Penyanyi : Manual Rotation for Posterior or Tranverse Babies
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Manual Rotation for Posterior or Tranverse Babies
This new study is just the latest in a series of studies that have shown that manual rotation lessens the need for cesarean during labor because of a malpositioned baby.
In these studies, a persistent posterior baby (baby facing mom's tummy instead of her back) is turned manually to the generally-easier-to-birth anterior position (baby facing mom's back). The question has been whether such techniques improve outcomes.
This study shows a dramatic improvement in outcomes with manual rotation.
This is a larger trial than many of the previous studies on manual rotation, which makes the findings even stronger. This study is interesting in that it also includes manual rotation for transverse arrest (baby gets stuck facing sideways, usually as they are trying to rotate from posterior to anterior). Not all manual rotation studies do.
Note that manual rotation is not without risks; there were more women in the rotation group with cervical lacerations, which is not fun. However, balance that against less need for cesareans, fewer severe perineal lacerations, less hemorrhage, and less infection, and I'd say manual rotation wins, hands down.
But Should We Intervene for a "Malpositioned" Baby?
One of the controversies within the natural childbirth community these days is whether persistent posterior babies should be considered malpositions or just variations of normal, and whether we really need to intervene at all in such cases or just be more patient.
Personally, I do believe that sometimes these positions are just a variation of normal and don't have to be a big deal. Sometimes all that's needed is just a tincture of patience and time, and the "malpositioned" baby is born just fine. Sometimes the baby's "malposition" is even actually needed because of a unique pelvic shape or some other factor we are not yet aware of. So I agree─up to a point─with folks who tell pregnant women not to obsess too much over their baby's position or to feel that if they have a posterior baby that they are doomed to a cesarean etc.
However, I think it's naive to believe that such positions are always benign and will always be born vaginally and without damage if just given enough time. I think research is quite clear that OP labors are often harder and longer, and that there are often poorer outcomes for mother and baby.
Yes, I do wish doctors would also study maternal repositioning and other less interventive alternatives so there were other options in the arsenal for a malpositioned baby. I bet some of these babies would rotate just fine with other, less-invasive techniques, and then the more-invasive manual rotation could be used only when truly needed. I also wish that care providers would be more patient in labors, because many positions will remedy themselves with a little extra time, or be born in that position just fine.
However, I don't believe that all malpositioned babies will be born safely "if just given enough time." Some babies and mothers will experience significant difficulties. Many more will be subjected to forceps/vacuum extraction and cesarean deliveries, with all the associated risks. The question is whether these complications and operative deliveries could have been avoided if manual rotation had just been tried.
This new study compared manual rotation with expectant management─just waiting─and found that outcomes were significantly improved in the active intervention group. Other studies have also found that prophylactic rotations improved outcomes. So perhaps "just waiting" is not always the best thing.
Remember, these malposition labors can sometimes be just HELL for both mother and baby. It's not always wise to wait to intervene until mother is exhausted and baby is in distress. Sometimes an earlier intervention like manual/digital rotation can be judicious and helpful.
So while I want care providers to have more patience and use other, less invasive techniques first, I am thankful that manual rotation is in the arsenal too. I think the results of these studies clearly show it should be learned by more care providers and applied when less-invasive techniques are not helping.
For the many many MANY of us out there who have had long hard labors and then cesareans for malpositioned babies, I say Hallelujah that care providers are re-learning this manual repositioning skill again. About time!
Huge thanks to the midwives and doctors who kept this technique alive when it went out of obstetric fashion. I hope they are teaching others and spreading the word to more midwives and especially doctors. Far too many women are being cut open because care providers don't know how to handle differences in fetal position.
Manual repositioning can be a very valuable skill to have and will surely improve outcomes in many cases. That doesn't mean it should be used too quickly or in place of less-interventive techniques, but that it clearly does have a place in the spectrum of options.
Shaffer BL, Cheng YW, Vargas JE, Caughey AB. Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. J Matern Fetal Neonatal Med 2011 Jan;24(1):65-72. Epub 2010 Mar 30. PMID: 20350240
In these studies, a persistent posterior baby (baby facing mom's tummy instead of her back) is turned manually to the generally-easier-to-birth anterior position (baby facing mom's back). The question has been whether such techniques improve outcomes.
This study shows a dramatic improvement in outcomes with manual rotation.
This is a larger trial than many of the previous studies on manual rotation, which makes the findings even stronger. This study is interesting in that it also includes manual rotation for transverse arrest (baby gets stuck facing sideways, usually as they are trying to rotate from posterior to anterior). Not all manual rotation studies do.
Note that manual rotation is not without risks; there were more women in the rotation group with cervical lacerations, which is not fun. However, balance that against less need for cesareans, fewer severe perineal lacerations, less hemorrhage, and less infection, and I'd say manual rotation wins, hands down.
But Should We Intervene for a "Malpositioned" Baby?
One of the controversies within the natural childbirth community these days is whether persistent posterior babies should be considered malpositions or just variations of normal, and whether we really need to intervene at all in such cases or just be more patient.
Personally, I do believe that sometimes these positions are just a variation of normal and don't have to be a big deal. Sometimes all that's needed is just a tincture of patience and time, and the "malpositioned" baby is born just fine. Sometimes the baby's "malposition" is even actually needed because of a unique pelvic shape or some other factor we are not yet aware of. So I agree─up to a point─with folks who tell pregnant women not to obsess too much over their baby's position or to feel that if they have a posterior baby that they are doomed to a cesarean etc.
However, I think it's naive to believe that such positions are always benign and will always be born vaginally and without damage if just given enough time. I think research is quite clear that OP labors are often harder and longer, and that there are often poorer outcomes for mother and baby.
Yes, I do wish doctors would also study maternal repositioning and other less interventive alternatives so there were other options in the arsenal for a malpositioned baby. I bet some of these babies would rotate just fine with other, less-invasive techniques, and then the more-invasive manual rotation could be used only when truly needed. I also wish that care providers would be more patient in labors, because many positions will remedy themselves with a little extra time, or be born in that position just fine.
However, I don't believe that all malpositioned babies will be born safely "if just given enough time." Some babies and mothers will experience significant difficulties. Many more will be subjected to forceps/vacuum extraction and cesarean deliveries, with all the associated risks. The question is whether these complications and operative deliveries could have been avoided if manual rotation had just been tried.
This new study compared manual rotation with expectant management─just waiting─and found that outcomes were significantly improved in the active intervention group. Other studies have also found that prophylactic rotations improved outcomes. So perhaps "just waiting" is not always the best thing.
Remember, these malposition labors can sometimes be just HELL for both mother and baby. It's not always wise to wait to intervene until mother is exhausted and baby is in distress. Sometimes an earlier intervention like manual/digital rotation can be judicious and helpful.
So while I want care providers to have more patience and use other, less invasive techniques first, I am thankful that manual rotation is in the arsenal too. I think the results of these studies clearly show it should be learned by more care providers and applied when less-invasive techniques are not helping.
For the many many MANY of us out there who have had long hard labors and then cesareans for malpositioned babies, I say Hallelujah that care providers are re-learning this manual repositioning skill again. About time!
Huge thanks to the midwives and doctors who kept this technique alive when it went out of obstetric fashion. I hope they are teaching others and spreading the word to more midwives and especially doctors. Far too many women are being cut open because care providers don't know how to handle differences in fetal position.
Manual repositioning can be a very valuable skill to have and will surely improve outcomes in many cases. That doesn't mean it should be used too quickly or in place of less-interventive techniques, but that it clearly does have a place in the spectrum of options.
Shaffer BL, Cheng YW, Vargas JE, Caughey AB. Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. J Matern Fetal Neonatal Med 2011 Jan;24(1):65-72. Epub 2010 Mar 30. PMID: 20350240
Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Clinical and Policy Perinatal Research, University of California, San Francisco, CA 94143-0705, USA.
OBJECTIVE:
To examine mode of delivery and perinatal outcomes in women with occiput posterior (OP) or transverse (OT) position in the second stage of labour with a trial of manual rotation compared to expectant management.METHODS:
A retrospective cohort study was designed to examine mode of delivery and perinatal morbidity in women who underwent a trial of manual rotation (n = 731) compared to expectant management (n = 2527) during the second stage of labour with the fetus in OP/OT position. Chi-square test was used to compare categorical outcomes and multivariable logistic regression models were used to control for potential confounders.RESULTS:
Compared to expectant management, women with manual rotation were less likely to have: caesarean delivery (CD) [adjusted odds ratio (aOR) 0.12; 95% confidence interval (CI) 0.09-0.16], severe perineal laceration [aOR 0.64; (0.47-0.88)], postpartum haemorrhage [aOR 0.75; (0.62-0.98)], and chorioamnionitis [aOR 0.68; (0.50-0.92)]. The number of rotations attempted to avert one CD was 4. In contrast, women who had a trial of rotation had an increased risk of cervical laceration [aOR 2.46; (1.1-5.4)].CONCLUSIONS:
Compared with expectant management, a trial of manual rotation with persistent fetal OP/OT position is associated with a reduction in CD and adverse maternal outcomes.Demikianlah Artikel Manual Rotation for Posterior or Tranverse Babies
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