Level of agreement between midwives and obstetricians performing ultrasound examination during labor.

OBJECTIVE: To evaluate the level of agreement between ultrasound measurements to evaluate fetal head position and progress of labor by attending midwives and obstetricians after appropriate training. METHODS: In this prospective study, women in the first stage of labor giving birth to a single baby in cephalic presentation at our Obstetric Unit between March 2018 and December 2019 were invited to participate; 109 women agreed. Transperineal and transabdominal ultrasound was independently performed by a trained midwife and an obstetrician. Two paired measurements were available for comparisons in 107 cases for the angle of progression (AoP), in 106 cases for the head-to-perineum distance (HPD), in 97 cases for the cervical dilatation (CD), and in 79 cases for the fetal head position. RESULTS: We found a good correlation between the AoP measured by obstetricians and midwives (intra-class correlation coefficient [ICC] = 0.85; 95% confidence interval [CI] 0.80-0.89). There was a moderate correlation between the HPD (ICC = 0.75; 95% CI 0.68-0.82). There was a very good correlation between the CD measured (ICC = 0.94; 95% CI 0.91-0.96). There was a very good level of agreement in the classification of the fetal head position (Cohen's κ = 0.89; 95% CI 0.80-0.98). CONCLUSIONS: Ultrasound assessment of fetal head position and progress of labor can effectively be performed by attending midwives without previous experience in ultrasound.

Manual rotation of occiput posterior or transverse positions: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: The primary objective of this systematic review was to assess the association between spontaneous vaginal delivery and manual rotation during labor for occiput posterior or transverse positions. Our secondary objective was to assess maternal and neonatal outcomes. DATA SOURCES: An electronic search of PubMed, EMBASE, ClinicalTrials.gov, and the Cochrane Register of Controlled Trials covered the period from January 2000 to September 2021, without language restrictions. STUDY ELIGIBILITY CRITERIA: The eligibility criteria included all randomized trials with singleton pregnancies at ≥37 weeks of gestation comparing the manual rotation groups with the control groups. The primary outcome was the rate of spontaneous vaginal delivery. Additional secondary outcomes were rate of occiput posterior position at delivery, operative vaginal delivery, cesarean delivery, postpartum hemorrhage, obstetrical anal sphincter injury, prolonged second stage of labor, shoulder dystocia, neonatal acidosis, and phototherapy. Subgroup analyses were performed according to types of position (occiput posterior or occiput transverse), techniques used (whole-hand or digital rotation), and parity (nulliparous or parous). METHODS: The quality of each study was evaluated with the revised Cochrane risk-of-bias tool for randomized trials, known as RoB 2. The meta-analysis used random-effects models depending on their heterogeneity, and risks ratios were calculated for dichotomous outcomes. RESULTS: Here, 7 of 384 studies met the inclusion criteria and were selected. They included 1402 women: 704 in the manual rotation groups and 698 in the control groups. Manual rotation was associated with a higher rate of spontaneous vaginal delivery: 64.9% vs 59.5% (risk ratio, 1.09; 95% confidence interval, 1.03-1.16; P=.005; 95% prediction interval, 0.90-1.32). This association was no longer significant after stratification by parity or technique used. Manual rotation was associated with spontaneous vaginal delivery only for the occiput posterior position (risk ratio, 1.08; 95% confidence interval, 1.01-1.15). Furthermore, it was associated with a reduction in occiput posterior or transverse positions at delivery (risk ratio, 0.64; 95% confidence interval, 0.48-0.87) and episiotomies (risk ratio, 0.84; 95% confidence interval, 0.71-0.98). The groups did not differ significantly for cesarean deliveries, operative vaginal deliveries, or neonatal outcomes. CONCLUSION: Manual rotation increased the rate of spontaneous vaginal delivery.

Digital and Manual Rotation of the Persistent Occiput Posterior Fetus.

Persistent fetal occiput posterior (OP) position is a topic of interest with implications for intrapartum management. Although studies report a low incidence of persistent OP position, anecdotal evidence suggests an increase in prevalence given changes in maternal demographics. Clinicians are often familiar with interventions such as position changes and the use of props and a rebozo to address persistent OP position in early labor; however, midwives remain uncomfortable with the techniques of digital and manual rotation. This article reviews current evidence and recommendations for the management of persistent OP position in the second stage of labor. Further research is needed to guide clinicians on the optimal timing and techniques for digital and manual rotation.

Improving students' ability to perform a standardized foetal biometry plane using ultrasound simulators.

OBJECTIVE: The objective of this study is to assess progress made in the ultrasound (US) measurement of femur length (FL) by students after one hour of training on US obstetric simulators. MATERIALS AND METHODS: Medical residents and midwives registered for the 2016 French national foetal US diploma were invited to a 1-hour US training course with simulators. The time to acquire the FL plane with changing foetal presentation was prospectively measured before and after the training. Every image was recorded, and quality criteria were assessed. RESULTS: Thirty new learners trained in foetal US were evaluated. The time needed to measure the FL was significantly shorter in the post-test versus the pre-test (86s versus 125, P=0.015). The quality criteria were statistically similar before and after training regarding the angle to horizontal (10.0° versus 9.6°, P=0.84) and FL (31.3mm versus 32.0mm, P=0.15). CONCLUSION: The time needed to obtain the FL plane was reduced by 30% after a 1-hour US simulation training session.

Danish women's experiences of the rebozo technique during labour: A qualitative explorative study.

OBJECTIVE: The study aimed to explore women's experiences of the rebozo technique during labour. METHODS: This was a qualitative study based on individual telephone interviews, analysed by means of qualitative content analysis and inspired by interpretive description. 17 participants were recruited from two different-sized Danish hospitals and identified by applying a purposeful sample strategy. RESULTS: The main theme expressed the women's overall experience with the rebozo: "Joined movements in a harmless effort towards a natural birth". The women experienced that the technique created bodily sensations, which reduced their pain, and furthermore they expressed that it interrelated the labour process and produced mutual involvement and psychological support from the midwife and the women's partner. The rebozo technique was in most situations carried out because the midwife suspected a foetus malposition. CONCLUSION: The experiences of the rebozo technique were overall positive and both of a physical and psychological nature. The results indicate that health professionals should view rebozo as an easy accessible clinical tool with high user acceptance and possible positive psychological and clinical implications. The study contributes with a deeper and more nuanced understanding of a topic where only limited knowledge exists, however, efficacy studies are warranted.

Rebozo Technique for Fetal Malposition in Labor.

Fetal occiput posterior position is associated with increased maternal and fetal morbidities. Currently, clinicians have limited evidence-based techniques or tools to remedy fetal occiput posterior position. The traditional Mexican rebozo technique of pelvic massage, sifting, or jiggling offers a potentially valuable tool to help correct fetal malposition. This article reviews the adaptation of 3 rebozo techniques that can be used in labor to encourage optimum fetal positioning; outlines hospital considerations for safety, fetal heart rate monitoring, and universal precautions; and reviews the implementation plan to introduce and sustain use of the rebozo in a large academic medical center.

Fetal malposition: impact and management.

Fetal malposition, either occiput posterior or transverse (OT), leads to greater risk of cesarean delivery, prolonged labor, and increased perinatal morbidity. Historically, there is a known association between epidural use and malposition that was assumed to be due to the increased discomfort of laboring with a fetus in the occiput posterior position. However, evidence now suggests that the epidural itself may contribute to fetal malposition by impacting the probability of internal rotation. Fetal malposition may be impacted by manual rotation. Manual rotation has been associated with greater rates of delivering in the occiput anterior position and lower rates of cesarean delivery.

Management of fetal malpresentation.

Fetal malpresentation is an important cause of the high cesarean delivery rate in the United States and around the world. This includes breech, face, brow, and compound presentations as well as transverse lie. Risk factors include multiparity, previously affected pregnancy, polyhydramnios, and fetal and uterine anomalies. Appropriate management can reduce the need for cesarean delivery in some cases. This review discusses management options and focuses specifically on external cephalic version and vaginal breech delivery.

Midwives׳ decision making about transfers for 'slow' labour in rural New Zealand.

UNLABELLED: Midwives who provided Lead Maternity Care (LMC) to women in rural areas were invited to share their experiences of decision making around transfer in labour. Ethics approval was obtained from the NZ National Ethics Committee. OBJECTIVE: to explore midwives׳ decision making processes when making transfer decisions for slow labour progress from rural areas to specialist care. DESIGN: individual and group interviews were conducted with a purposive sample of rural midwives. The recalled decision processes of the midwives were subjected to a content and thematic analysis to expose experiences in common and to highlight aspects of probabilistic (normative), heuristic (behavioural), and group decision making theory within the rural context. SETTING: New Zealand. PARTICIPANTS: 15 midwives who provided LMC services to women in their rural areas. FINDINGS: 'making the mind shift', 'sitting on the boundary', 'timing the transfer' and 'the community interest' emerged as key themes. The decision processes were also influenced by the woman׳s preferences and the distance and time involved in the transfer. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the findings contribute insights into the challenge of making transfer decisions in rural units; particularly for otherwise well women who were experiencing slow labour progress. Knowledge of the fallibility of our heuristic decision making strategies may encourage the practitioner to step back and take a more deliberative, probabilistic view of the situation. In addition to the clinical picture, this process should include the relational and aspirational aspects for the woman, and any logistical challenges of the particular rural context.

Primate pelvic anatomy and implications for birth.

The pelvis performs two major functions for terrestrial mammals. It provides somewhat rigid support for muscles engaged in locomotion and, for females, it serves as the birth canal. The result for many species, and especially for encephalized primates, is an 'obstetric dilemma' whereby the neonate often has to negotiate a tight squeeze in order to be born. On top of what was probably a baseline of challenging birth, locomotor changes in the evolution of bipedalism in the human lineage resulted in an even more complex birth process. Negotiation of the bipedal pelvis requires a series of rotations, the end of which has the infant emerging from the birth canal facing the opposite direction from the mother. This pattern, strikingly different from what is typically seen in monkeys and apes, places a premium on having assistance at delivery. Recently reported observations of births in monkeys and apes are used to compare the process in human and non-human primates, highlighting similarities and differences. These include presentation (face, occiput anterior or posterior), internal and external rotation, use of the hands by mothers and infants, reliance on assistance, and the developmental state of the neonate.

The role of yoga: breathing, meditation and optimal fetal positioning.

Yoga is considered a good form of exercise in pregnancy (NHS Choices recommend exercise such as yoga, amongst others) to help women keep fit during their pregnancy and prepare for the birth. But apart from the physical postures, yoga has plenty to offer. The breathing and meditation techniques keep pregnant mothers healthy and relaxed, and provide the mental focus to aid childbirth. In this article we look at yogic breathing and meditation techniques for midwives to recommend to expectant mothers, and some postures that specifically help to encourage an optimal fetal position.

Management of occiput posterior position in the second stage of labor: a survey of midwifery practice in Australia.

BACKGROUND: The management of the occiput posterior (OP) position has been controversial for many years. Manual rotation can be performed by midwives and could reduce cesarean sections and instrumental births. We aimed to determine current midwifery views, knowledge, and practice of manual rotation. METHOD: A de-identified, self-reported questionnaire was e-mailed to all Australian College of Midwives full members (n = 3,997). RESULTS: Of 3,182 surveyed, 57 percent (1,817) responded, of whom 51 percent (920) were currently practicing midwifery. Seventy-seven percent of midwives thought that manual rotation at full dilatation was a valid intervention. Sixty-four percent stated the procedure was acceptable before instrumental delivery, but 30 percent were unsure. Most practicing midwives (93%) had heard of manual rotation, but only 18 percent had performed one in the last year. Midwives would support the routine performance of manual rotation for OP position if it reduced operative births from 68 to 50 percent and would support manual rotation for occiput transverse (OT) position if it reduced operative births from 39 to 25 percent. CONCLUSION: This study indicates that manual rotation is considered acceptable by most midwives in Australia, yet is only performed by a minority. Midwives would be willing to perform prophylactic manual rotation if it was known to facilitate normal vaginal births suggesting a scope to introduce this procedure into widespread clinical practice.

Acupuncture in post-date pregnancy: a pilot study.

AIM: Pharmacological labor induction is obtained through intracervical/vaginal prostaglandins and/or oxytocin infusion; however, the use of these agents produces fetal and maternal side effects. Traditional Chinese medicine advocates the use of acupuncture to soften the cervix and induce uterine contractions. The aim of the present study is to investigate the effect of acupuncture to induce labor. Acupuncture was applied in post-date pregnancies one week before a planned induction; the primary outcome was the rate of women submitted to labor induction for prolonged pregnancy at week 41 + 5. METHODS: After informed consent, 221 undelivered women ranging between 40 + 2/40 + 6 gestational age were considered eligible for the study and 202 were randomized to receive acupuncture or observation. Sessions of acupuncture were planned every odd day from the randomization till 41a week plus 4 days. At 41 + 5 week a pharmacological induction of labor was planned. RESULTS: The total rate of labor induction did not significantly differ between observation and acupuncture group (20% versus 17%). Moreover no differences were found as far as the indications to induce labor, in particular "prolonged pregnancy" was similar between groups (8/96 versus 5/99). To investigate between-group differences in time elapsed between inclusion and delivery, survival analysis was performed excluding women requiring labor induction: women receiving acupuncture showed a trend to deliver earlier than women in the observation group (p < 0.09). CONCLUSION: The present study demonstrated that acupuncture applied every odd day for one week seems ineffective in reducing the rate of labor induction performed for prolonged pregnancy at 41 + 5 weeks. Previous reports reached similar conclusions, independently of the different timing, duration and mode of stimuli application.

Can midwives promote normality in an occipitoposterior labour through autonomous practice?

It is common practice for epidural analgesia to be offered to women in labour with a suspected occipito-posterior (OP) position. Therefore, this article will challenge whether this practice ensures informed choice and optimal outcomes. Based on a case study, I will explore how midwives can promote normality in an OP labour through autonomous practice. My intuition was that Jane (a pseudonym) may not have consented to an epidural had she known the risks, and as a result, she might have achieved a spontaneous vaginal birth. Midwives should be practising according to non-maleficence, therefore doing no harm (Cluett and Bluff 2006). With the complications associated with epidurals, should midwives question their role in a suspected OP labour?