first she is coping well and the soreness is clearing. She uses nipple shields for alternate feeds to help her breasts heal.

The baby rarely settles after a feed unless he also has some formula either from a cup or a bottle. However, once he has formula he sleeps well.

Does this indicate a shortage of milk? I recall when I was breastfeeding many years ago, my breasts were full and leaky most of the time. My daughter does not seem to feel like this and there is no leakage. Is there something we can do to make sure she has plenty of milk?

— Brenda (Sian's Mum)

A: My experience with nipple shields has been very negative and almost every woman I know who has used them has had difficulty with milk supply, hungry babies, clogged ducts and mastitis. She needs help (ASAP) to correct the problem that is causing the sore and cracked nipples so that she does not have to use the shields. If she is going to alternate cup feeding to allow her nipples to heal, pumping her milk will help to maintain or increase her milk supply and also avoid feeding the baby formula. It's possible that when she is feeding from the breast the baby is not able to suckle enough (common with nipple shields), and consequently is not receiving enough milk and not enough of the hind milk (which which contains all of the protein, making the baby feel full, content and sleepy). She should at the very least pump (with a good pump!) after using the shield to ensure that she empties the breast (to avoid clogged ducts and infection) and the baby receives the hind milk. Milk thistle (tea) is a great herb to help increase supply. Hope that is helpful.

— Gwen

A: I have helped over 200 moms with nursing new babies. I agree with the responses about chiropractic as I have seen it work wonders. Often the painful latch is because of birth trauma (yes, birth trauma can occur with a natural birth; my third was a perfect, relatively easy, home, water, unassisted birth and she had birth trauma). When the suck hurts it is bad not just for mom but for baby too, as they get sore from nursing since it is lots of work and still does not get them enough milk when the latch is wrong.

I would add to the comments on chiropractic that often these babies need craniosacral work. I have found the problem often is the shape of baby's mouth when opened as wide as possible. Even when little the baby should be able to open it really wide. The mouth should be shaped like an oval mirror with the oval up and down. If it is round or oval the other way it is wrong. These are good indications that baby needs craniosacral work.

The majority of babies that I worked with needed only one or two half-hour sessions. My third child was very improved after just one session (on the third day of her life), but needed a couple of months of weekly sessions. Another clue to the need of both chiropractic and craniosacral work is colic. If baby has colic it likely needs both.

Also often if mom is having attachment issues with baby or nursing just is not "going well" a visit or two to the craniosacral therapist will do wonders. I hope this information can be helpful to others.

— Anna Matsunaga

Responses to any Question of the Week may be sent to E-News at any time. Write to Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.

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Think about It

The Coalition for Improving Maternity Services (CIMS) reports that New York City and other communities in the US are working to improve the "level of transparency related to childbirth." This entails reporting on maternity services, including the rates of induction and c-section.

Birth advocates across the country are mobilizing at grassroots levels to work on this project. Grassroots advocates (under the umbrella of the Coalition for Improving Maternity Services and with support from Lamaze International, among others) officially launched the Transparency in Maternity Care Project in New York City on July 21, 2007. The Grassroots Advocacy Committee has been collecting hospital data on hospital care practices and interventions and has developed a birth survey to gather women's personal stories about their birth experiences.

To learn more about the Transparency in Maternity Care Project and The Birth Survey, go to or contact Jeanne Batacan at 455 Spring Avenue, Morgan Hill, California 95037, 408-779-7479,


In response to Birgit Johansen's letter in Midwifery Today E-News 9:16:

Actually vaccines are only for viruses and don't prevent bacterial infections. Measles, mumps, rubella, varicella, polio, hemophilus influenza B, flu virus, pertussis and HPV are all viruses that can be prevented with vaccines. Pneumonia can be bacterial or viral, thus the vaccine only prevents the viral form. HPV only prevents some of the viruses, not all types. There are other viral infections with vaccines out there as well.

I do agree you need to present all sides of an issue to women. Some women are not interested in hearing about herbal options though, and others don't want to hear the medical side of things. Every woman and pregnancy is unique. It's what makes the ART in midwifery.

Blue Bradley, RN, Doula, and CNM student

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