Baby Malpositions: Implications for Birth 

by KMom

Copyright © 2000-2001 KMom@Vireday.Com. All rights reserved.

DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider.

CONTENTS

 

Introduction

There are two terms that are used to refer to how the baby is located in the mother's body, presentation and position.  Although some resources use these terms inconsistently, presentation properly refers to which part of the baby 'presents' first at the vagina; in other words, whether the baby is head-up (breech), head-down (vertex), or shoulder-first/sideways (transverse). Position usually refers to how the back of the baby's head is lying in reference to the mother's spine (towards her spine or away from it, etc.).  

Traditionally, the obstetric community has placed great importance on a baby’s presentation (breech, transverse, or vertex). Subtle problems in baby position and how they impact labor have been largely ignored, however.  In other words, if the baby is head-down it is assumed to be ready for vaginal delivery and any deviation from a ‘normal’ labor curve viewed as a failure of the mother’s ability to labor and birth, therefore ‘needing’ drugs and/or surgical intervention.  

However, when subtle variations of the head-down position occur, a longer and more difficult delivery may result, often even necessitating forceps or a c-section.  Research shows that persistent malpositions often end up with a high degree of intervention and operative delivery, yet the obstetric community still does not recognize the role positioning plays.  

Many c-sections are performed unnecessarily because of subtle baby malposition problems, yet few doctors or even midwives pay close enough attention to the influence of baby's position on the progress of labor.  Many c-sections (or long, hard labors) could probably be avoided with more careful attention to preventing baby malposition, a quicker diagnosis of malposition during labor, and by employing corrective measures during labor if malposition is a possibility.  Since few doctors and only some midwives are being trained in this, parents, doulas, and childbirth educators must step into the gap and educate and advocate for themselves.

Kmom's Story In Brief: I have had two cesareans and one vaginal birth.  All three births probably had some degree of fetal malposition involved, so this is a subject near and dear to my heart!  In fact, I believe that I was able to have a Vaginal Birth After Cesarean (VBAC) with my 3rd child largely because we paid strict attention to the issue of baby position, and although the third baby did probably have a malposition, it was a relatively minor one that was able to resolve more easily.  

My own personal experience has led me to believe that baby position is of VITAL importance, and the many cesarean stories I have collected for the Birth Stories FAQ convinces me that many other women have also experienced unnecessary cesareans for unresolved baby malpositions.  Yet most often they believe it was because the baby was 'too big', their pelvis 'too small', or that they simply 'don't dilate well'.  In reality, there may be alternate explanations. This FAQ is an attempt to present this largely understudied area of knowledge in hopes that other women may help prevent or resolve baby malposition before a cesarean becomes necessary.  

You can read other stories of malpositions on this website in the FAQ, BBW Birth Stories: Malpositions.  Some of these malpositions ended up resolving and ending in vaginal birth; most ended up in cesareans.  Read them and see first-hand how malpositions affected labor and birth. Other websites that discuss the issue of malposition include www.cefcares.org/fetal/position.htm,   www.gentlebirth.org/archives/position.html, www.homebirth.org.uk/ofp.htm, and  www.aims.org/uk/posterior/htm. 

 

Definition of Malpresentation

Not all resources use the terms correctly, but basically malpresentations are those in which the baby's head does not present at the cervix first.  Malpositions, in contrast, all present with the head down BUT may not be situated  in the way that is most optimal for birth.  The head may be tilted to one side, the baby may face towards the mother's tummy instead of towards her back, the baby's chin may not be tucked under, or the baby may have a hand/arm up by its head.  All of these are head-down, but the subtle variations may cause labor to be harder, more drawn out, more painful, or even cause the baby to get 'stuck'.  All can usually be fixed (or may resolve on their own) so that the baby can be born vaginally, but there is a high rate of problems if the position is not resolved.

The basic presentations are breech (bottom- or feet-first), vertex (head-down), or transverse (sideways).  In most current obstetric practices, only vertex presentations are considered for vaginal delivery, although some providers trained in the old ways will consider vaginal delivery for some breeches or will try everything possible to turn a baby to vertex before resorting to a c-section.  However, most OBs these days simply schedule a c/s if the baby is thought to be breech or transverse, often without even trying to turn the baby.  The most common presentations are:

Vertex: Baby is head-down, a requirement for vaginal delivery in most practices.  Most OBs generally don't distinguish between the subtle variations in positions among head-down babies; they just care that the baby’s head is presenting first.

Transverse: Baby presenting with its shoulder or side first; there is a high chance of cord prolapse.  Baby must turn (or be turned) for birth, or come by c-section.  If baby does not turn and a c/s is needed, the incision may need to be low vertical or perhaps 'classical' (up-down) because of the baby's difficult position.  Transverse can sometimes be prevented/fixed through maternal position changes or ‘external version', but few doctors try.  

Breech: Baby's head is up by mother's ribs; the baby's bottom or legs present first instead of its head.  This presentation results in more risk to the baby, whether born by c/s or vaginally.   Most OBs today have not been trained in the art of vaginal breech birth and so routinely deliver by c/s (despite questionable evidence that it improves outcomes); some midwives and OBs still know how (and are willing) to attend breech births. Among breech babies, there are a number of variations as to exactly how the baby presents.  Some of these are more favorable for safe vaginal delivery than others.

Again, the main difference between malpresentation and malposition is that malpresenting babies have a part other than their head near the cervix and ready to come out first.  Malpositioned babies are all head-down but may not be in the most optimal head-down position for birth.

 

Definition of Malposition (All Head-Down)

"Position" assumes the baby is head-down; the terminology refers to how the BACK of baby's head (occiput) relates to the mother's body.  Occiput anterior (OA) means the back of baby's head is toward the mother's front and occiput posterior (OP) means the back of baby's head is towards the mother's spine.  However, most people find it easier to think in terms of where the baby's eyes are facing, and this is the referencing used here.  

For the spatially challenged among us, there are illustrations of some of these positions on the internet at  www.cefcares.org/fetal/position.htm. As noted, other articles discussing various positions and what to do about them can be found at www.gentlebirth.org/archives/position.html, www.homebirth.org.uk/ofp.htm, and  www.aims.org/uk/posterior/htm. 

 

Common Complications Seen With Baby Malpositions

There are a host of problems often associated with subtle baby malpositions, most of which get attributed to other causes by most OBs.  Women who have been told that their pelvis is "too small", their babies "too big", or that their cervix "just doesn't dilate well" may well have had a problem with baby malposition instead.  The popular mentality most doctors have been trained into is that labor problems must lie with the mother, rather than a problem that has gone unrecognized by the provider.  So they often reinforce the myth of the ‘too small’ pelvis or the ‘huge’ baby that can’t fit through.  Only rarely is this true, however.  

A good analogy is a key (the baby) and a lock (the mother’s pelvis).  If the key is aligned properly, it slides right into the lock, turns easily, the door opens, and the person moves through.  However, if the key is upside down (posterior), sideways (occiput transverse), or even slightly angled to the side (asynclitic), the key has a hard time getting into the lock, let alone getting the person through the door.  The solution is either to pull back the key and then turn it to align it with the lock, or to jiggle the key until it works its way into place.  Similarly, with babies, the solution is either to ease the baby out of the pelvis so it can turn more easily, or to ‘jiggle’ the baby through maternal shifts in position so that it can work its way into place.

When a baby is LOA (anterior and perfectly positioned), the pressure placed on the cervix is even and smooth, labor advances smoothly and usually fairly quickly, and the baby is usually able to proceed through the soft pelvic bones without problems or delays.  The mother's pelvis stretches and expands at the ligaments to let the baby through, and the baby's soft head bones fold like a vegetable steamer at the fontanelles (called molding) to also facilitate easy passage.  The labor curve generally follows the accepted 'averages', and the birth usually proceeds without any real difficulties.  

When a baby is malpositioned, the pressure on the cervix is placed inconsistently, and it often dilates slowly, erratically, or stalls out altogether, even though the mother experiences sufficiently strong contractions and significant pain.  The diameter of the baby's head that presents is usually bigger, which means that more molding of the baby's head must take place.  If the baby is at the wrong angle, he may be forced against the pelvis uncomfortably (especially if pitocin is added to augment contractions), which may cause fetal distress.  

Often the baby gets 'hung up' or stuck before getting past "0" station (entry to the pelvis proper).  This also often causes the labor to be slow and inefficient ('uterine inertia' or 'uterine dystocia'), stop altogether ('failure to progress'/FTP), or keeps the baby from moving through the pelvis despite good contractions or even full dilation and pushing ('cephalo-pelvic disproportion'/CPD, or 'baby too big for mother's pelvis').  

For example, although there is more than one possible cause for the following problems, the occurrence of one or a cluster should raise a high suspicion for baby malposition: 

Although most literature concentrates on the labor problems found with malpositioned babies, many chiropractors and others believe that malpositioned babies often experience other problems after birth.  They believe that the baby’s less-than-optimal position may place pressures on its spine or cranial bones, causing subtle pressures on important nerves in the spinal column or keeping the bones in the baby’s head from moving freely.  They observe that malpositioned babies experience higher rates of severe colic, ear infections, nursing problems, fussiness, etc. after birth, and these problems often respond to spinal manipulations or to ‘freeing’ the cranial bones through the use of Cranio-Sacral Therapy (CST). 

Although research is limited, many parents and chiropractors anecdotally report great improvements with CST or spinal manipulation on malpositioned babies/those requiring operative delivery.  In one of the few studies available on this, a Danish randomized controlled trial compared the use of spinal manipulation to the use of dimethicone (similar to Mylicon, often recommended by doctors for colic) and found that manipulation did significantly better at helping colic symptoms (Wiberg, 1999).  Similarly, in a case series, Hewitt (1999) found that spinal adjustment and/or CST helped babies with dysfunctional nursing resolve their nursing difficulties.  Although more research is needed, it seems likely that the effects of baby malposition may extend beyond labor difficulties and may affect the baby after birth as well in some cases.  

Research on Malpositions

Not all malposition situations follow the same scenario.  A lot depends on how the baby begins labor and what happens thereafter.  For example, some babies start labor malpositioned but rotate during labor.  These moms and  babies usually have hard labors but things ease once the baby resolves its position. Most of these babies end up being born vaginally and all is well.

Some babies start labor well-positioned but rotate or shift to a less-optimal position during labor.  This may be because of the mother's position (often on her back) or the lax musculature caused by an epidural.  These babies often are born vaginally, if not easily (and some end up being born by c/s as well).  However, most of these babies tend to do pretty well.  

The most difficult cases involve babies that start labor malpositioned and stay that way all through labor ( 'persistent posterior').  Studies show that between 60-90% of these babies are born via 'operative delivery' (i.e. forceps, vacuum, or cesarean).  These tend to be very difficult, hard labors, and often the doctor breaks the waters or utilizes pitocin along the way; fetal distress, meconium, or even bruising is not unusual in these cases.  Many persistent malpositions result in cesareans after long hard labors.  

Sizer and Nirmal (2000) studied a very large group of babies that delivered posterior or who were documented as having to turn in order to be born.  Only 14.6% were born in a spontaneous vaginal delivery.   85.4% required operative deliveries (43.7% by forceps or vacuum extractor, and 41.7% by cesarean).  If only 14% of these babies can be born normally and without the help of risky interventions, this shows that malpositions like posterior can have a significant impact on labor and birth.   

Gardberg et al. (1998) found that while only 1/3 of posterior positions began that way before labor, babies that persistently stayed posterior required operative deliveries (forceps or cesarean section) 66.7% of the time.  Of the group that began labor with a malpositioned baby, 2/3 needed operative delivery.  

Another study (Fan 1997) found that the group with a persistent transverse position required operative delivery 83% of the time, and the group with persistent posterior positioning required operative delivery 92% of the time.  The authors also noted an increase in the amount of ‘uterine inertia’, plus longer and more abnormal labors.  

Interestingly, a significant number of posterior positions actually occur during labor; that is, baby was well-positioned before labor but turned to a less optimal position during labor.  Midwives have long theorized that these might be because of the lax musculature that can occur with an epidural, especially when combined with common maternal positioning on the back.  Gardberg's 1998 study seems to indicate this; it found that about 2/3 of posterior positions became that way during labor.  Sizer and Nirmal (2000) also found that epidurals were strongly associated with posterior babies. 

Not all studies have found higher rates of problems with malpositioned babies.  Neri et al. (1995) found a similar rate of c/s, though he did find an increased length of pushing and increased use of low forceps.  However, this may simply reflect that the babies that become malpositioned during labor often resolve their positions on their own or can be helped out with 'low' forceps (forceps used at the outlet only).  It would have been interesting to know what the percentage of problems was with the sub-group that was persistently malpositioned all through labor.

In summary, studies have found particularly increased rates of problems with persistent posterior and other malpositions, and this reflects the anecdotal observations of many midwives.  Many women in Vaginal Birth After Cesarean (VBAC) groups also have found (or strongly suspect) that their cesareans were actually done for malpositioned babies.  The scope of this problem is probably wider than most providers suspect.

Over the years, physicians’ attitudes about malpositions have changed.  In the early part of the 20th century, many doctors were very concerned at the problems associated with malpositions.  In 1936, J.B. Jacobs (as quoted in Neri 1995) stated that, “To say that the occipito-posterior, because of its frequency and unfavorable effect upon labor as well as infant mortality, is the most serious obstetrical complication, is merely to confirm the attitude held by almost all modern writers at this time.”  

Because a cesarean was such a dangerous operation then, doctors developed a number of highly interventive forceps maneuvers to help turn the baby.  Although this was sometimes harmful to the baby, it was seen as less risky than cesarean surgery or prolonged labor in a ‘stuck’ position.  Over time, however, physicians began to become more and more troubled by the amount of risk posed by some of these forceps maneuvers.  Soon, conservative and expectant management became the norm, especially since cesareans became safer over the years and the baby 'could always be taken by cesarean'.  

In fact, conservative management is the opinion still espoused by studies such as Neri 1995.  Since some posterior babies are indeed born vaginally anyhow (generally those that are smaller and whose chins are well-tucked under, or those who become posterior during labor), they reasoned that malpositions are not terribly relevant.  They also felt that even when a malposition is suspected, conservative management is best---not worth the risk of forceps maneuvers.  Sizer and Nirmal (2000) agreed, stating that use of high forceps for rotation is "a practice that would not be countenanced today."  Their basic position is to urge a stronger consideration of elective cesarean when baby is malpositioned.   

Both of these studies reflect the common attitude of OBs that the strongly interventive and risky high forceps rotation is the ONLY way to change a malpositioned baby's position.  They ignore the significant data and anecdotal experience that a baby's position can often be changed simply by changing the mother's position!   And they completely ignore the possibility of preventing the problem beforehand.  

In their narrow point of view, there are only three choices when faced with a malpositioned baby (assuming they even recognize the malposition in the first place, which they often do not).  First, they can wait to see if baby turns on its own, which it does in a fair percentage of cases, but which may also lead to a long hard labor for the mother and significant fetal distress.  Second, they can try to undertake the dangerous and risky high forceps rotation, which may do more damage than it averts.  Or third, they can choose to do an elective cesarean, which of course they see as no big deal but which does cause more maternal morbidity and risk to any future pregnancies.  As the obstetric community begins to recognize more and more the problems associated with malpositions, more and more will be urging elective cesareans.

At least those doctors are beginning to recognize that baby malpositions ARE a problem; most doctors today consider the baby's position to be largely irrelevant, as long as it is head-down. Even today, baby malpositions are often not charted at all, not even when a cesarean occurs.  The size of the baby or the mother’s pelvis (“CPD”) is considered to be the main problem, not the baby’s position.  Many many women have had cesareans for "CPD" or "Failure to Progress" when actually the real problem was a malpositioned baby that no one recognized or knew how to turn.  

Only recently has significant attention returned to the issue of baby malposition, and mostly from midwives, doulas, and nurses.  Childbirth educator Pauline Scott and midwife Jean Sutton wrote perhaps the most valuable contribution on the subject, called Understanding and Teaching Optimal Foetal Positioning.  This summarized their experience with diagnosing, preventing, and treating baby malpositions.   They contend that greater attention to posture in the late stages of pregnancy can lower the number of cases of fetal malpositions, and that proactive use of certain maternal positions can often turn the malpositioned baby in labor, preventing the high rate of operative deliveries and difficult labors (“dystocia”) common to malpositions.  Childbirth educators and doulas Penny Simkin and Ruth Ancheta have recently published a new book called The Labor Progress Handbook, which addresses the same issues in even greater detail, along with other suggestions for helping labor dystocia situations. 

Several nurses have written about the importance of maternal positioning for treating malpositions (Andrews and Andrews 1983, Biancuzzo 1993), and midwife Valerie El Halta (1995) also wrote about the problems with posterior positions and how to proactively resolve them.  Of the doctors who have written about posterior positioning, most (including the ones cited above) are European or Chinese.  Thus, because most of the information about baby malposition, its influence on labor, and proactive treatment for it has been written about in foreign journals, nursing journals, or in midwifery journals and texts, most American OBs do not know this information or largely dismiss it.  

Why Malpositions Happen

No one knows for sure why malpositions happen.  As noted above, malpositions may occur because of our modern tendency towards poor posture and unphysiologic positioning.  These malpositions tend to be very responsive to maternal repositioning, and often resolve if the mother has sufficient mobility in labor. However, the way most women are forced to labor (on their backs in bed, with limited mobility due to constant fetal monitoring) can make it difficult for babies to turn. 

Some midwives have noted a tendency towards posterior positions when the placenta is anterior (front-lying), since babies reportedly tend to face the placenta.  A 1994 study by Gardberg and Tuppurainen confirms that anterior placentas predispose to a posterior position.  Anterior placentas are particularly common with women who have had prior cesareans or other uterine surgery, but can be found in other women as well.  

Malpositions may also occur with large and significant fibroids.  These may tend to crowd the baby in-utero and force the baby to assume an unnatural position.  Sizer and Nirmal (2000) noted that malpositions were more common with big babies; they theorized that it may be more difficult for larger babies to rotate when labor progresses, so perhaps this is why these were the ones that tended to have persistent malpositions that did not resolve on their own.  

Some authorities note that women who are very short-waisted, sway-backed, have bad backs, or have had a previous back injury tend to have a lot of malpositioned babies and back labor.  Women who have experienced a pelvic injury may also have a higher rate of malpositioned babies.  

In addition, women with Symphysis Pubis Dysfunction (i.e., pain turning over in bed, discomfort lifting one leg to put on clothes, sciatica, a 'clicking' feeling in the hips/pelvis,  difficulty moving apart their legs to get in and out of the car, etc.) probably have a misaligned pelvis, especially in the front where the pelvic bones almost meet.  This area is called the 'pubic symphysis', and if these bones are out of alignment, they pull on the soft cartilage in between the bones (pubic symphysis), causing a great deal of pain both in front and in the back, and may predispose the woman to a baby malposition.  

A misaligned pelvis can cause the soft tissues to pull, twist, or spasm the uterus out of its optimal shape, thus forcing the baby into a less-than-optimal position and making it difficult for the baby to descend properly.  When the pelvis and sacro-iliac area are put into better alignment and the soft tissues released, the baby can resume its most optimal position and usually turns.  However, if the pubic bone misalignment continues, the woman is at risk not only for baby malposition, but also  significant and debilitating pubic symphysis damage during birth from common obstetric interventions and positions. 

Therefore, some providers believe that women may benefit from regular chiropractic care in pregnancy, especially women with bad backs, pubic symphysis pain, a history of malpositioned babies, or prior c/s for Cephalo-Pelvic-Disproportion.  In particular, the woman may need not only her back/sacroiliac area realigned, but also the pelvis and the pubic symphysis areas in particular.  (For more information about Symphysis Pubis Dysfunction (SPD), see the FAQ on this site on Pubic Pain.) 

Another very popular theory among some midwives and OBs is that malposition may have to do with the pelvic shape of the woman (i.e., the relative size of each part of the pelvis, thus creating the pelvic ‘shape’--see www.fpnotebook.com/OB31.htm for further explanations about pelvic shapes).  Although most women have the most ‘desirable’ type of pelvic shape (gynecoid), some women have a pelvic shape (anthropoid, android or very rarely, platypelloid) that may allow less room in certain parts of the pelvis.  This may make the baby more comfortable in a different position such as posterior, or it may make it harder for the baby to move under the pubic bone during birth.   Thus pelvic shape might conceivably influence baby position. 

How relevant if pelvic shape to birth?  Authorities disagree.  OBs tend to treat it very fearfully.  Many use pelvic shape and pelvimetry (measuring the relative dimensions of parts of the pelvis through x-rays or manually) to tell women their pelvises are ‘too small’ and they will ‘need’ a c-section without any trial of labor.  This is unreasonable because pregnancy hormones loosen the pelvis and ligaments significantly by the end of pregnancy, and the baby’s head has bones that overlap or ‘mold’, and between the two, there is usually MUCH more flexibility for the baby to be born than pelvimetry in pregnancy would indicate.  

Some doctors insist on pelvimetry (measuring the pelvis manually or by x-ray) after a CPD cesarean in hopes of being able to predict whether a VBAC is likely or not, but studies show this does not reliably predict vaginal birth.  A significant number of women predicted (via pelvimetry) to have 'inadequate pelvises' and to need future CPD cesareans go on to have VBACs anyhow (Goer, Obstetric Myths vs. Research Realities). For example, Thubisi (1993)  found that 55% of women in the Trial of Labor group judged to have an 'inadequate' pelvis by postpartum x-ray pelvimetry had a vaginal delivery anyhow.  If more than half the women predicted to have inadequate pelvises birthed vaginally, pelvimetry is not useful and may be harmful.  The authors called x-ray pelvimetry 'not necessary' for a trial of labor, and noted that "it increases the caesarean section rate and is a poor predictor of the outcome of labor."

Other OBs have tried to determine other ways of determining true CPD, including strict interpretations of stalled labor parameters.  O'Herlihy (1998) found that only 84 women out of 42,793 actually met these strict criteria for 'true' CPD when carefully reviewed.  40 of these women with 'strictly defined' CPD had a trial of labor after prior cesarean, and 68% birthed vaginally, 7 with larger babies.  15 of these 40 women had had a cesarean at full dilation (10 cm) previously, yet 73% went on to birth vaginally with no serious maternal or neonatal problems.  The authors concluded that even strict definitions of CPD should not be used as an automatic 'recurrent' indication for elective repeat cesareans

So unless there is significant malnutrition or grievous previous injury, pelvic shape or pelvimetry should not be used for choosing an elective c-section.  No one can tell the degree of molding, flexibility in the pelvis, or loosening that may occur during labor, so an adequate trial of labor is the only way to tell for sure ‘if the baby will fit’.  Many women with pelvises initially judged to be ‘too small’ or the 'wrong shape' do end up delivering vaginally, and about 2/3 of women who have had previous cesareans for “CPD” and try for a VBAC do end up having subsequent vaginal births, often with babies even bigger than their cesarean “CPD” babies. This casts the diagnosis of "CPD" under considerable suspicion.

Midwives tend to be of two schools of thought about pelvic shape/pelvimetry.  Some midwives think it is modestly relevant, especially if other factors like prior back problems or pubic symphysis pain are present.  However, midwives differ from OBs in that they use pelvic shape to help women find the most effective position to help the baby move through the pelvis.  Sometimes lying down at a certain stage, arching the back markedly, or using the McRoberts position—knees to ears---may help babies get under the pubic bone that might otherwise have difficulty descending.  Unlike OBs, these midwives do not use pelvimetry to scare women into elective c-sections that are probably unnecessary, but they may use it to help women find the most efficient way to birth.   

On the other hand, other midwives dismiss the importance of pelvic shape altogether.  They feel that it is a ridiculous limitation, that evolution has assured that nearly all women will have functional pelvic shapes, and that pelvimetry has proved wrong too often to trust.  Midwife Gloria Lemay writes about this in her article, "Pelvises I Have Known and Loved," which can be found online at www.birthlove.com/pages/pelvises.html.

In summary, all malpresentations and malpositions probably do not occur because of one factor only, but may occur because of a combination of factors such as:  

Malpositions do not have to be an immutable sentence to a difficult labor, lots of intervention, or a c-section.  There are things that can be done to turn babies into the most optimal position for birth.

 

Strategies To Correct Malpositions

Before Labor 

The best defense against malposition is a good offense, or to use another cliché, an ounce of prevention is worth a pound of cure.  It’s much easier to prevent a problem from occurring in the first place than it is to fix it once a woman is in labor.  And it is much easier to turn a baby before it engages in its mother’s pelvis than once it enters the mother’s pelvis or gains its full-term size.  Attention to baby position is important throughout the last weeks of pregnancy, not just at the beginning of labor.  

Chiropractic Care

One of the best things a mother can do all during pregnancy to help promote a good baby position for birth is to get regular chiropractic care, especially if she has had previously malpositioned babies, back pain, sciatica, or has a lot of pubic pain in pregnancy.   As noted above, one of the theories behind malpositioned babies is that if the mother’s pelvis, pubic symphysis, or sacro-iliac area is out of alignment, it can twist the soft tissues (supporting ligaments etc.), which in turn can torque the uterus.  If this occurs and the uterus is twisted slightly out of its normal shape or position, the theory is that the baby may have no choice but to assume a malposition in order to fit comfortably, or even if optimally positioned, may have trouble descending beneath the pubic bone.   Restoring the pubic symphysis/pelvis/sacrum area to proper alignment is supposed to help the uterus resume its most optimal position, enabling the baby to turn too. 

Dr. Larry Webster’s “In-Utero Constraint Technique” has been used by many chiropractors to help realign the mother’s pelvis/sacroiliac area and turn many breech babies, and a variation of it has also been used to help turn posterior or other malpositioned babies.  In addition, a direct adjustment to the pubic bone area may also be necessary to help completely alleviate pubic symphysis problems.  Although it is not easy to find a chiropractor properly trained in these techniques (or adequately trained in treating pregnant women), the International Chiropractic Association’s Council on Chiropractic Pediatrics (1-800-423-4690, or www.chiropractic.org) or the International Chiropractic Pediatric Association (770-982-9037, or www.4icpa.org) may be able to refer mothers to a chiropractor familiar with this technique.  

Posture

As noted, Sutton and Scott (the midwife and childbirth educator who authored Optimal Foetal Positioning) attribute many baby malpositions to poor maternal posture due to our modern conveniences like easy chairs, plus a decrease in exercising.  Because the following positions all reduce the amount of space in the anterior part of the pelvis (which may predispose a baby towards a posterior position), they recommend:

Instead, they recommend having mothers maintain upright or forward-leaning positions as much as possible, with their hips higher than their knees.  They also recommend getting the belly lower than the spine, like in the all-fours position.  These help improve the angle between the maternal spine and the pelvic brim, which encourages the baby to move into and engage in the LOA position.   

To help encourage the baby to turn its heaviest side towards the floor (and gravity) and thus the LOA position, many providers often recommend:

Until baby has engaged in your pelvis in the proper LOA position, they also recommend avoiding deep squatting.  Once you are sure the baby is LOA, you can proceed with deep squatting to help baby engage deeply in the pelvis in that position.

However, it's important to note that attention to posture issues must be constant in the last month or two of pregnancy in order for it to be effective; simply occasionally assuming an all-fours position once in a while is not going to be enough.  Mothers (especially those with a past tendency towards malpositioned babies) have to very vigilant about not sitting with their knees are higher than their pelvises, about sitting upright/leaning forward and not slouching back at all, about watching their posture constantly in the last month or two.  This can be very  frustrating for those used to slouching in comfy easy chairs, putting their feet up, or leaning back on a couch!  However, those of us who have endured a malpositioned baby can say that a little frustration over the last month or two is probably worth a lot in terms of preventing the intense pain of a malpositioned baby and the recovery from a cesarean!

Other Techniques

Although it sounds very 'alternative' and 'crunchy', many midwives feel that mothers can communicate with their babies in utero and direct them to visualize their babies in the best "LOA" position for birth (baby's spine lying along mother's left side of the belly, back of baby's head slightly towards the left of mother's belly, baby's eyes looking towards mother's spine or a little towards the right hip, chin tucked under, hands and arms snuggled against the body).  Many midwives tell their mothers to visualize this position repeatedly to their babies and to ask the baby to be in this position.  In addition, many tell mothers to photocopy the illustration of a perfectly positioned baby found on page 129 of Natural Childbirth After Cesarean and post it all over the house where she will see it frequently.  

Although little scientific data exists on the effectiveness of visualization and talking to the baby (and most OBs would scoff), there is some scientific data that relaxation, visualization, and hypnotic suggestion can help turn a large percentage of breech babies (see the work of Dr. Lewis Mehl and Gayle Peterson, PhD; 80% of breech babies turned in their study, which is a much higher rate than conventional therapies like 'external versions'). Anecdotal evidence certainly suggests that visualization and suggestion can help turn babies, and the the scientific data of Mehl and Peterson supports this.  It seems unlikely to cause harm if tried, and it may well help.  Although difficult to verify its utility scientifically, it is another tool to consider using, and one that many midwives swear by.

During Labor

There are many things that can be done to help a baby shift its position just before or even after labor has begun.  Most of these involve the old midwives’ dictum, “If you can’t move the baby, move the mother.”  In other words, if baby’s position is off and doesn’t move easily, use shifts in the mother’s position to help the baby disengage and re-align more favorably in the mother’s pelvis.  However, in order for this to take place most easily, it is important the the bag of waters still be intact.

Avoid Breaking the Waters

It is critical that Artificial Rupture of Membranes (AROM, or breaking the waters artificially) does not occur if a malposition is a possibility.  Amniotic fluid often cushions the baby, protecting it from distress due to a poor fit in its malposition.  If this cushion is taken away, the baby may experience significant distress as the contractions force it down against the pelvis despite its poor fit. This distress may cause the baby to pass stool prematurely (meconium), which can sometimes cause problems for the baby.

AROM also often increases the mother’s pain levels strongly because the cushioning effect of the waters is eliminated, and the pain levels can quickly become unbearable.  After AROM, many mothers elect to have an epidural or other pain relief because the pain becomes so strong.   Although sometimes the epidural will relax the pelvic floor enough for the baby to rotate, more often the lack of muscle tone prevents the baby from rotating. 

AROM also may inhibit the baby from turning into the more favorable anterior position.   The waters keep baby from engaging so deeply it gets stuck and cannot turn; after AROM, it is much more difficult for the baby to rotate.  AROM is also often accompanied by pitocin, which artificially strengthens contractions and can force the baby deep into the mother’s pelvis in its poor position, causing 'labor dystocia', ‘deep transverse arrest’ or 'arrest of descent' (i.e., getting stuck) and making rotation into the anterior position almost impossible.  Although it may still be possible to realign the baby by using the open knee-chest position to help the baby move out of the pelvis enough to turn, even this position may not be able to ‘unstick’ the baby in deep transverse arrest.

Unfortunately, most OBs (and some midwives) typically use AROM and pitocin in induced labor or in a labor that has slowed down and gets ‘stuck’, reasoning that this will bring the baby’s head down and make for more efficient pressure on the cervix.  However, this is the worst possible thing they could do if the baby is malpositioned, and often results in the baby getting wedged in, unable to turn, and unable to be born normally.  A c-section must often then be done due to fetal distress, maternal exhaustion after a long hard labor, or “CPD” (‘baby is too big or pelvis is too small’). 

Techniques to Turn the Baby

Not only is important to keep the bag of waters intact if at all possible, it is also vitally important for the mother to be off of her back or bottom if malposition is suspected.  The mother needs to make more room in the pelvis for her baby to turn, and traditional lying and semi-sitting positions force the tailbone inwards and constrict the space available.  Making more room in the pelvis can be done by: 

These techniques certainly don't sound very scientific and may seem kind of strange.  They certainly aren't used very often by most doctors!  Some of them come from traditional 'granny midwives' in third-world societies, where a cesarean was not an option for a difficult labor or a 'stuck' baby, and although that seems very 'primitive' to many doctors, these techniques often worked.  In fact, belly dancing reportedly started in a number of societies as a childbirth ritual instead of a sexual enticement.  Other women in the community would help the mother 'dance' the baby out.  As unscientific as that sounds, the shifting of the pelvis probably helped 'shake out' and resolve many malpositions in a timely fashion, and keeping the mother up and mobile probably helped use gravity to aid the force of contractions.  

Midwives who utilize these techniques often report that they are extremely effective for many women.  Again, many OBs view these techniques dubiously because they come from midwifery and see them as ‘voodoo medicine', but they often do work.  Certainly, the much lower cesarean rate of most midwives (usually about half that of OBs, and sometimes even lower) is a good testimony to the effectiveness of many of these 'alternative' techniques.  They are not likely to cause harm in most instances, so it makes no sense to keep women from trying them.  It's better than a risky high forceps maneuver or automatically resorting to major surgery!

Midwife Jean Sutton (who co-wrote Optimal Foetal Positioning) found that when she was appointed Principal Nurse-Midwife at her maternity unit and emphasized prenatal education on fetal positioning, the transfer rate to the hospital fell from 30% to 5%, and the forceps delivery rate fell from 3-4 per month to 2-4 per YEAR.  Paying attention to prevention before and during early labor can often significantly lower the rate of problem births.  

If the baby is suspected to be posterior in labor, one low-tech technique that often works to turn the baby is getting the mother on all fours and laboring on hands and knees, or alternatively, turning the mother onto her side (sources differ as to whether she should lie on the same or opposite side of the baby’s spine).  Although data is limited, several studies seem to show that these techniques can help turn many posterior babies. 

Ou 1997 divided women with posterior babies during labor into two groups.  One group used a lateral position (side-lying on the same side as baby’s spine) and the control group did not.  88% of the side-lying group’s babies rotated to anterior and were born vaginally, while in the control group (no position change), 83% had a c-section.   As might be expected, labor was shortened; the study group averaged 6-hour labors vs. 10.5-hour labors in the control group.   

Andrews and Andrews 1983 (as analyzed in Obstetric Myths vs. Research Realities, Goer) randomized non-laboring women at 38 weeks to 4 variations of the hands-knees position, plus they had a control group who sat upright.  All the groups who used the hands-knees position had a majority of the babies rotate to anterior within 10 minutes.  Of the control group, no babies rotated. 

If the baby does not turn easily using these techniques, it is probably well engaged in the pelvis and having a hard time turning.  In this scenario, the open knee-chest position may help.  In this position, the mother gets on her hands and knees, then places her shoulders and head on the floor.  It's important that her legs NOT be under her abdomen at this point.  A 'closed' knee-chest position means that hips and knees are flexed so that the thighs are partially under her abdomen, and this gives the baby less room to move out of the pelvis and interferes with gravity's effect.  In the 'open' knee-chest position, the legs are NOT under her abdomen, and the hips are flexed to an angle greater than 90 degrees.  This is a critical difference, for this tilts the pelvis forward enough for gravity to encourage the baby to disengage from the pelvis, which may then allow it to reposition itself better before re-engaging in the pelvis.  There is a good illustration of the open knee-chest position in the The Labor Progress Handbook on page 41, in The VBAC Companion on page 69, or at www.cefcares.org/fetal/position.htm (although this illustration shows the thighs under the mother's abdomen a bit too much; a mother using this illustration should remember to open her hips up a bit more lengthwise to a bigger angle).

The tilt board (often used for turning breeches) can help here too.  In this, a slant board (for example, an ironing board) is propped against a sofa, and the mother lies back on it, head down and feet up, for 30 minutes or so at a time (unless she gets dizzy).  Illustrations of this position can also be found in The VBAC Companion or The Labor Progress Handbook.  By putting the pelvis higher than the fundus (top of the uterus) and tilting the pelvis, the baby often disengages and has more space and opportunity to turn.  Although sometimes uncomfortable for the mother (especially in labor!), these positions facilitate rotation of the baby and often prevent a long hard labor and/or a cesarean, so a few minutes of temporary discomfort can be viewed as a trade-off for less discomfort later!

Other alternatives that midwives report using successfully for turning a malpositioned baby include the homeopathic remedy pulsatilla, visualization of the correct position during a warm bath and asking the baby to move, or acupuncture or acupressure just outside the nail bed of the little toe, etc.  Cardini and Weixin (1998) found that moxibustion (applying heat near the acupressure point by the nail bed of the little toe) helped turn 75% of breech babies (vs. 48% in the 'external version' group), probably by making them become more active and therefore more likely to turn.  It is possible that it may have this effect also with posterior or other malpositioned babies.   

Janie McCoy King also discusses a technique commonly known as ‘abdominal lifting’ to help correct malpositions.  In this, the mother interlocks the fingers of both hands under her abdomen and lifts upward and inward while bending her knees to tilt the pelvis (bending the knees and doing a pelvic tilt while lifting the abdomen is very important).  This changes the angle of the baby relative to the mother’s pelvis and often enables baby to slip down into the pelvis or lifts baby out of the pelvis so it can improve its position.  Penny Simkin, author of The Labor Progress Handbook, notes that many Mexican midwives do a version of this using the Rebozo (a type of shawl) tied around the mother’s abdomen, then lifted up and out from behind during a contraction while the mother does a pelvic tilt.

All of these techniques can be very helpful in getting a malpositioned baby to turn to LOA (Left Occiput Anterior, the easiest position for birth).  Once the baby has turned, if it has trouble descending under the pubic bone many women find that the McRoberts position (knees to ears) or arching their backs VERY strongly helps the baby move through.  

Although the obstetric community has formally studied few of these techniques, there is some data in the midwifery and nursing literature on their use, as well as years and years of anecdotal evidence.  Unfortunately, the obstetric community is highly reluctant to utilize the resources, and usually refuse even to study these techniques.  Even within the midwifery community there has been a relative lack of emphasis on the position of the baby.  Only recently has there been a resurgence of interest and writing on the subject, and midwives, nurses, and doulas are just now beginning to study again the old ways of turning a baby to a more favorable position in the womb to ease labor and get better outcomes.

 

Summary

Baby malpresentation (i.e., breech or transverse) is a well-recognized problem in the obstetric community.  On the other hand, baby malpositions (posterior, asynclitic, compound, etc.) tend to be treated as largely irrelevant by the obstetric community.  

Because some posterior babies are born vaginally, for example, they do not generally believe that posterior positioning is a real factor for anything more serious than back labor.  Their general approach is that if labor slows down or stalls, Artificial Rupture of Membranes and adding Pitocin is the proper course of action.  Yet if malposition is indeed the problem, AROM and Pitocin augmentation are the worst things that can be done.  If the baby cannot descend even after AROM and Pitocin, either the baby’s size or the mother’s pelvis is usually blamed.  Often the mother is not even told of the malposition, and it is usually not even written down in the charts.  Many mothers go through life, blaming their bodies for ‘not working right’ or their pelvises for being ‘too small’, and end up having many unnecessary cesareans, which carries its own set of risks.

Many midwives, nurses, doulas and a few OBs are now beginning to recognize, however, that subtle deviations in the baby’s position can cause many of the labor dystocia problems that providers see.  Although babies can sometimes be born in other positions, Left Occiput Anterior is the position that is most optimal, most efficient, and easiest on mother and baby.  

Even though a few OBs (mostly abroad) are beginning to recognize again the importance of baby position, their approach is not very helpful.  They believe either in letting the mom have a long difficult labor (to see if baby rotates on its own), intervening with a very risky high forceps rotation, or circumventing normal birth entirely and choosing an elective cesarean. 

Typically, most OBs ignore the possibility for prevention of the problem in the first place, and dismiss the low-tech interventions that midwives have used for years to prevent or treat malpositions.  Yet many midwives report that once they start paying very close attention to the baby’s positioning and proactively correcting it, their rate of cesareans, difficult labors, and ‘stuck babies’ drops dramatically.

The time to proactively work on baby position is long before labor starts.  Mothers should be encouraged to consider regular chiropractic care during pregnancy to keep their backs and pelvises in alignment; women with back problems or pubic symphysis pain may particularly benefit from this. Women should also avoid poor posture and positions where their knees are higher than their hips.  Instead they should adopt mostly forward-leaning positions, and be encouraged to spend a lot of time on their hands and knees.  Those with persistently malpositioned babies may benefit from any number of techniques such as pelvic tilts, the open knee-chest position, the Webster Technique, pulsatilla, etc. 

If a malposition occurs during labor, techniques such as asymmetric labor positions (lunges, rocking the hips side to side, going sideways up the stairs, etc.), pulsatilla, abdominal lifting, laboring on all-fours or in the open knee-chest position, or even side-lying can help the baby shift.  The most critical things are to keep the mother as mobile as possible so her positioning can help baby rotate, avoid closing up the sacral area (i.e., don't sit or lie back on on the buttbones!) so baby has room to move, and avoiding breaking the waters or adding artificial labor drugs (AROM and Pitocin) so the problem is not exacerbated and baby still has the opportunity to turn.  Positions such as the McRoberts position or arching the back very strongly may also help the baby turn, or may help it descend under the pubic bone more efficiently once it has turned.

Unfortunately, most information about the importance of baby position and low-intervention techniques for resolving it has been found in foreign obstetric journals, nursing journals, chiropractic journals, midwifery texts and journals, or in guidelines for labor support personnel (doulas).  Thus most OBs and even many midwives do not know about these techniques, or may not take it seriously because of its ‘alternative’ source.  This leads to a ‘chicken and egg’ dilemma, where providers refuse to take these concerns seriously because not enough formal scientific data exists on it, yet how can formal data exist on it when most mainstream providers refuse to study it?

The refusal of many providers to consider these alternatives has led to many unnecessarily painful and difficult labors, many unnecessary cesareans, and many women feeling their pelvises are ‘inadequate’ or ‘too small’.  The abundance of data showing that the majority of women with a previous cesarean for “CPD” who labor do end up birthing vaginally (often with a bigger baby) implies that many of the original cesareans may have been due to baby malpositions instead.  Although there are relatively few scientific studies of the highest quality that examine resolving baby malposition, some data does exist and supports the efficacy of these techniques.  In addition, anecdotal evidence from hundreds of midwives, doulas, and birthing women shows how important these can be for easing many ‘difficult’ labors and in preventing cesareans.  

As more providers discover the importance of these techniques, more and more formal study will be done, and acceptance will eventually follow.  In the meantime, it is up to childbirth educators, doulas, and parents to start to acknowledge and spread the word about the influence of baby malposition on labor and birth, and what can be done to help it.  Birthing women would do well to read Optimal Foetal Positioning and/or The Labor Progress Handbook, and every doula, nurse, childbirth educator, midwife, or doctor that works with birthing women should read and own these books as well.

 

Post Script: Kmom's Story---3 Malpositions (2 Cesareans and a VBAC)

My birth stories are good examples of the troubles a baby malposition can cause.  I share them here in hopes that others may find them instructive.  Other birth stories involving malpositions can be found in the FAQ, BBW Birth Stories: Malpositions.

My first birth was highly interventive, highly medicalized from early on.  I was induced right at 40 weeks because of a borderline case of gestational diabetes, and nearly every intervention in the book was involved.  Long story shorter, the doctor broke the bag of waters early in labor before the baby was even engaged; although we cannot be sure, it seems quite likely that she was in some less-than-optimal position and became fixed in this position once pitocin was added and the waters were broken.  Labor was long and very difficult.  Eventually I did dilate fully and we pushed for two hours, but it was extremely painful and the baby never descended past a -2 station (high up in the pelvis).  I also had terrible back labor, like a welding torch being held to my back and side.  We eventually chose a cesarean, though that turned out to be an even worse nightmare.  It was a very difficult birth, to put it mildly.  The cause of the cesarean was put down to "Cephalo-Pelvic Disproportion", or baby too big for mother's pelvis.  

My second birth was much better in many ways, although it too turned into an unexpected cesarean. I paid very close attention to nutrition and exercise and was able to avoid a recurrence of gd, which meant I could transfer to the care of a nurse-midwife.  My OB wanted to induce labor early to get a smaller baby, but I did NOT want to go through another induction, so I went with a nurse-midwife who would not insist on early induction.  Unfortunately, I knew little about the importance of posture near term, and spent a lot of time leaning back with my knees higher than my hips.  This was the position I was in when my water broke at 39+ weeks.  We didn't know it then, but his position was posterior (facing my tummy instead of my back) and he became fixed into that position when the waters broke before labor.  I went into labor naturally, had a wonderful labor (much easier than an induction!), dilated fairly quickly although I experienced transition-like symptoms early on, and got to 9.5 cm before getting stuck with a cervical 'lip'.  Eventually we got to pushing, and we pushed for nearly 5 hours before choosing a repeat cesarean.  At first pushing felt good, but as we got him down to the pelvis (0 station), the back labor and 'welding torch' effect to my side started up again.  The last several hours of pushing were very hard.  Fortunately, the c/s went well this time, and as they pulled him out, the surgeons said, "Well, no wonder!  He was posterior!"  However, nowhere was this written on our charts, as if it was irrelevant.  If we hadn't heard them say it, we wouldn't have known it. The official 'cause' of the c/s was again "CPD".  

My third birth was a VBAC (Vaginal Birth After Cesarean).  I had read up on baby malpositions and was convinced that this was what had probably caused my cesareans, and was sure that if we could avoid a malposition, I could almost certainly birth vaginally.  I chose a direct-entry midwife for my care, one who specialized in correcting malpositions.  I also found a chiropractor who knew how to do the "Webster Technique" and helped resolve some significant sacro-iliac back pain issues, although I only found her late in pregnancy and only had a couple of treatments with her.  We encouraged labor to come at 38 weeks.  I was expecting a fairly easy dilation stage, since I had dilated twice before to 10, and the natural labor had not been that difficult to handle.  However, this labor got stuck at around 5 cm for several hours despite strong contractions and significant pain.  We chose to break the waters at that point in hopes that it would help bring more pressure on the cervix to dilate.  (Big mistake--I won't do that again!)  Labor quickly became unbearable.  We labored for several more hours despite extreme pain levels and little dilation, at which point I elected to go in for an epidural (against the midwife's wishes) in hopes of preserving a chance for a VBAC.  However, getting ready for the epidural got me more mobile, and the hospital bed was uneven, which caused my hips to shift a lot as we got into position for the epidural.  The baby apparently had had his arm across his face, which tends to cause extremely painful labors, lots of back pain, and can hold up dilation.  Shifting on the uneven bed apparently made his arm move away from his face, and suddenly we were pushing! No epidural for me. We took care of a stubborn cervical lip, I arched my back strongly, and then he was born within 15 minutes or so of starting to push!  (Lots better than 2-5 hours of pushing, let me tell you!)  I unfortunately did not avoid a malposition completely, but at least this time it was a malposition that resolves fairly easily with the right moves, and once resolved, the baby was born quickly.  Baby position can make a LOT of difference.

I really feel that my births are an interesting representation of the difficulties that baby malposition can cause. You can bet that next time I will again pay VERY close attention to posture during pregnancy, and get regular chiropractic care (I later found that adjusting the pubic bone itself helped resolve SO much of my back discomfort; I wish we'd done this in pregnancy in addition to the back adjustments!).  I will also choose NOT to break the waters artificially, and to be even more mobile in labor (I may take up belly-dancing!).   Hopefully, others can learn from my experiences and not have to endure some of the difficulties I did.  

Best wishes for a wonderful and optimally-positioned birth!  :-)           ------Kmom

 

References

* highly recommended, especially for VBAC moms!

BOOKS

*Understanding and Teaching Optimal Foetal Positioning, Jean Sutton and Pauline Scott. Tauranga, New Zealand: Birth Concepts, 1996. 

*The Labor Progress Handbook, Penny Simkin and Ruth Ancheta with Jilly Rosser.  Oxford: Blackwell Science Limited, 2000.  

Back Labor No More!!  Janie McCoy King.  Dallas: Plenary Systems, Inc., 1993. 

The Thinking Woman's Guide to a Better Birth, Henci Goer. New York: Berkeley Publishing Group (A Perigee Book), 1999.

*Obstetric Myths Vs. Research Realities, Henci Goer. Westport, Connecticut: Bergin and Garvey, 1995.

Birthing Normally: A Personal Growth Approach to Childbirth, Gayle Peterson.  Berkeley, California: Shadow and Light, 1984. 

JOURNAL ARTICLES

El Halta,Valerie. Posterior Labor: A Pain in the Back.  Midwifery Today, Winter 1995.  36:19-21.

Gardberg, M and Tuppurainen, M.  Persistent Occiput Posterior Presentation—A Clinical Problem.  Acta Obstet Gynecol Scand, January 1994.  73(1):45-7. 

Gardberg, M and Tuppurainen, M. Anterior Placental Location Predisposes for Occiput Posterior Presentation Near Term. Acat Obstet Gynecol Scand, February 1994.  73(2):151-152.  

Gardberg, M et al.  Intrapartum Sonography and Persistent Occiput Posterior Position: A Study of 408 Deliveries.  Obstetrics and Gynecology, May 1998.  91:746-9.

Fan, L et al.  The Characteristics of Labour Course and Perinatal Prognosis in Cases of Fetal Persistent Occiput-Transverse Position and Persistent Occiput-Posterior Position.  Chung Hua Fu Chan Ko Tsa Chih.  October 1997.  32(10):620-2.

Ou, X. et al.  Correction of Occipito-Posterior Position by Maternal Posture During the Process of Labor.  Chung Hua Fu Chan Ko Tsa Chih.  June 1997.  32(6):329-332.

Biancuzzo, Marie.  How to Recognize and Rotate an Occiput Posterior Fetus.  American Journal of Nursing, March 1993.  pp. 38-41.  

Thubisi, M et al.  Vaginal Delivery After Previous Caesarean Section: Is X-Ray Pelvimetry Necessary?  British Journal of Obstetrics and Gynaecology.  May 1993.  100(5):421-4. [from abstract]

O'Herlihy, C.  First Delivery After Cesarean Delivery for Strictly Defined Cephalopelvic Disproportion.  Obstetrics and Gynecology.  November 1998.  92(5):799-803. [from abstract]

Cardini, F and Weixin H.  Moxibustion for Correction of Breech Presentation: A Randomized, Controlled Trial.  Journal of the American Medical Association, November 1998.  280(18):1580-1584.  

Schwartz, A et al.  Face Presentation.  Aust N Z Obstet Gynaecol.  August 1986.  26(3):172-6. 

Sizer, AR and Nirmal, DM.  Occipitoposterior Position: Associated Factors and Obstetric Outcome in Nulliparas.  Obstetrics and Gynecology.  November 2000.  96(5 Pt 1):749-52.

ONLINE RESOURCES

 

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