We all have experiences of those births that just seem to go seamlessly; experiences that make us remember, throughout the chaos that is midwifery and obstetrics, the reasons why we all do what we do. Those low risk, straightforward births where women appear to need no more than a hand to hold and some gentle reassurance. Those births where everything seems to just click into place.
We also have all cared for and know too well those women who seem to have every factor going against them. Those women who endure a long induction process, failed forceps and caesarean section. We question why these women’s bodies seem to work against them; writing the experience off as the path these ‘high risk’ women are destined to follow.
However, we do have to question our role in this. To realise that these women are the ones that need our honed skills more than any and it takes us going back to basics.
Probably one of the simplest measures we can take is just to encourage women to move. This exercise alone has been proven to benefit the physiological mechanisms of birth and the greater maternal experience.
The promotion of mobilisation in childbirth has been documented for centuries, developed and adapted from a plethora of evidence and its importance cannot be underestimated. Particularly for those women whose birth plans are complicated by an induction, the benefits of early mobilisation cannot be dismissed; influencing maternal satisfaction, pain perception and analgesia needs whilst promoting optimal fetal positioning and reducing the likelihood of further interventions. In fact, a Cochrane review reported that mobility and upright positions can reduce the length of labour by an average of 1hr 22 mins and reduce the incidence of caesarean section by 29%!
Mobilisation following ARM should always be offered as standard practice regardless of parity. Gravity will aid descent of the fetal head placing pressure on the cervix, releasing natural prostaglandins and contributing to effacement.
This cascade of hormones and physiological processes can further assist with maturation of the cervix and even be enough to initiate labour. This is most likely seen in multips, but primips should be able to receive the benefits too. Vertical positions have been found to encourage good fetal alignment and uterine contractions, reducing the need for augmentation and perineal damage during birth.
Due to the localised action of Dilapan-S® , women are comfortable and do not commonly experience strong uterine contractions as found with Prostaglandins. The lack of these tightenings means the presenting part exerts less pressure on the cervix. When using other mechanical methods such as balloon catheters, the weight of the balloon exerts a downward pressure onto the cervix, although women often find this uncomfortable.
Dilapan-S® has a different mode of action to these existing methods as it works by osmosis to dilate. This exerts a gentle radial pressure in the cervix rather than an instant downward pressure, explaining why women report such high satisfaction during the process. Although this can result in slightly less effacement (with respect to cervical length) being noted using Dilapan-S® , this is easily rectified.
In our experience, mobilisation both during the ripening process and after ARM leads to improved outcomes and is therefore encouraged for this reason.
There are different manoeuvres proposed to assist with persistent OP positions including invasive fetal head rotation, but studies have shown that none of these are as effective than the simple act of mobilisation!!!
The impact of malpositions on mother and baby cannot be disregarded. Persistent occipito-posterior (OP) presentation is linked to adverse outcomes including prolonged labour, higher risk of PPH, increased caesarean and assisted delivery rates, as well as higher incidence of 3rd and 4th degree trauma. Theses adverse incidents are not only traumatic for mothers and partners, but have been further associated with, amongst others, neonatal trauma, low APGAR scores, term admission to NICU and fetal academia.
It is understandable that we get excited by new trends or technology in midwifery, such as the recent advancements in mechanical IOL, but we need to make a conscious effort to amalgamate these new advances with those basic midwifery skills and, at every opportunity, reduce interventions, improve outcomes and normalise birth.
As we gain experience, we must remind ourselves of those lessons we are taught as enthusiastic students, simple cornerstones of midwifery, that can make such monumental difference to women’s birth experiences.
My role at AGH is to provide clinical support, assisting clinicians to master the use of Dilapan-S® and benefit from its potential to deliver excellent outcomes.
0203 950 6415
A, Lawrence, L. Lewis, G. J. Hofmeyr, and C. Styles. “ Maternal positions and mobility during the first stage labour,” Cochrane Database Syst Reviews, vol.15, no.2, 2013.
P, Simkin, “The fetal occiput posterior position: State of the science and a new perspective,” Birth, vol.37, no1, pp.61-71, 2010.
M, J Guttier and V. Othenin-Girarad, “Correcting occiput posterior position during labour: the role of maternal positions,” Gynecologie Obstetrique Fertilite, vol. 40, no.4,pp. 255-260, 2012.
- Gizzo, C. Saccardi, S. Di Gangi et al “Ultrasound investigation during labour of consensual or nonconsensual fetal spine in an occiput posterior cephalic presentation can improve the management of delivery?” Ultrasound in medicine and Bilology, vol. 39, no.3, pp, 550-551, 2013.
WHO handbook for guideline development. Geneva: World Heath Organization: 2014. World Health Organization, 2011.
- W Cheng, A. Hubbard, A. B. Caughey, and I. B. Tager, “The association between persistent fetal occiput posterior position and perinatal outcomes: an example of prosperity score and covariate distance matching,” American Journal of Epidemiology, vol 17, no 6, pp.656-663, 2010.