'Optimal Foetal Positioning' (OFP) is a theory developed by a midwife, Jean Sutton, and Pauline Scott, an antenatal teacher, who found that the mother's position and movement could influence the way her baby lay in the womb in the final weeks of pregnancy. Many difficult labours result from 'malpresentation', where the baby's position makes it hard for the head to move through the pelvis, so changing the way the baby lies could make birth easier for mother and child.
The 'occiput anterior' position is ideal for birth - it means that the baby is lined up so as to fit through your pelvis as easily as possible. The baby is head down, facing your back, with his back on one side of the front of your tummy. In this position, the baby's head is easily 'flexed', ie his chin tucked onto his chest, so that the smallest part of his head will be applied to the cervix first. The diameter of his head which has to fit through the pelvis is approximately 9.5 cm, and the circumference approximately 27.5cm. The position is usually 'Left Occiput Anterior' or LOA - occasionally the baby may be Right Occiput Anterior or ROA.
The 'occiput posterior' (OP) position is not so good. This means the baby is still head down, but facing your tummy. Mothers of babies in the 'posterior' position are more likely to have long and painful labours as the baby usually has to turn all the way round to facing the back in order to be born. He cannot fully flex his head in this position, and diameter of his head which has to enter the pelvis is approximately 11.5cm, circumference 35.5cm.
If your baby is in the occiput posterior position in late pregnancy, he may not engage (descend into the pelvis) before labour starts. The fact that he doesn't engage means that it's harder for labour to start naturally, so your baby are more likely to be 'late'. Braxton-Hicks contractions before labour starts may be especially painful, with lots of pressure on the bladder, as the baby tries to rotate while it is entering the pelvis. Be aware that if you accept induction on the basis of being postdates, and your baby is in a suboptimal position, you may have a tough haul ahead of you. See "Overdue - but desperate for a homebirth?" for more discussion of this issue.
The majority of babies who are Occiput Posterior during labour, actually started off labour in an Occiput Anterior position. According to Gardberg (1998), who has published a number of studies on posterior presentation, about 2/3 of babies who are 'persistent occiput posterior' start off OA, while 1/3 were OP when labour started.
'Persistent Occiput Posterior' means that the baby is born in the OP position - otherwise known as "face to pubes". The majority of babies who are OP at some point in labour, will turn to occiput anterior during the labour and will be born face-down ("face to bum" if you like!). Gardberg found that 87% of babies who were OP at the start of labour, rotated to OA to be born.
Posterior presentation is more of a problem for first babies and their mothers than it is for subsequent births; when a mother has given birth before, there is generally much more room for maneouvre, so it is easier for the baby to rotate during labour. It can still be hard work, though, as the story of the birth of Deborah Black's third baby, Kyle, shows.
Sutton and Scott note that the rate of posterior presentation has increased drastically in the last few decades, apparently in line with changes in the way women use their bodies. Sitting in car seats and leaning back on comfortable sofas, together with less physical work, have combined to produce an increase in posterior presentations. Paying attention to your posture in the last few weeks of pregnancy can help to reverse this trend. Since keeping reasonably active in pregnancy, and practising good posture, isn't going to do anyone any harm, this theory at least deserves to be considered.
Recent research has suggested that there may be little point in practising OFP techniques in late pregnancy as a 'routine intervention', ie as a matter of course - for instance, if your baby is already occiput anterior. However, if your baby seems to have settled in an OP position, then it may well be worth putting in some effort to shift her.
Pay attention to your posture at the time when your baby may be starting to 'engage', which means its head will be descending into the pelvis. This means for the last six weeks of your first pregnancy, and the last two or three weeks of subsequent pregnancies. In your second and later pregnancies, the uterus is more roomy and the baby will not normally start to descend into the pelvis until later, and often not until labour starts.
This is important because you need to know when your baby moves into a good position, so that you can encourage it to stay there! You can learn to tell what position your baby is in, by asking midwives to show you what to look out for, and by practising feeling for the baby yourself.
When the baby is anterior, the back feels hard and smooth and rounded on one side of your tummy, and you will normally feel kicks under your ribs. Your belly button (umbilicus) will normally poke out, and the area around it will feel firm. When the baby is posterior, your tummy may look flatter and feel more squashy, and you may feel arms and legs towards the front, and kicks on the front towards the middle of your tummy. The area around your belly button may dip in to a concave, saucer-like shape.
If you feel the baby move, try work out what body part was moving. Remember that heads feel hard and round, while bottoms feel soft and round! It may take a lot of concentration and trying to work things out at first, but you soon get the hang of it. You may find it easier to feel your baby's position if you lie on your back with your legs stretched flat out.
If your baby is posterior, you may find that you suffer backache during late pregnancy (of course, many women suffer backache then anyway). You may also experience long and painful 'practice contractions' as your baby tries to turn around in order to engage in the pelvis.
The baby's back is the heaviest side of its body. This means that the back will naturally gravitate towards the lowest side of the mother's abdomen. So if your tummy is lower than your back, eg you are sitting on a chair leaning forward, then the baby's back will tend to swing towards your tummy. If your back is lower than your tummy, eg you are lying on your back or leaning back in an armchair, then the baby's back may swing towards your back.
For more detailed discussions of positioning, some good diagrams, and lots of tips for turning babies, please see the sources listed at the end of this article.
Avoid positions which encourage your baby to face your tummy. The main culprits are said to be lolling back in armchairs, sitting in car seats where you are leaning back, or anything where your knees are higher than your pelvis.
The best way to do this is to spend lots of time kneeling upright, or sitting upright, or on hands and knees. When you sit on a chair, make sure your knees are lower than your pelvis, and your trunk should be tilted slightly forwards.
(Nothing to do with baby positioning, but... if you're swimming, make sure you have goggles so you can swim in a good position, with your face partially or wholly in the water as you dip down. Doing breaststroke with your neck craned, holding your face out of the water, is bad for your neck and back at any time, let alone in pregnancy when ligaments are loose.)
First of all, don't panic! Most posterior babies will turn in labour, but read on to find ways of helping him or her turn before.
When your baby is in a posterior position, you can try to stop him/her from descending lower. You want to avoid the baby engaging in the pelvis in this position, while you work on encouraging him to turn around. Jean Sutton says that most babies take a couple of days to turn around when the mother is working hard on positioning.
If your baby is persistently posterior, Jean Sutton recommends using a special kneeler-rocker chair for the last few weeks of pregnancy. This is like a kneeling stool, which sits you in a helpful upright position with knees lower than your chest, but it has rockers underneath it. The combination of upright posture and rocking movement encourages the baby to rotate.
In the UK, you can hire a kneeler-rocker from Jill Sutton (Jean's daughter-in-law) on 020 8890 8298 - cost £40 for a four-week hire period in 2000.
Elsewhere, try midwifery or doula organisations, or specialist back chair shops (which sometimes sell kneeler rockers, although they probably have not heard of them used specifically for this purpose). For example, Norwegian furniture company Stokke make a kneeler-rocker designed to encourage good posture at your PC or desk. It is not constructed specifically with pregnant women in mind, as Jean Sutton's rocker is, but would still be useful. You can see their Stokke Variable Balans online, and get details of suppliers. In the UK, you can buy this chair from Back In Action.
When your baby turns to an anterior position, you can encourage him to descend further into the pelvis - by walking around upright, massaging your bump downwards, deep squatting, and swimming - and now you can use lots of breaststroke "frogs' legs" kicking.
Remember, most posterior babies will turn during labour (87% according to Gardberg study - see refs), but even if yours doesn't, a baby can still be born vaginally in the posterior position - "face to pubes" - and this can happen at a homebirth. Sometimes a posterior labour can make things just too tough, but it can work out.
You may try your hardest to get your baby into a good position, but he may be determined to stay the way he is - if so, there are things you can do in labour to help a posterior baby to be born.
The majority of babies who experience a posterior labour, actually start labour in an ideal position, and then turn posterior while you are in labour. Gardberg et al found that 68% of posterior babies took this route. This seems very unfair - but if it happens, these tips should still help.
These movements can help the baby wriggle through your pelvis, past the ischial spines inside it, by altering the level of your hips. They are also helpful if the baby is anterior but has a presentation problem, eg his head is tipped to one side (asynclitic).
For the second stage:
Sometimes women are concerned that sleeping on one's back is dangerous in pregnancy, either because it may deprive the baby of oxygen, or because it may encourage posterior presentation. Here are some comments from independent midwife, Virginia Howes, of Kent Midwifery Practice:
One thing I do come across often is the idea that sleeping on your back is bad when you are pregnant. Women should sleep in whatever way they are comfortable. The important thing is a good night's sleep and women do not need to feel guilty when they wake up on their back. This is a myth that has come about through a misunderstanding of the facts and unfortunately is constantly perpetuated.
When epidurals were first introduced into childbirth the dose of drugs used was considerably higher than it is now and the paralysing block very dense. Women were being left on their back and unable to move even if they wanted to. The heavy uterus would press onto the big oxygen-carrying blood vessels in the lower back and cause a decrease in a woman´s oxygen levels and consequently the oxygen reaching the baby. Thus came about the information that women should not be left to lie on their backs when they have an epidural. Quite correct information for that group of women.
However if a woman without an epidural lies on her back and her oxygen levels are compromised, the first thing that will happen is she will become short of breath. That will happen prior to the baby being compromised and of course the woman will move off of her back or wake up and move.
Virginia Howes - Kent Midwifery Practice
Midwives and mothers who have learned about, and used, Optimal Foetal Positioning techniques are convinced that it works. There is a wealth of anecdotal evidence in favour of it. However, there have not been many trials or studies on the subject so far, because they would be extremely difficult to organise. Practising techniques to turn a posterior baby can take a lot of commitment on the part of the mother, which could not be assumed in a randomised trial. There would also be ethical problems with a trial - would mothers in the control group be told not to adopt upright or forward-leaning postures? Or would they simply not be told that taking care with their posture could lead to an easier labour?
The most recent research on using hands-and-knees position in labour, where the baby is known to be OP, has supported OFP theory. Stremler and colleagues confirmed that babies were OP by ultrasound, then asked the women concerned to spend at least 30 minutes out of an hour on hands-and-knees while labouring. The baby's position was checked after an hour. Twice as many babies had turned OA at the end of that hour in the hands-and-knees group, as in the control group. However, because of the small numbers involved this did not reach statistical significance. I think most of us would be prepared to take a chance on that! What did reach statistical significance, however, was the women's experience of back pain; the hands-and-knees group experienced significant reductions in persistent back pain than the control group.
A study published in the British Medical Journal January 2004 found that just going on hands-and-knees in late pregnancy (but not labour) was not enough to stop you having a posterior baby at birth. This is probably because many babies (approx two thirds) who are OP in labour, have only turned OP during labour. Therefore it's not what you do before labour which is important, so much as what you do during labour. The reference is:
Azar Kariminia, Marie E Chamberlain, John Keogh, and Agnes Shea
Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth
BMJ, Jan 2004; 10.1136/bmj.37942.594456.44
The Kariminia et al study (above) did not really look at OFP techniques in the way a committed woman might practise them - women in the study were asked to go on hands and knees and do pelvic rocks for just 10 minutes, twice a day. It did not look at whether babies were posterior or anterior at the start of labour - only at their position at the end of labour. It did not look at the position or movements of the mothers in labour, and the study didn't include any advice to women on labour positioning. Finally, it did not note whether the babies who were OP at the end of labour, had started labour OP, or had started labour OA and had turned OP during labour. So what it tells us is that a token, brief attempt at OFP techniques from 37 weeks onwards, is not on its own going to do very much for the average woman. I don't think many OFP supporters would disagree with that! It's a great shame that the study did not look at the positions the babies were in at the start of labour, or the positions of the mothers during labour. I imagine that the briefness of the OFP exercises was probably because the motivation came from the researchers, not the mothers; if they'd asked women to commit to a more comprehensive exercise and positioning package, fewer women would have complied.
There is an interesting letter from three UK midwives criticising the study, on the BMJ website. They say:
"The use of hands and knees posturing, otherwise referred to as the 'all fours posture', is widely used by midwives. It is surprising that Kariminia et al (2004) refer to it as an intervention based on personal belief (1). The use of the all fours posture has long been supported by the laws of physics and physiology (2). The law of gravity states that all objects are drawn towards the earth, and that the acceleration of movement is dependent on the mass and the availability of space. If this is applied to the fetus where the mother has adopted the all fours posture the heaviest poles of the fetus (the trunk and the occiput) would be drawn towards the earth, and into an anterior position. Such movement would be hindered only in two cases;  if the mass (the fetus) was not heavy enough to exert a force of acceleration or  if there was no available space into which the mass (fetus) could move. It appears that such principles were not considered by the authors for the intervention used in their study. Firstly, by implementing the intervention at 37 weeks, the availability of space was restricted. Midwifery practice advocates such intervention at 34-35 weeks when more space is available. Secondly the intervention was not implemented when the fetus was in an active state, which would have encouraged further movement of an already moving object. Another very important principle that was neglected related to the specific nature of the associated rocking with the all-fours posture. If 'rocking' equates to swaying of the pelvis from side to side this would exert only a frictional force which, solely, would not be of great benefit. If, however, posturing included movement of the maternal trunk backwards and forwards whilst on all fours this would both increase the available space at the pelvic inlet and along with gravitational and buoyancy forces will encourage frictional movement (3). As the mother moves her trunk forward, her spine is encouraged to move away whilst the maternal symphasis drops down, thus increasing the available space in the pelvic inlet and allowing the fetus more room to rotate to an anterior position.
If the study intervention did not consider any of these vital principles, it is hardly surprising that the result of the trial was negative. At best what the authors can claim is that their particular form of maternal posturing was both ineffective at decreasing the incidence of occiput-posterior position at birth and painful to the study participants. It cannot by any means be concluded that appropriate hands and knees exercise should be discontinued as a way of changing fetal position. No doubt further research is required, but it would be a mistake to use this study alone as a rationale for dismissing maternal posturing as a potentially effective means of changing fetal position. "
Aishah Bibi, Registered Midwife
Bernadette Earley, Registered Midwife
Sara Webb, Registered Midwife
Birmingham Women's Healthcare NHS Trust
(1) Kariminia et al (2004) Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. British Medical Journal 2004(328) pp.490-493
(2) Barnum C G (1915) The effect of gravitation on the presentation and position of the fetus. Journal of the American Medical Association. 64 pp.498-502 (3) Sears F W & Zemansky M W (1960) College Physics (3rd Edition) Addison-Wesley Publishing Company, Reading, Mass.
There has been one other small study  which looked at the short-term effects of mothers adopting a hands-and-knees position, compared to sitting, when their baby was in a lateral or posterior position. Mothers were asked to go on hands and knees, or to sit, for a short period of time, and the position of the baby was noted ten minutes afterwards. The study found that babies were far less likely to remain posterior after mothers had been on hands and knees.
This could be very useful for women whose babies are in the posterior position when they go into labour. However, since the babies' positions were only assessed for ten minutes after one session on hands and knees, this study doesn't tell us very much about the longer-term effects of alterations in the mother's posture. You can read the abstract in the Cochrane Pregnancy and Childbirth Database.
Some good evidence for the effectiveness of the theory comes from its author's own practice. When Jean Sutton was appointed Principal Nurse Midwife at a maternity unit in New Zealand, she emphasised antenatal education on foetal positioning. The transfer rate from maternity unit to hospital fell from 30% to 5 % and the forceps delivery rate fell from 3-4 per month, to 2-4 per year, over a period of several years .
Perhaps the most valuable aspect of OFP theory is that it gives you a set of tools to use if you find your baby has turned OP during labour. Remember that many babies are OA at the start of labour, but may turn OP as the labour progresses - thought to be more likely if the mother is lying back or sitting back, and if she has an epidural. If you can move, you can do something about it.
My first baby, Lee, kept trying to settle in a posterior position because his placenta was attached to the front wall of the uterus (anterior placenta). Babies generally tend to face the placenta, and most placentae implant on the back wall of the uterus (posterior placenta). So if your baby's placenta is on the front wall then you will need to be extra-careful about positioning as the baby's natural tendency may be to settle in a posterior position. This has long been noted amongst midwives, and has now been confirmed by research (eg Gardberg .)
I would feel Lee turning towards my front as he got larger, and every time I would go down on all fours, rock my hips and wiggle around until I felt his back towards my belly button. Then I'd stand up and walk around to settle him there, massaging him downwards. Despite his best efforts to turn around, I won!! And had a 9 hour, straightforward, completely natural labour to produce a 9lb 6oz (4,250g) first baby... I was told that if he'd remained in a posterior position then I would probably have ended up a very hard labour, and probably major intervention and perhaps a caesarean given his size.
Certainly OFP made me feel that there was something positive I could do before labour to help things go well, rather than crossing my fingers and hoping I was lucky. But, as most OP babies start off labour in the perfect position anyway, is it really worth the effort? Only you can say. If your baby is not OP in late pregnancy, there's limited point in spending your last weeks bouncing on a birthing ball and becoming anxious. For most labours, it's what happens when you are in labour which is most important.
If your baby does appear to be in a posterior position, you will probably need to put considerable effort into persuading him to move around. It is no use spending five minutes on your hands and knees every now and then, and then saying "I tried to turn him, but it didn't work...". Optimum Foetal Positioning should be a lifestyle for you, for those last few weeks of pregnancy, not just an occasional distraction. Adopting a 'good' position now and then will not make much difference if you are in 'bad' positions for the majority of the time. A 'good' position is not a magic cure, a pill that you can take to turn your baby. The only person who can get your baby into a good position is you, and unfortunately, you are going to have to do the work to make it happen!
It may be that your baby is going to stay 'sunnyside up' and will just refuse to turn; perhaps that's the way he/she needs to be. However, it can't hurt to try to get the baby to turn. If you do end up having a posterior labour (and they're not all dreadful, but many are harder than they would otherwise be), at least you'll know you did all you could to make things easier for you and the baby.
On the other hand, it is important to note that some babies will turn to a posterior presentation in labour, despite having been apparently ideally positioned beforehand. You can live and breathe optimum foetal positioning in your last trimester, and still have a posterior baby. Sometimes things really aren't fair...only you can decide how much effort it is worth investing into this antenatally. It's in labour that OFP is really important.
Midwife Virginia Howes, of the Kent Midwifery Practice, says:
In my opinion women know a lot about optimal fetal positioning and are keen to try and optimise the baby's position in preparation for birth. I do find however that some women get really worried about it and that on occasion gives me a dilemma about discussing it with them as I do not want to worry them unduly.
MOST babies know exactly what a good position is for them and adopt it. Second time or subsequent mothers need to consider it even less as most of their babies either turn prior to or during labour or even stay in the same position and birth perfectly fine.
It is, in my experience, a first-time rare occurrence that babies remain in the occipital posterior position. This may also be however due to the fact that most of the women I care for labour and/or give birth at home, and do so in upright positions, not laying flat on a bed. I think if women can remain active till D-day and in early labour, it is a good thing. Where possible, without exhausting themselves, my advice is to keep active with plenty of walking, working, dancing, yoga etc. Also do not put on too much weight as bigger babies appear to get into the occipital posterior position more often than smaller ones. We do not have much in the way of actual research evidence to support the ideas about optimal fetal positioning but tacit and anecdotal evidence from midwives and other active birth experts such as Jean Sutton is valuable.
Virginia Howes - Kent Midwifery Practice
Julia N had a wonderfully straightforward home waterbirth with her first baby, despite him turning OP halfway through her labour - he righted himself before the end.
Sam RK was dreading a long labour and wondering what pain relief she'd need, when she found out that her first baby was back-to-back. But things progressed much faster than she expected: "The pool had three inches of water in it, the 2nd midwife was still on her way with the entonox and I had a baby!"
Rachael K planned a home birth for her first baby; her waters broke at home, but she spent several days in latent labour before her baby showed signs of distress, and Rachael changed her plans to a hospital birth. Baby Matilda was a brow presentation, and was born by emergency c-section.
Naomi W had her 7th baby at home, very quickly, with just two of her other children there for company. Her midwife and husband arrived shortly afterwards to find a very competent mother with a healthy baby. In case this all sounds a little too easy, Naomi had endured the traditional lot of mothers of large families - seemingly endless 'Is it? Isn't it?' prelabour and weeks of irregular contractions which didn't appear to be doing anything, when her baby was in the OP position.
Inger developed pre-eclampsia and transferred to hospital for induction. Her baby was OP and was turned by forceps at full dilation, after which she managed to push him out herself.
Gina's first baby turned from ROA before labour to OP. She transferred to hospital when he passed meconium, and her story shows that while OP can make a first labour tougher, it doesn't have to end with an assisted delivery : "Incredibly, I had managed a posterior labour with a synto drip with just the aid of a TENS machine and my yoga breathing! I don't remember having any particular pain in my back, perhaps because of the TENS, although I couldn't stand to be on my back at all. "
Rachel Vincent's third baby was in a persistent OP presentation, born facing upwards; despite this, Rachel managed to deliver him without even a graze.
Tina Redford had her third baby at home. He was in the occiput posterior position, and was much larger than Tina's first two.
Gemma planned a homebirth for her first baby, but her painful, posterior labour didn't fully establish, and she transferred to hospital for help - which took a while to be given..
Judith's baby was not in an awkward position at all, but I'm including her story here because she describes a number of active labouring positions and movements which her midwife recommended to bring her baby's head down, and which could be useful if you were trying to persuade a baby out of a slight malpresentation.
Caroline Brown's first baby was OP in labour but Caroline still managed using only TENS and water for pain relief.
Charlie Paris's first baby was persistent occiput posterior, born face-up, and she still managed to have a straightforward homebirth.
Jane was expecting a two-hour labour for her seventh baby, but instead had a two-DAY stop-start labour, because he was posterior.
Victoria's fifth baby was born at home after a very tough labour. Esmé was not only posterior, but with both hands by her face.
Leighan's third baby was a face presentation - this happens in only around 1 in 500 births, and I'm not aware of anything you can do to prevent it.
George's first baby, Jemima, moved from right anterior to left anterior in the second stage of labour. George used OFP techniques because babies in the right anterior position often move to posterior in labour, and she managed to avoid this.
Sarah Mitchell's first baby, Amber, was born at home. Amber's head was asynclitic (tilted to one side).
Kiara's first baby, Ben, managed not only to turn himself posterior - probably during labour - but his head was also deflexed and asynclitic, ie tilted up and to the side. He was born by caesarean section after three hours of pushing could not budge him.
Caroline Creasey's fourth baby, Mia, was born at home in water. Mia was in the posterior position and stayed that way throughout labour - she was born face-up.
Deborah Black's third baby, Kyle, was born at home, after a lot of effort to turn him from a posterior position in the second stage.
Sarah Sadler's first baby, Kirsty, was born in hospital after transferring from home because of a long second stage. Kirsty had decided to start labour in the posterior position...
Karen Fairweather's first baby, Emily, was born in hospital with the help of forceps after she transferred from a planned home birth. Emily was OP in the second stage of labour.
Suzanne Williams's first baby, Kira, was asynclitic (head tilted slightly to one side) and had her hands up by her face, so it was quite an achievement for Suzanne to give birth to her without assistance. Despite this, Kira was born at home, only five hours after Suzanne felt her first contraction.
Steph Amor's first baby was posterior, and she used OFP techniques in her second pregnancy to try to avoid a repeat. Everything went smoothly...
Kate Wood transferred to hospital because her midwives were worried about the progress of her posterior labour. Kate still managed a natural birth in hospital.
Jo Robertson transferred to hospital because of slow progress in a posterior labour, prolonged rupture of membranes, and meconium in the waters. Her baby turned during labour, and Jo had a very positive birth in hospital.
Rachel tried very hard to have her first baby, Freya, at home, but after labouring for nearly two days, she transferred to hospital. After that marathon, she gave birth soon after arriving in hospital, with the assistance of a ventouse. Midwives commented that Freya was in a 'funny position' and Rachel suspects that she was posterior.
More to come later ... I would not want to give the impression that the majority of OP labours end in transfer to hospital - it's just easier to find birth stories of OP labours amongst those which ended in transfer.
'Understanding and Teaching Optimal Foetal Positioning' by Jean Sutton and Pauline
Scott, in New Zealand: Birth Concepts, 1995.
This book is out of print but has been replaced by:
How will I be born - 2007 edition by Jean Sutton. Available from Rob Sutton at 182 Cygnet Ave, Feltham TW14 0DR UNITED KINGDOM for an inclusive cost of £10.00.
Pauline Scott's new book Sit Up and Take Notice: Positioning for a Better Birth was published in Australia in 2003 and copies occasionally come up in the UK via Amazon.
Posterior Babies - what mothers can do - from the UK's Association for Improvements in the Maternity Services (AIMS)
Article on posterior babies, with photos of a pregnant mother's tummy when carrying a posterior baby, and tips on how to spot a posterior presentation: www.mother-care.ca/pos_sym.htm
Posterior Presentation - A Pain in the Back! Article by midwife Valerie el Halta on posterior babies and how to turn them anterior for faster, easier labours: www.mother-care.ca/pos_pain.htm
UK Midwife Archives page on presentation, from the Association of Radical Midwives (www.midwifery.org.uk)
The Midwife Archives on the gentlebirth.org website have an amazing collection of wisdom and experience on just about every subject related to pregnancy and birth. The pages on positioning start at www.gentlebirth.org/archives/position.html
Article on positioning and how to improve it, with good diagrams of baby in womb and pictures of exercises for mum: www.cefcares.org/fetal/position.htm
By Shiatsu practitioner Suzanne Yates (who also runs courses for parents and professionals in Bristol, UK):
'Exercise for relieving backache'
Shiatsu and Optimum Foetal Positioning, originally published in 'Practising Midwife'.
'The Dreaded Persistent Occiput Posterior' on www.midwifeinfo.com
All data and recommendations in this article are from  below unless stated otherwise.
 'Understanding and Teaching Optimal Foetal Positioning' by Jean Sutton and Pauline
Scott, in New Zealand: Birth Concepts, 1995.
Available in the UK from Jean Sutton's daughter-in-law, Jill Sutton, for £6 sterling - please send cheque made out to J Sutton with A5 or larger envelope, and 41p stamp, to: 95 Beech Rd, Feltham, TW14 8AJ.
Available online from NCT Maternity Sales.
 Modern Midwife , January 1997 Vol 7 No 1, article by Mary Nolan
 Recommendations from other sources, including antenatal classes I have attended, and discussions with midwives and antenatal teachers, which are not specified in Jean Sutton's 'Optimum Foetal Positioning'.
 Hofmeyr GJ, Kulier R. Hands/knees posture in late pregnancy or labour for fetal malposition (lateral or posterior) (Cochrane Review). In: The Cochrane Library, Issue 2, 2000
 Gardberg et al (1998)
Obstet Gynecol. 1998 May;91(5 Pt 1):746-9.
Intrapartum sonography and persistent occiput posterior position: a study of 408 deliveries.
Gardberg M, Laakkonen E, Salevaara M.
Department of Obstetrics and Gynecology, Vaasa Central Hospital, Finland.
OBJECTIVE: To use intrapartum sonography as a tool to investigate the development of the persistent occiput posterior position during labor, as well as to identify parameters correlating with the outcome of labor.
METHODS: A prospective study of 408 women in labor after 37 weeks' gestation with a singleton fetus in a vertex position using sonography at the onset of labor was performed. Fetal position, placental location, and maternal BMI (body mass index) were recorded. Outcome of labor was monitored for all relevant parameters.
RESULTS: Most (68%) of persistent occiput posterior positions develop through a malrotation during labor from an initially occipitoanterior position. Only 32% of persistent cases were occipitoposterior (dorsoposterior) at the onset of labor; operative interventions were required in 87.5% of these. Of the 61 (15%) occipitoposterior positions at the onset of labor, 53 (87%) rotated into an occiput anterior position. Persistent occiput posterior position was more common in the initially occipitoposterior group (P < 0.01, Fisher exact test), and posterior placental locations were fewer (z test, P = 0.05). Also, operative deliveries were more common in the group remaining occipitoposterior throughout labor (P < .01, Fisher exact test). A higher maternal BMI correlated with neonatal weight (P < .01, Pearson correlation), an increase in operative deliveries (P = .032, Pearson correlation), lower Apgar scores at 1 minute (P = .02, Spearman correlation), and increase in posterior placental locations (P = .037, two-tailed t test).
CONCLUSION: In most cases, persistent occiput posterior position develops through a malrotation and only in a little more than one-third of cases through absence of rotation from an initially occipitoposterior position. Higher maternal BMI correlates with higher fetal weight, increased operative deliveries, lower Apgar scores at 1 minute, and posterior placental locations. Intrapartum sonography proved to be useful in investigating the development of the persistent occipitoposterior position.
PMID: 9572223 [PubMed - indexed for MEDLINE]
 Gardberg (1994)
5: Acta Obstet Gynecol Scand. 1994 Feb;73(2):151-2.
Anterior placental location predisposes for occiput posterior presentation near term.
Gardberg M, Tuppurainen M.
Department of Obstetrics and Gynecology, Vaasa Central Hospital, Finland.
325 sonographies were performed in singleton pregnancies past 36 weeks with the fetus in a vertex position in order to examine a possible association between placental localization and occiput posterior presentation (OP). OP was found in 11.6% of all cases. The distribution of the placental locations in the OP group differed significantly from the occiput anterior (OA) group. Also, an anterior placental location was seen significantly more often in the OP group.
PMID: 8116354 [PubMed - indexed for MEDLINE]
 Stremler et al (2005)
Birth. 2005 Dec;32(4):243-51.
Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor.
Stremler R, Hodnett E, Petryshen P, Stevens B, Weston J, Willan AR.
The Hospital for Sick Children, Toronto, Ontario, Canada.
BACKGROUND: Hands-and-knees positioning during labor has been recommended on the theory that gravity and buoyancy may promote fetal head rotation to the anterior position and reduce persistent back pain. A Cochrane review found insufficient evidence to support the effectiveness of this intervention during labor. The purpose of this study was to evaluate the effect of maternal hands-and-knees positioning on fetal head rotation from occipitoposterior to occipitoanterior position, persistent back pain, and other perinatal outcomes.
METHODS: Thirteen labor units in university-affiliated hospitals participated in this multicenter randomized, controlled trial. Study participants were 147 women laboring with a fetus at >or=37 weeks' gestation and confirmed by ultrasound to be in occipitoposterior position. Seventy women were randomized to the intervention group (hands-and-knees positioning for at least 30 minutes over a 1-hour period during labor) and 77 to the control group (no hands-and-knees positioning). The primary outcome was occipitoanterior position determined by ultrasound following the 1-hour study period and the secondary outcome was persistent back pain. Other outcomes included operative delivery, fetal head position at delivery, perineal trauma, Apgar scores, length of labor, and women's views with respect to positioning.
RESULTS: Women randomized to the intervention group had significant reductions in persistent back pain. Eleven women (16%) allocated to use hands-and-knees positioning had fetal heads in occipitoanterior position following the 1-hour study period compared with 5 (7%) in the control group (relative risk 2.4; 95% CI 0.88-6.62; number needed to treat 11). Trends toward benefit for the intervention group were seen for several other outcomes, including operative delivery, fetal head position at delivery, 1-minute Apgar scores, and time to delivery.
CONCLUSIONS: Maternal hands-and-knees positioning during labor with a fetus in occipitoposterior position reduces persistent back pain and is acceptable to laboring women. Given this evidence, hands-and-knees positioning should be offered to women laboring with a fetus in occipitoposterior position in the first stage of labor to reduce persistent back pain. Although this study demonstrates trends toward improved birth outcomes, further trials are needed to determine if hands-and-knees positioning promotes fetal head rotation to occipitoanterior and reduces operative delivery.
Randomized Controlled Trial
PMID: 16336365 [PubMed - indexed for MEDLINE]
 Cochrane database review of hands-and-knees in late pregnancy
: Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001063. Related Articles, Links
Cochrane Database Syst Rev. 2000;(2):CD001063.
Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior).
Hofmeyr GJ, Kulier R.
University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, Frere and Cecilia Makiwane Hospitals, Private Bag X 9047, East London, Eastern Cape, South Africa, 5200. email@example.com
BACKGROUND: Lateral and posterior position of the baby's head (the back of the baby's head facing to the side or the mother's back) may be associated with more painful, prolonged or obstructed labour and difficult delivery. It is possible that certain positions adopted by the mother may influence the baby's position. OBJECTIVES: The objective of this review is to assess the effects of adopting a hands and knees maternal posture in late pregnancy or during labour when the presenting part of the fetus is in a lateral or posterior position, compared with no intervention. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (November 2004) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2004). SELECTION CRITERIA: Randomised trials of hands and knees maternal posture compared to other postures or controls.
DATA COLLECTION AND ANALYSIS: Both review authors assessed trial eligibility and quality.
MAIN RESULTS: Two trials of hands and knees posture during pregnancy were included. In one trial involving 100 women, four different postures (four groups of 20 women) were combined for the comparison with the control group of 20 women. Lateral or posterior position of the presenting part of the fetus was less likely to persist following 10 minutes in the hands and knees position compared to a sitting position (one trial, 100 women, relative risk (RR) 0.25, 95% confidence interval (CI) 0.17 to 0.37). In a second trial including 2547 women, advice to assume the hands and knees posture for 10 minutes twice daily in the last weeks of pregnancy had no effect on the baby's position at delivery or any of the other pregnancy outcomes measured. No trials of hands and knees posture during labour were included.
AUTHORS' CONCLUSIONS: Use of hands and knees position for 10 minutes twice daily to correct occipitoposterior position of the fetus in late pregnancy cannot be recommended as an intervention. This is not to suggest that women should not adopt this position if they find it comfortable. The use of this position during labour has not been addressed in this review. In view of the promising short-term effects of the technique and its simplicity, further trials are justified to determine whether encouraging the use of hands and knees posture during rather than before labour, has any effect on substantive outcomes.
PMID: 15846611 [PubMed - indexed for MEDLINE]
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