 Dr. Arnold Leahy has been in clinical practice in New York City for 35 years as director of St. Vincent's Hospital Midwifery Service for over 20 years. Betsy designed an institutional practice for community-based, hospital-based, and private practice midwives function in a collegial setting. Betsy is data chapter chair on multiple local and state committees lectured in Japan and is currently employed in a midwife operated private practice in Brooklyn. One of the first midwives of the U.S. to earn a doctorate in midwifery, her project focused on her passion for auspicious posterior labor and its effects on practitioners and birthing people. And Betsy, take it away. Thank you so much, Kailin. Will you help me? Are you gonna help me with my two slide polls? Or do I do those myself? Betsy, I can't hear you. Are you talking? Yes. Do I need to be louder? There, can you hear me now? Let me make myself louder. I can hear you, Betsy. This is the ring. Can you hear me? I can hear you well. Is that better? I made myself louder. Yeah. Okay. Okay. Good. So it's just you, Kailin, is it? I can hear. We can help you with your polls. So, where you go? All right, thanks so much. So, happy Midwifery Day, everyone. I am so happy to be here. I've been a midwife for 37 years. Before that, I was a nurse. And as you heard, I've done a lot of things. Please feel free to use my slides and everything else I have in it. Update it, use it, share it. This is my, I used to say it's the bane of my existence. When I was a very beginning nurse, I once, you know, I pushed with someone for hours. And in every single position that we could think of, anything else, and the baby did not come out, we wound up in a cesarean section, and I was quite sad. And that's where I learned, not everybody, every baby fits out. I'm kind of brain dumping on you because I've been at this for a long time. And one of these days, I am going to have to retire. So I want everybody to have all this information. This has been going on for thousands and thousands of years. When you look at some of the older literature, the, just last month, when the German midwives put up Justine Sigmund, she had a banner on Google, she had a textbook, and it's mentioned in there. So we know this has been going on for a long time. This is the ancient art of midwifery. It's what we do. And then we have the modern science. That's where we come up with the research and what we're doing with this. About 12 years ago, my hospital closed and I moved to a new institution as an experienced midwife. It's a very collegial situation and the physicians help us and we help them. And one Friday night, one of the attending physicians came to me and asked if I would examine his patient for him. He really felt the baby was posterior and his plan was to perform a C-section in about an hour if the baby was not delivered. So I confirmed his findings and I asked if I could, since I had the hour, could I do my little tricks? I repositioned the patient in what I call the store and we'll talk about that later. And 30 minutes later, he came to me with a few choice words. As now the woman was fully dilated and he thought he was gonna be stuck for two hours and then would have to do the C-section. 30 minutes later, she had the baby in her arms and he was home on time. The more fun part of this was that two weeks later, we had the little holiday party and he was over in the corner trying to demonstrate my star position. And that kind of made me the expert and the person everybody goes to now. So I don't know everything about OP. I've been doing collecting stuff and you probably all have things up your sleeve as well but we need to put this together and make sure that we share this information because we wanna make sure that everybody can use it. Let me go to the next page. Oh, that's me. And if you want me please, anytime. And these are my thank yous to all my people. My favorite book, Oxford and Foot, Kevin Riley, he told me I couldn't win everything. My midwifery class for my originally program, my doctoral program, my current midwifery family, Sarah Webb, Penny Sinkin, people who've helped Dorothy Alang and then my family. And of course on the far left is my daughter who gave me my own very personal experience with OP. And most of the evidence, most of what's taught about OP is not supported by the evidence and most of what we know about labor isn't either. And I didn't make that up. That's from Peggy Sinkin, who many of you may know in this country. And I think my poll things come next, right? Oh, so my questions to you are so that now I can know about yous, how much experience in you field do you have? Zero to five years, five to 10 or more than 10? So I know where I'm gonna focus. I kind of in the middle between a lot of experience and in the first five years. And how many of you have had an OP birth experience yourself where you yourself have had a baby that was OP? So did you feel like you were being a lobster being cracked over and over and over again? Was that dull, aching pain in your back that never went away? That's how you know, we know what's going on. All right, so I'm just gonna quickly run over OP quickly. Most of you know what it is. It's the most common malposition of the fetus, 20 to 35% of laborers, 90% rotate to a more favorable OA most of the time. And depending on your study, 1.78 to 12% of fetuses remain persistently, or as I like to say, abstinently, accepted posterior at or up to birth. ROP is five times more common than LOP because that's the same axis as LOA. So that same bend in the colon that allows the babies to focus there, that kind of is where they go. LOP, when the baby's LOP, those are all from the ones that won't turn for some reason. And OP can account for up to 12 or 18% of the births depending on the study that you're looking at. The sequela, longer laborers, two and a half times a second stays, two and a half times longer. Maternal and provider exhaustion. You know, someone who has been through two or three shifts of staff. And has gone past what we always called the golden rule of the woman should not labor through two sons. Moving to, if you're in a community-based setting, winding up having to move to a higher level of care or to the hospital, increased operative delivery rates, sadly, up to 23% in one study will have a spontaneous vaginal birth if the baby remains posterior. So everybody else has an operative birth. And increased sequela in terms of hemorrhage, higher order lacerations, increased infections from mother and baby, longer hospital stays for those who deliver vaginally as well. And I'm just gonna have a few slides of what it really looks like. The larger bipyretal pyramidal diameter negotiates the maternal pelvis. As the baby comes down, that face is smashing underneath the symphysis as it tries to maneuver. The larger diameter has to do a lot of wiggling to figure out the way out. And the fetal head diameter is trying to fit through that little, the two triangles that become the pelvis and the diameter of the pelvis they have to fit through. And this is just the comparison of the OA versus OP. You've all seen it. This is right from Oxford and Foot, which is the book I always use. I read this every couple of years just because it has such a great description of the mechanisms of labor. And when you understand them and the physics of it, you can really appreciate how the baby needs to move. Again, more of our lovely pictures. Just again, so you can get a feel of, see how that baby is not well flexed. That's where you get a lot of problems. You get the asynclatism, all those things that contribute to occipit posterior. And how should we diagnose it? Well, traditionally, we have done it by Leopold's maneuvers, back pain, location of the fetal heart sounds, the divot, that little soap dish right above the symphysis, feeling all the small fetal parts instead of the nice smooth back, coupling of contractions and that long disultery labor pattern. Sadly, these may not be accurate. Ultrasound may be the way that we have to go. I'm a little old fashioned. I use the ultrasound to confirm what I believe, but I really use my hands most of the time. The accuracy of these factors in diagnosing occipit posterior has either studied or is not supported, but experienced midwives and physicians traditionally use them in their overall assessment. Multiple studies have shown that sonogram is superior to abdominal palpation and vaginal exam. And one recent study listed ultrasound as the gold standard in the quote unquote, hands of an experienced operator. However, this is not 100%. A 2019 analysis by Tau compared ultrasound to fetal position at birth and it said that it had great potential but was not definitively predictive of fetal position. Abdominal palpation, the small parts are easily palpable. You can feel the cephalic prominence maybe. You could see that divot. Where do you hear the fetal heart tones? Are they very loud? Are they softer? You're really hearing the souffle. And the lie, how that baby is, it's not a straight vertical line, it's often a skew. And when you do the exam, you can feel that, hopefully you can feel that little diamond in the sky. That's how I try to remember it. And again, ultrasound may be the only reliable way to determine fetal position. Penny Sinkin and Sarah Webb. Speaking of Sarah Webb, Sarah's accuracy study compared abdominal palpation with ultrasound. Midwives performed an abdominal palpation on women with a single term vertex fetus in an antenatal clinic. The women were in early labor or having an induction. They, after the midwives did the palpation, they walked over to the labor unit, which where they received an ultrasound before their admission. Midwives were found to be accurate in only 16% of the examinations. Those midwives with more than five years experience or were community-based were more accurate. And I really know why Sarah did this because she was trying to preserve the separation that no one knew what was going on. She was trying to preserve the blinding. But the women were in early labor and they ambulated all things we know that can change the fetal position. And we use them often when people are in labor. So when I did my study, I kind of based it on Sarah's study and she was actually one of the people on my committee. And she and Penny Sinkin were very helpful. I abdominal palpation at expert practitioners or the APIC study, it was a mixed method study. And I had 17 pairs of midwives and pregnant people who came to a very small ultrasound center where the pregnant person received a sonogram in one room and just was not in labor. It was a scheduled sonogram for post-dates or whatever. And then they would move into the next room where midwives would perform an abdominal palpation. And what I was studying was their accuracy, but also their technique. What was it that they did to ascertain the position? And I had, I filmed them and then I had, they were a camera so we could see what they were seeing. There's something called GO-BASE template theory, which is basically, it tells you that in your brain you have a chunk of information and then there's like little slots on the side and it's how your brain discriminates between different things. So those of us who do this, it looks like intuition, but we are in milliseconds just switching out different bits of information. Oh, this is the head, this is the, here are the feet. Oh, I feel this, this is the back. And that's how we come to the conclusion of what we're saying is the position. In my study, the midwives were accurate within 45 degrees except for one person. They were all spot on for where the back was except for one person. And the techniques they use were walking their fingers across the abdomen, not just the whole hands, but the abdomen midwives looked away or closed their eyes while they were feeling where the baby was. And that I think was a really big tell. Those midwives who were more accurate also were faster. The one thing about my study was is that the midwives who participated were all from basically the same three programs in the New York city area. So my hope is to do it at a larger session either nationally or internationally. So maybe at the next ICM where we can get different people's way of doing things because I think that it's very telling about how we do this. The one thing was is that there was additional pair that I had to disqualify because it turned out because I had no idea. I didn't look at anything until after the woman had left and then we looked at, we didn't know what the position of the baby was until I collected the forms from the sonographer. But the one midwife, she's like, at the end, she's like, I don't know, I'm just picking something. Well, it turned out that first off, she did not actually have five years experience because I was trying to use people who were more experienced. That's what I was really starting with since Sarah's study showed that to be helpful. But the other thing was the baby was breech. She didn't listen to her instincts. So the fetal spine and the fetal head may be in different positions. I know that you all know this from what we've studied. We know that the baby's not just standing there at attention, the head moves back and forth. And when the fetal spine and the fetal occipit are posterior, so when the fetal spine is posterior and adjacent to the maternal back, birth will most likely occur from the posterior position. If the fetal head is OP, but the spine is lateral or on the side, birth is more likely to occur in the OA position. And I've collected five studies now where it really shows that the back probably is a better prognosticator for position at birth than is the head. And I think that the back may be the answer into us figuring out what the better thing to do is. And you'll see as we go along. So I've tried to look at this in terms of different kinds of ways to figure out how can we use this. So if we looked at contributing factors, there's strong evidence that null parity, maternal stature, if you're shorter, epidural at birth, a narrow suprapubic arch, those are physical things that I think we've really all known for a really long time. And maternal age over 35 contribute to occipit posterior. There's weak evidence for gender. There were a couple of studies that tried to say that a male gender was gonna give you a, was more likely to have a posterior baby and the anterior placenta, post maturity, weight gain, estimated fetal weight. So those things are things that kind of anything that makes the baby bigger, the more mature the baby is, of course the baby has to be bigger. So those things all contribute to that but that does not have enough evidence yet. Race was also something that came up in the US studies. There's two large studies that pointed to black or African-American as a risk factor. It does not hold up in the international data and this needs further investigation and probably has more to do with the healthcare disparities that we find in the United States than with anything that's really gonna contribute to being posterior. So when you look at the risk factors in terms of what's modifiable and non-modifiable, you cannot fix your parity except to have another baby. You can't fix your stature. You can't make yourself any taller. You can't fix that narrow, super pubic arch and you may or may not be able to move where that baby's spine is, at least the mother can't. You can modify your epidural use, so avoid or delay using the epidural until at least the head is engaged at station zero. And some of the studies showed that rupture of membranes may play into it in terms of artificial rupture of membranes. You may wanna delay that before proceeding. That may help a little bit. This is some of the research that's available. There's really a lack of good or randomized controlled studies to help us with that. When we talk about associated factors, and there's only seven prospective cohort studies. We're three retrospective cohort studies. And some of their ends are quite large, but it's not enough to really give us some, tell us what we really need to do. In terms of telling whether OP is a rotation, in other words, the baby rotates into a malposition, or it's a static position that the baby's is OP and stays OP, there's mixed results on that. Can we prevent oxydipid posterior? There aren't any studies that tell us that. In labor management, we have six RCTs with mixed results. Modified sims variations are associated with rotation and hands and knees is not, even though a lot of us use it. And like I said, I have five studies now that really show that it may be the back that's gonna help us out. So one of the larger studies was, these people became very, almost good friends with me when I was doing all my research. The two large US studies are Chang and Ponke. And at the end of one of them, it's 23% of birthing people with an OP baby, give birth via spontaneous vaginal delivery. Everyone else has an operative delivery. And when all is said and done, sometimes that might be the best thing, the best that you can tell someone is like, you tried everything. You tried every position and the odds were stacked against you. And this is from the Ponke study, the same bit of information. The 23% is from people who were nulliparous. The 57% statistic was for people who were multiparous. And that's kind of sad that if you were multiparous that you only have a 57% chance of having a spontaneous vaginal delivery. So what is there for management, prevention? There's been optimum positioning, left lateral, ambulations, squatting, spinning babies, all prenatally. And there are no studies that support prenatal positioning or exercise to prevent occipitoposterior. Some of the problems are that some of the data is like this, people aren't working around with the sonogram at their house. Many times you're just, it's by the examination of the provider to tell you what you think that is. And that's how they decided where the position of the baby was. I do have one trick that I use particularly this works well with people with loose musculature, so multips. If you use an abdominal binder after 37 weeks, you can help that baby stay over directed over the pelvis because a lot of times when the baby is kind of hanging outside the, you know, almost like hanging outside the mother, you can see where the baby's gonna have a hard time getting into position. So if you do that, that can actually, that's the one thing I found that's helped. I don't really have any good studies for it yet. As far as labor management, we get the same thing, optimal positioning, spinning babies, the mild circuit, manual digital rotation. And we have three randomized controlled studies that show maternal position modification can increase rotation from OP to OANG backwards. And when we do these things, the art or art, what are we doing? We wanna change the angles of the pelvis, you know, shifting that angle so that there's a little bit more room for that baby to spin. Straighten the head and the body axis. Keep that body, keep that baby's body straight. Trying to make a little bit more room with different positionings. Getting the head under the synthesis. Sometimes that synthesis is narrow and just, it's long and you have to rock that baby under the synthesis or give it a little help. And pain management, this is something, you know, that we struggle with every day in trying to, do we give some, does we have epidural? Do we not have an epidural? If that's one of the things that we have available to us. Now these are three midwifery research studies specific to occipit posterior. This is our science, right? I was so excited to see these as I was doing my work. Buena Vista from Spain in 2018, 225 occipit posterior confirmed with sonogram. There was a free position and a modified sims and I'll show you some of that. And she had more occipit anterior births than OP. Most of those babies rotated. A couple of years ago Yang and China, 400 confirmed OP with sonograms. And what they did was they had a, it was like a progressive thing where at this point, up until this point, you stood up and you did a chair. At this point, when you were pushing, you pushed on a stool. If it's a certain point, the baby did not rotate, then you went to a, they did a vacuum or a forceps. And they had a much, but their outcome was for shorter labor and less bleeding and pain management. And Liu from China, she had 226 confirmed occipit posterior and she did an extreme hip flexion and hip abduction on the opposite side so that the baby was on, she used the back and the correction was, was significant to the 0.05 percentile. So that, you know, a lot of really good information. There's more of stuff going on and these are all midwifery studies. One of the things I have a hard time is in doing studies is, you know, OP is not a single thing. It's a lot of, a lot, we don't always know the answer of why this baby's posterior. Sometimes you'll know, but sometimes you don't. And so to know how do I know which one is gonna work in this particular case is often difficult. So the beauty of the Yang study is that there was several methods involved and it gave the baby the opportunity to rotate. So that's really an important thing. Here we go with many of the things we do. This is the peanut ball. Also you can see it's called knees together which is something that has been proposed recently and I have seen this work dozens of time when I don't have another thing because when you put the knees together, you rotate the trochanters out and you give people more room. The birthing ball using a sterile water's injection, lunging, hands and knees, sifting with a Robozo or with a sheet. That is the star. The pink dress lady is the star where you put somebody on almost all the way over on their abdomen and bend their knees. I use the back up. The baby's back up. I find that works better because I use that as a weight but that helps them turn. And then the last picture is from the Chinese study where she used, you can see it's basically like a fire plug and that's it because you can see those things. They change the angles of the pelvis and this is the walchers which is an old position. It helps to direct the, it changes again the angles of the pelvis. You dangle the legs over the end of the bed. So I basically put, you know, in hospital, I put the baby, the bed all the way up and dangle the legs over the bed for at least three contractions, excuse me. And the happy baby pose, another way to try to give a little bit more weight to the pelvis. And what I call, I straighten out the back. So oftentimes when you look at a posterior baby, you can see how they're hanging off to one side. If you, when they're, when, when you're in the second stage and there's pushing, if you hold that baby in a straight line, that then the maternal force is in a straight line and those babies will move down a little bit and you will see that that straightens it out. Cause often the spines are not, you know, straight, they're a little crooked and that will help straighten them out. And then we have what, that's what I call the judicious use, use of the hands to straighten out the spine. And then if nothing else works, you have vacuum, forceps, the traditional scantzoni maneuver where the keeling forceps are applied, the head is rotated, the forceps are removed and then reapplied and the baby is delivered as OA. And then if those things don't work, we have, we have cesarean sections. We do have, I wanna just go back. I'm gonna talk about manual rotation of the fetus, which I actually do and I teach that. I just wanna have a quick word about presenting risk information. This is based on a British pamphlet where they explain how to give people an idea of what risk is. So like very common and I put it to what I have in my neighborhood so people will understand, something that's very common, like one out of 10 might see it. That's like a person in your family. So that's OP labor, somebody C-section. Everybody knows someone in their family who's had a C-section at this point probably. Let's come, something that's just regularly common, that one in a hundred, somebody who lives on your street. So that would be an OP birth, someone who's gestational diabetes, preeclampsia and things that like in a building, something that's very rare, like someone who's in a large city. So that would be something like, the things we don't like to say all the time like a prolapse cord or something like that. With manual or digital rotation, which is literally turning the baby. On the left-hand side, on the right-hand side is when you do digital rotation and you just use your fingers to help that baby keep going in the way that you're going. On the left-hand side is you manually cup the head and de-station it, you lift it and then you are rotating the fetal head 135 degrees towards the way the face is. So then the face will in fact be down and the baby will be O-A. And this is a skill that's used worldwide. Here in the United States, we are trying to reintroduce that and get people to do it because some of the older people know it and I'm just teaching the younger people so they don't lose that skill. The FIPS trial, which was published now two years ago was, I was always excited about this, was in Australia. It was a double-blind randomized controlled study. They had a manual rotation compared to a sham rotation. So in other words, these women consented to having someone put their hands up their vagina and rotate the baby and some of them just did not. They just did some sort of something so people would believe that the procedure had been done because they felt that if they knew the procedure was done, the attendance would be much more forceful and encourage the woman to push. So they had 254 nulliparous, multiparous and at least 37 weeks. They were OP on sonor in the early stage and the results were sad, like a non-significant decrease in operative births. So it was a little sad, but hooray, the baby is a smarter than us because while when the 254 people that were randomized, there was another 141 who had a rapid second stage. The babies are smarter than us. There were more where the investigator was not available so we don't know what happened to them. And there were some people who were eliminated from the study because they had fetal distress. So there is basically more people who did not complete the study than completed the study and the rapid second stage people who just the baby came flying out, whether they rotated or not, those people were more than one arm of the study. So I felt very encouraged by that even though it didn't sound like the greatest data, I thought that was the best thing ever because the babies are smarter than us. When you do manual rotation, there's prophylactic versus therapeutic. It's not recommended to do it before full dilation. Prophylactic is when they're fully dilated and they haven't been pushing that long. But as we see, most babies will rotate. But the therapeutic one is when you do it immediately prior to birth or an operative vaginal birth that's sort of like the Hail Mary pass. So there has to be a sweet spot to be found so that we can do it because if you wait too long, the head is impacted and you can get really bad perineal tears and there's just a lot of molding and cap it and you know how bad that can be. And sometimes it's really sad to have to go do a vaginal repair after the cesarean which is not so much fun. In Europe and Australia, this is considered a standard practice and the birth attendant may just do it and moves on. Here in the United States, it's a little bit more difficult and if you can find a mentor to help you do it, the risks are failure, cervical laceration, prolapse cord, it really does happen, and the or fetal intolerance to labor. And the thing is if this fails, there are a few options, only an operative delivery or a cesarean remain as you do that. And the other thing about this data is most of the data that we have is hospital based. So for those people who are community based, we need some more data. So the future of OP, the art and science of midwifery, we need to recognize this is our area of expertise. This is what we do. And I hope every single one of you will do this and become the specialist if you're in hospital in your institution or in your area. I have people, I've been teaching residents and other people and when they leave or the doulas or go to other hospitals, they call me and say, I've done all these things. What else can we do? And all I ever asked them to do is tell me if it works because that's just how we're gonna keep data. We need to use our research capabilities to identify new ways to approach OP. And I want progressive research where multiple levels of treatment in one study because that's, I personally just can't do one thing where we do A or B and if it doesn't work, then what happens? We're leaving how many, if this accounts for all these C-sections, we're leaving all these people to face a C-section. So I cannot, we have to find a better way to do that. And then we need to share results. We need, you know, I'm collecting this stuff, I'm sharing it, I wanna make sure everybody has it. I don't wanna go, I'm really afraid that when I go, it's gonna go away. So I wanna make sure that I give it to everybody. We need international roundtables. The people who are doing community birth, people who are in other places where we don't have some of these resources. We need to work together so that we can have some of those things for everybody. Oh, and so this is my little thing. Somebody gave, one of my patients gave it to me to say thank you for getting out the OP baby. And just a reminder that not all superheroes wear capes. Those of us who toil in the service of birthing people and their families have a gift and we share it every day. And I wanna thank you for your kind attention. Share, if you have any questions, I'm all for it. And I'm so happy, so happy to be with you on this virtual International Day of the Midwife. Thank you so much Betsy. And so now do we have, we have time for about one or two questions. There's a question, Betsy. Very new community midwife here. How can we safely integrate manual rotation in the home setting? I know plenty of people who are community based who do that. They've been at it for a while. I mean, as a community midwife, you have mentors and people who you work with along the line and you should be able to get a more senior midwife to help you with that. And hopefully that way you can build your skills. I don't see any other question.