The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Suboptimal Fetal Positions

See also:

• Pubic Lift

Subsections on this page:

• Resources
• Importance of Position
• Alternative View on Importance of Fetal Position
• Engagement of Baby's Head
• Posterior References
• Possible Causes of Posterior Position
• Chiropractics and Ligament Issues and Acupressure for Posterior
• Posterior Position
• Digital Rotation
• Sterile Water Papules
• Belly Lifting
• Homeopathics for Posterior
• Knee-Chest
• "Chunging" to Turn a Posterior Baby
• Trendelenburg position for rotating an OP baby
• Walcher's Position/Arched Back/Lordosis
• AROM for Posterior
• Comfort for Posterior
• Posterior and Epidurals
• Asynclitic Head
• Nuchal Arms or Cord
• Face Presentation

Resources

Posterior Labor- A Pain In The Back! - by Valerie El Halta - this is the classic article that brought the issue of posterior babies to the light in midwifery circles.

The Occiput Posterior Fetus: How Little We Know by Penny Simkin, PT - This is FABULOUS!

It is just the slides but she has McRoberts as one way to increase effectiveness of 2nd stage. Her perspective is really interesting. I have also found McRoberts to work with Op or even more extreme, Trendelenburg, that is with the hips above the head, on the back, legs drawn up in McRoberts, first rest for 15 minutes then Push like hell.

Spinning Babies - lots of information about baby's rotations during pregnancy, labor and birth.

Belly Mapping by Gail Tully, BS, CPM, CD(DONA) - this is a FABULOUS article and explains the issues very well.

How to Prevent a Posterior Labor from motherspirit.net

Malpositions and malpresentations from WHO's Guide to Managing Complications in Pregnancy and Childbirth

How to do a Diaphragmatic Release to allow a posterior baby to rotate.

I have yet to see diaphragmatic release work. I have seen it tried.

ditto.  maybe we're doing it wrong???

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.
Birth. 2005 Dec;32(4):243-51.

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.

Commentary from the Lamaze Institute for Normal Birth

Importance of Position

Visualization/Affirmation Poster

Position Affects Presenting Diameters

1. Measured from where the back of the head and neck meet to the centre of the front fontanelle (soft spot) - when the head is fully flexed (tucked into chest) and baby is in normal position - diameter = 9.5cm
2. Where the back of the head joins the neck to the centre of the forehead - when the head is almost completely flexed = 10cm
3. From the bridge of the nose to the lower back of the head - when the baby is lying posterior (back to mothers back) and not properly flexed = 11.5cm
4. From the point of the chin to the highest point on the head - when the baby's head is half flexed and the baby's brow is presenting = 13.5cm
5. From where the chin meets the neck to the highest point on the head - when the face is presenting and the head is not fully extended = 11cm
6. From where the chin meets the neck to the centre of the front fontanelle - when the head is fully extended and the face is presenting = 9.5cm

Alternative View on Importance of Fetal Position

I wouldn't be putting any energy at all into turning a primip's baby anterior.  This must be very psychologically undermining for her.  She's starting out her birth thinking she's broken or something is wrong.

I would:
1. tell her to thank her lucky stars that her baby knew how to get head down
2. tell her that we (mws, drs, nurses) think we know what way babies are presenting but half the time we are wrong
3. tell her that when her birth sensations are strong, her uterus will push the baby down and through the pelvis in the easiest way possible.
4. tell her that she was made to have babies

What I would be working on is convincing her about is to have her baby at home.

Engagement of Baby's Head

If it appears that baby is not engaged, try checking while mom is standing. Or have her sit up while checking.

In an average baby, if the lowest part of the head is at the ischial spines -- 0 station  -- then the widest part of the head must be through the pelvic inlet (perhaps some call this the "brim"). This is because the distance from the inlet to the brim -- in an average pelvis - is approx 5 cm, and the distance from the biparietal diameter of the baby's  head  to the vertex is only 3 to 4 cms.  So if you can feel it that low then it "should" be through the inlet.

Zero station is one way to measure engagement  --which is when the widest part of the head has fit  into the pelvic inlet.   As the doc you referenced said, we can't reach the BPD internally to compare it with the pelvic inlet, so we use the vertex at the spines as our marker.

However ---- we can usually assess this abdominally and if you can feel a lot of head above the pubes, then even though the vertex is at the 0 station, this particular baby is not engaged.

I think one problem is that most assume a head a 0 station means engagement -- when it only means "the presenting part is at the spines and the head is  PROBABLY  engaged".  We can't rely on station only for this information and we need to check abdominally too. In well flexed vertex babies it is very reliable; but different positions and situations throw the measurement off.

There are a couple reasons zero station doesn't always work  to show engagement.

 The lowest part of the head presenting in the pelvis  is not always the occiput (the part we call "the top of the head".  In deflexed posterior, the lowest portion of the head may be at the spines (0 station), but the biparietal diameter is well above the inlet since the distance from the sub-occipital-bregmatic point to the BPD is much further than the 4 cms of a vertex presentation.  In a face, the distance from BPD to the chin may be  twice the distance as in a vertex and the presenting part may be almost at the perineum before BPD of the head is actually engaged in the inlet!

We can  visualize the situation  like this. Place your index finger on the tip of your occiput . . . I mean the top of your head; the "pointy part" where your hair crown usually is; the place where the sutures all come together.) Are we at the same spot?

OK, now place your thumb on the biparietal diameter -- this is the widest part of your head;  that bulge just behind and above your ears.

(Now, if you suddenly became a well flexed vertex baby in the womb, your index finger would be on your mom's cervix and your thumb would be at her pelvic inlet. Got things so far?)

Notice the distance between your finger (on the vertex) and your thumb (on the BPD). YOu can measure or mark the distance  on paper if you wish.

 Now move your index finger  about half way towards the front of your head. This is the sub-occipital-bregmatic point (latin for "between the vertex and the brow). and is the lowest part of the head  presenting in a deflexed posterior baby. Notice the distance between your thumb and index finger. It may be as much as a third longer!

So.... This is why an OP baby may measure at a 0 or even  plus station and still not be engaged in the pelvis. The lowest part of the head may be deep in the pelvis, but the widest part (the BPD) has not even entered the inlet!

We also deal with moms of different shapes and sizes and a woman with a shallow pelvis will have an engaged baby when the baby is at a plus station. A woman with a deep pelvis may actually be engaged, but the  head will still not be at the spines.   And maternal position can  throw this off as well.

Try this. "When the presenting part has reached the ischial spines we  call this zero station, and in a vertex presentation it is one sign  that the BPD of the  baby's head may be fully engaged in the inlet of  the maternal pelvis".  Perhaps that covers things enough to satisfy examiners.

The Biparietal diameter may not be in the pelvis at all! Especially  with a deflexed posterior.

We americans learned this station shorthand and most were told it is  an accurate measure of engagement. I would qualify that and say  station shorthand is a good way to measure descent through the pelvis  and it may be useful for determining engagement of the fetal head.

Helping Baby Descend

Abdominal Binders

For babies that just don't have any kind of drive angle into the pelvis during active labor - lots of contractions, mushy cervix, no descent. I have the woman lie on her back on the bed and pull her belly up while we apply the binder (the latest was some sort of major Velcro thing, awkward, but worked). Then she can be up and around again with the baby hitched up - sort of serves as a constant tummy lift.

Another method, which can be used in pregnancy as well as during labor (and is especially helpful for those with pendulous abdomens!) is to take a large piece of cloth (a bedsheet works well) and wrap mom's lower belly tightly. She will have to lift her belly as you tie, and it will likely take 2 people to pull the sheet tight and tie it. Her hips will be partly covered, her fundus will not, and the knot will be right over her low back/sacrum---lovely counterpressure which usually feels wonderful to her. For those "relaxed" grand multips (and others, but most often grand multips) it helps prevent malposition and backache during pregnancy.

Posterior References

I think you will find that there is little document evidence in the form of trials etc relating to OFP - the only one I could find was:

Hands/knees posture in late pregnancy or labour for fetal malposition (lateral or posterior).
Hofmeyr GJ, Kulier R.
Cochrane Database Syst Rev. 2000;(2):CD001063. Review.

As you prob know Jean Sutton is the queen of OFP - and yes it is anecdotal in that she has reflected on her own practice. However she has very dramatic figures to quote having been appointed to Principal Midwife in her unit in NZ and introduced her OFP ideas she reduced her transfer (to consultant unit) from 30% to 5% and the forceps rate from 3 or monthly to 2 or 3 annually. Now anything that even touches those figures is worth considering.

Here are some refs I've picked up along the way:

Nolan M (1997).  Jean Sutton and optimal fetal positioning.  Modern Midwife, vol 7 no 1  pp 15- 17

Sutton J & Scott P (1994).  Optimal fetal positioning: a midwifery approach to increasing the number of normal births.  MIDIRS vol 4, no 3  pp 283 - 286

Sutton J (1996).  A midwife's observations of how the birth process is influenced by the relationship of the maternal pelvis and the foetal head. Journal of the Assoc. of Chartered Physiotherapists in Women's Health, No 79, pp 31 -33

Walmsley K (2000).  Managing the OP labour.  MIDIRS vol 10, No 1 pp 61 - 62

Denmark R (2000).  Posterior Babies - Mothers can trust their instincts.
AIMS Journal, Summer  Vol 12 No 2

Franco S (2001).  Optimal Foetal Positioning:  Rocking your way to a straightforward birth.

www.pregnancytoday.com/reference/articles/foetalpositioning.htm

www.homebirth.org.uk/ofp.htm

Possible Causes of Posterior Position

Obstetrical Pelvis  - Some types of pelvis are associated with posterior babies or asynclitic heads.

From a handout included in the book, purchased at Midwifery Today conference, March, 1999:

Jean Sutton, Birth Concepts, c/o 95 Beech Road, Feltham, Middlesex TW14 8 AJ (presumably in the UK?)

Jean endeavours to visit the U.K. at least once a year to conduct study days on Optimal Foetal Positioning.  If you or anyone you know are interested in organising a day then please contact either Rob or Julie Sutton on telephone 0181 890 8298 for further information.

The costs involved are:

    - weekday events 15 pounds per attendee with a minimum of 30 attendees
    - weekend events 15 pounds per attendee with a minimum of 50 attendees.

There's a wonderful midwife giving talks and workshops over here (UK) with some good thoughts on this one. Her name is Jean Sutton and she's a midwife (40 years' experience) from NZ who started by pondering ( a long time back) why she was seeing increasing numbers of posterior presentations.........? and long, difficult first stages.

What she's doing is trying to get us all to think about how to encourage the babies to get into a good position and to be well-flexed before labour starts.

She thinks that sitting all the time in chairs with hips lower than the pelvis has a lot to answer for.......It's kinda hard to write about, but easier to actually DO or to show mums.

Think about the anatomy of the pelvis and the position of the baby........and getting the head well down on the cervix. The head is the heaviest part so gravity tends to make the baby turn so that the head gets into the inlet. If pregnant women are leaning backwards all of the time, or for a great deal of their time, then the next heaviest part of the baby is the backbone........which will tend to flip around to give a posterior presentation. Does this make sense??? A pelvis and a doll help.......

So.... in labour part of the work that needs to be done is to encourage the baby to get into an anterior position with the head well down on the cervix and well flexed? Long first stage......

What she started to do was to encourage all of the mums she was seeing to maintain upright or forward leaning positions as much as possible....to get their hips higher than their knees and their bellies lower than the spine for at least a short time every day from about 36 weeks; kneeling with your bottom on a low stool or a couple of cushions or a pile of books; sitting on the edges of a chair and so on. Result? she hardly sees any posterior babies any more.

I wish I could SHOW you what she's saying because it makes a lot of sense to me.

In case, you're asking.... where is the evidence?? Try reading: Sutton J "A midwife's observations of how the birth process is influenced by the relationship of the maternal pelvis and the foetal head" J. Association of Chartered Physiotherapists in Women's Health, 79, Aug. 1996 pp 31-33 She's also just had a book published over here, but I can't for the life of me remember what it's called.

Or, to make our lives easier, if you can get hold of MIDIRS from June 1997, the whole article is in there. In the same edition, there's also:

one by Caroline Flint (Sensitive Midwifery) about trying to get a mum who was having a really long second stage to start climbing up and down the stairs ....... Eventually (long story!) the mum obliged and baby appeared.

and one by Ilana Machover (an Alexander teacher and CBE) about good positioning before and during labour

If Jean Sutton starts doing workshops in your area then I'd encourage you to try to get along and hear what she has to say.

She's also just had a book published over here.  It's called Understanding and Teaching Optimal Foetal Positioning by Jean Sutton and Pauline Scott. It is published by Birth Concepts. ISBN 0-473-04135-9. I paid $12 for it.

I got a copy at a conference a few weeks ago from Nancy Wainer Cohen. It's more of a booklet than a book, but it is a very good book for care providers.

According to Midwifery Today,  Understanding and Teaching Optimal Foetal Positioning by Jean Sutton can be ordered directly from Jean sutton by enclosing check for $10 in a large envelope to:

Birth Concepts
55 Hollister Lane
RD3
Taraunga
New Zealand

or you can order it online from Mother Care Catalogue

The book Optimal  fetal positioning is available in the UK from the National Childbirth Trust.  Tel 0141 636 0600, Fax 0141 636 0606, email info@nctms.co.uk, web www.nctms.co.uk.

Anne Frye says that riding in cars with low seats -- knees above hips - - encourages breech babies ). I can't for the life of me figure how that could be true, or any reason "why" it would cause breeches or posterior babies. Maybe someone can enlighten me cause I really struggle with that.

This is what Jean Sutton and Pauline Scott say about OA and OP positions in their book Optimal Foetal Positioning:

The OL/A positions are the most favorable for a fetus to settle in prior to labor commencing. Of these positions, the LOL/A is the most common. The reason for this is that the maternal uterus lies with its fundus tilted forwards and to the right side of a mother's abdomen. The fetal back leans toward the concavity of the mother's abdominal wall. Because of the weight from the fetal back, the fetal head is able to flex and align itself correctly so that the vertex enters the pelvic brim in the lateral position (LOL), rotating to the anterior (LOA) once in the brim. Occasionally, a fetus will lie in the ROL/A position. If the fetus is more lateral than anterior, the chances of it rotating to the occipito-posterior are very high.

If a fetus is diagnosed as lying in the posterior part of the maternal pelvis (OP) prior to labor or just as labor commences, the labor process can verge on the abnormal. This is particularly so if the fetus is lying on the right side of the woman's uterus (ROL/P). In this position the fetal back lies toward the lumbar curve of the maternal spine. This, combined with the weight of the fetal back, means that the fetus has to strengthen its neck and adapt a more erect attitude (the 'military' position'). Because the head is de-flexed, the vertex presents at the pelvic brim in a larger diameter than the 'anterior' fetus. {there is an illustration in the book} If it cannot enter the pelvic brim, or if it fails to rotate into the OA position once it does manage to enter, the chances of an obstetrically managed labor and birth are very high.

If a woman (primigravida) regularly uses upright and forward leaning postures, particularly during the last 6 weeks of her pregnancy (the last 2-3 for a multigravida), her baby is given an excellent chance of positioning itself into the OA position. This is because when the pelvis tilts forwards, it allows more space for the broad biparietal diameter of the fetal head to enter the pelvic brim. Most of these postures, especially those that are forward leaning, are positions where a woman's knees are lower than her hips...

Relaxing in semi-reclining positions: If a woman sits with her knees higher than the hips, which happens when she slouches back in a sofa or armchair to rest, the angle of her pelvic brim to her spine is reduce from 120^ to approximately 90^. If the woman regularly uses these reclining postures during the crucial period when her baby is deciding to enter the pelvic brim ready for labor, it is almost inevitable that, if it is able to enter the pelvis at all, it will do so in the posterior part of the pelvis and consequently present as an OP.

This book is really quite good, and they give many "midwives' tips" on how to rectify "mal-positions" during labor.

Cord as Possible Cause for Posterior Baby

If you've been doing cat-table exercises and the baby hasn't budged, you may want to try to bring the baby around the other way. Figure out where the back of the baby's head is, and lie flat on your back to try to bring the baby's back more towards your spine. Then try to bring the baby's spine towards the other side, and then roll over on that side to help the baby roll a little further, and then try to get into a hands-knees or cat-table posture to bring the baby all the way to the front the long way around. (I hope this description makes sense.)

Don't do anything that feels wrong for you or feels like it's causing pain.

Some women just always sleep on the same side and always roll over on the same side when they're getting up. Sometimes just trying doing things the other way can give the baby a chance to unwrap, if it's cord that's holding them in place.

Technically, the baby's position doesn't matter until labor starts, but then it becomes important, and learning about it ahead of time is really wise. Trying to get the baby into a more anterior position now is probably a good idea, but the baby may shift position once the head engages or labor starts. It will help tremendously if you're aware of it along the way.

Hmmm..... these are interesting assertions. However, I am bothered by the hips lower than the knees thing..... What about squatting?

I knew I should have typed out that paragraph! Here's what they say about squatting in pregnancy, and how it may contribute to unfavorable fetal positioning:

As an exercise, deep squatting is not advisable in late pregnancy unless the woman's baby has 'engaged' in the pelvis in the OA position. An OP positioned baby can 'engage' before it has had a chance to rotate to OA. Deep squatting can encourage this. Once the head is in the pelvis, rotation is a lot more difficult. Because squatting has become very popular, many women exercise in a manner which reduces the angle between the spine and the pubic bone (i.e. in a deep squat.) In this position the back is rounded and the abdomen comes forward. An angle of 45^ to 65^ is produced with this type of squat, which makes it difficult for the baby's head to enter the pelvic brim in any angle.

In the last six weeks of pregnancy a woman can do modified squats safely, using a stool (approx. 25 cm high) with a cushion on it. The stool should be placed against a wall so that the woman does not lean forward but rather keeps her spine vertical, supported along its length by the wall. The knees should be spread comfortably wide apart following the angle of her feet.

Cord Entanglement as Possible Cause of Posterior Presentation - Why babies sometimes rotate ROA to OP to LOA to birth

Chiropractics and Ligament Issues and Acupressure for Posterior

I have found that these very persistent OP babies frequently are associated with a lot of discomfort along the round ligament.  You see mom wince when you palpate for Leopold’s third maneuver­you’ll find the round ligament on one or both sides very tight and mom expresses a great deal of discomfort when you massage this area.  But as explained to me by a chiropractic acquaintance­if you find the most tender spot along the ligaments and apply gentle pressure as is done in dealing with trigger points, the discomfort will ease after three or four minutes.  Then the fetus can sometimes be encouraged to move by mom getting into a knee chest position so that it backs out of the pelvis slightly and then it may reposition into  a LOP or ROP position from which it can be encouraged into a transverse position and rotate around OA.

I think they get caught by the ligaments and aren’t able to rotate their heads.  If mom has a pendulous or lax abdomen, the whole process may be helped along by applying an abdominal binder (sheet, firm fabric or rebozo) to the lower abdomen to lift baby up and more into a position over the pelvic inlet, after the massage and knee chest maneuvering.

Chiropractic instructions for this technique are given in Anne Frye's "Holistic Midwifery", page 809.

I showed that to my chiropractor, and he said the language was very odd. He said he could probably figure it out, but it wasn't standard chiropractic terminology.

Then mom lies supine and the 2nd contact point will be on the OPPOSITE side of the first. Feel along the iliac crest and find a tight spot. Place the back of your thumb (nail side down) on that spot & move your arm upward (inferior to superior) along the crest with very light pressure (really no "pressure", just the weight of your thumb).

So, let me see if I understand: When mom rolls over, the contact point will be on the left, if the first contact point was on the right and vice versa. Right?

Also, the point along the iliac crest: Will it be along the top, near the front, or near the back. I understand the reference "inferior to superior" but where do I quit feeling for the "tight spot?"

I would like to give this DC's name to my chiropractor to see if he'd be willing to see women for this.

Thanks for the info! This sounds easy, non-interventive, "putting moms back in control" and great!

Posterior Position

Posterior Birth Story

Four Posterior Births - Plans Next One As Waterbirth

Often, an anterior placenta takes up some room in the front of the mom's belly that would otherwise be occupied by the baby's back.  This can sometimes cause the baby to be somewhat posterior, although this tends to correct itself as the baby moves lower into the pelvis and the back moves down, beyond the placental location.

Sometimes, in an effort to correct this apparent posterior position, moms will spend a lot of time on hands and knees.  This can be a problem with an anterior placenta in that then the baby's weight is right on top of the placenta, which can cause some cord compression, especially with big babies or low fluid levels.  This can result in minor fetal distress or meconium.

So moms with anterior placentas who are doing hands and knees might want to limit the time to 2 or 3 minutes at a stretch.

I have found that the same rule applies to most midwifery situations -- what works for one may or may not work for others. You may have to try all kinds of things to get a posterior baby to turn.

My favorite trick is something I discovered accidentally while in labor with my fourth baby . ( To this day he continues to stubbornly do things his own way, refusing to budge when given direction that is in conflict with his own ideas.)

I was stuck at 8 cm for 3 hours with baby's head in ROP. I was seeking solace in my favorite spot , the bath tub, when , overcome with frustration, I turned toward the wall and hit it with my fist. As I turned, I felt him come down and I pushed him out 15 minutes later.

So, I like to have women get into the tub, relax a bit, and then turn to the side, or all the way around, to turn a posterior. I find that it usually works, unless you wait too long.

I will also use the methods described by Valerie El Halta in the Midwifery today article. I do find, as someone else mentioned, that many babies will fight you, either refusing to turn much, or turning right back to posterior, just when you think you're making progress. I've also seen thick mec with this procedure.

Hands and knees and belly supporting/pulling work as well as anything.

We often turn babies in our practice. We start by giving mom warm tea with 10gtts of skullcap and 5gtts of valerian. When she is nice and relaxed we lay her on a slant board, (boat hatch cover) for thirty minutes. We find that baby slides all the way out of the pelvis. He usually realigns his head himself. This way we don't make the decision about which way to turn him.

How steeply sloped is the hatch cover?

We set the hatch cover on the arm of the sofa. Mom lays upside down with her feet over the top of the hatch cover. Actually its more her knees over the top of the hatch cover. I can't say how steep that is. Maybe 80 or 90 degrees??? It's pretty steep. Someone sits on the floor next to mom, lights candles, quiet music, etc., ya know, all the midwifery kind of stuff.

Lie flat on the floor with a pillow or roll in the small of your back to push your belly out, baby hates it as it bends his back also and will turn, you can do 2nd stage this way too, to make them turn.

Does anybody really use Valerie El Halta's proactive measures for turning posterior babies?

I've tried this in Jan. and have seen it done several times, one doc in the hosp is really good at it. The one in jan was very interesting, nothing was working and we were starting to think about transporting. I had the woman lie down and had helpers really push her legs up, not very comfortable but better than transport. I just used two fingers and pushed the baby up some and then got my fingers on a suture line and really CRANKED hard in the direction that I felt the baby would turn the easiest. The baby would only move a little but then turning the mom to hands and knees swung the baby around and she was born 1/2 hr later. Just that little bit was enough to encourage rotation. At the hosp. I have seen this doc really turn a persistent op baby all the way to oa. His fingers are twice as long as mine though :-}

Even if this only works for you occasionally it is one more thing to try.

Posterior cervix prior to labor and anterior lip at end of first stage are common signs of an OP position.

Digital Rotation

Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section.
Reichman O, Gdansky E, Latinsky B, Labi S, Samueloff A.
Eur J Obstet Gynecol Reprod Biol. 2007 Mar 16

CONCLUSION: Digital rotation should be considered when managing the labor of a fetus in the occipito-posterior position. The maneuver successfully rotates the fetus reducing the need for cesarean section, instrumental delivery, and other complications associated with POP.

Sixty-one women with babies in OP position in the first half of second stage were randomized to manual or digital rotation of the fetal head versus no intervention.
The fetal heads were engaged or lower, and diagnosis of OP was confirmed by ultrasound if necessary. As you can see from the table below, there were way more spontaneous births in the group where rotation was performed.

They did digital rotation in 97% of the cases and manual rotation in the other three percent. Digital rotation does not involve putting the entire hand in the vagina. They describe it as follows:
“…the digital method, which was used in 97% of cases, entails exerting pressure with the tips of the fingers to rotate the posterior fontanelle upward and toward the symphysis pubis after placing the tips of the index and middle fingers onto the edge fo that part of the anterior parietal bone that overlaps the occipital bone in the area of the posterior fontanelle. For manual rotation, the whole hand in introduced into the birth canal. The head is then rotated after positioning the fingers under the lateral posterior parietal bone and the thumb on the anterior parietal bone.”
(Williams Obstetrics specifies that with the head in ROP, the left hand is used to rotate the occiuput anteriorly in a clock-wise direction; the right hand is used for the LOP position.)

The authors also state “in experienced hands, the success of digital rotation in rotation the fetus to the AO position is high.”

There were no significant differences between the groups regarding age, parity, gestational age and fetal weight.
 

No rotation (n=30) Rotation performed (n=31) p-Value

Spontaneous delivery(%) 26.4% 77.4% 0.0001
Vacuum extraction(%) 50% 22.6% 0.0001
Cesarean section (%) 23.3% 0 0.0001

Duration of 2nd stage (min) 156 (+ 33) 117.4 (+ 43.8) 0.0003

Delivered in OA position (%) 14.8% 93.3% 0.0001
Delivered in OP position (%) 85.2% 6.4% 0.0001

Sterile Water Papules

Use of acupuncture and sterile water injection for labor pain: a survey in Sweden.
Martensson L, Wallin G.
Birth. 2006 Dec;33(4):289-96.

CONCLUSIONS: Our study shows that acupuncture was used for both pain relief and relaxation, whereas sterile water injections were used almost exclusively for pain relief. The results also indicate a weakness in midwives' awareness and use of scientific knowledge and general recommendations about these methods.

Subcutaneous sterile water injection for labour pain: a randomised controlled trial.
Bahasadri S, Ahmadi-Abhari S, Dehghani-Nik M, Habibi GR.
Aust N Z J Obstet Gynaecol. 2006 Apr;46(2):102-6.

CONCLUSION: Administering one subcutaneous injection of sterile water in a painful point of the lumbosacral area is effective in reducing low-back pain during labour.

I find myself wondering whether sterile water papules don't also help to relieve back pain by reducing tension in muscles that are contracting the pelvis?

Sterile Water Injected Subcutaneously Provides Relief of Labor Pain [Medscape registration is free]

All about Sterile Water Papules (SWP) for the relief of low back pain in labor.

I am a midwife and an acupuncturist. I read with interest your queries about using injection therapy for back pain, as there is injection therapy in Traditional Chinese Medicine.  In Acupuncture: A Comprehensive Text from the Shanghai College of Traditional Medicine, translated by John O' Connor and Dan Bensky, published by Eastland Press in Seattle, the technique is clearly outlined.

Injections are carried out with a number of substances, among them sterile glucose, saline, distilled water, vitamins, procaine, as well as prepared injectable extracts of certain herbs. A 20-27 gauge needle is used. The amount injected depends on where the point injected is located. For the lower back, 2-15 ml would be used. Typically, less is used for weak patients. If the point is tender to light touch, injection should be made superficially, and less would be used. If the point is tender only with deep pressure requires deeper injection.

Cautions include: local soreness and distention, allergic reaction (depending on the substance injected), and care should be taken to not inject glucose into superficial tissue, only deep tissue. Sterile water, as was discussed in the earlier e-mail, would be the safest to use. Do not use this technique in pregnancy in the absence of labor.

Points are located either by theory (which acupuncture points are indicated for the pattern according to Chinese Medicine), by tenderness, by "positive response", or origin and insertion of related muscles or tendons. "Positive Response" points are those that have any irregularities that can be palpated on the skin surface: flat, round, strand-like, or nodular.  There are eight points on the sacrum itself that are indicated for lower back pain. These are known collectively as the "Baliao" points, and correspond to Bladder 31-34. They are located in the 1st through the 4th posterior sacral foramen, four on each side. They are located in the sacrospinalis and origin of gluteus maximus muscles. An acupuncturist would insert a needle directly into the foramen. This accomplished by palpating the foramen and inserting the needle on a slight angle towards the spine. The first two sacral foramen are the easiest to access, and in my experience, a great relief for menstrual backache.

For injection therapy, the needle should be as close to the foramen as possible.  The above information is according to Traditional Chinese Medicine. I provide this information not to give you the impression that you can now practice a technique in Chinese Medicine after reading the e-mail, but I thought it might be interesting information in light of what you already are trained to do.

At least a couple of our premier midwifery supply houses sell sterile water to inject for sterile water papules.  When I've ordered from both these places, the solution that arrived was clearly marked "NOT FOR INJECTION".

Sterile water intended for injection is available, and I assume this is what they use in the hospitals.

Does anyone have any comments about the suitability of using "non-injectable" sterile water for SWP?  What could be the negative side effects (medical, moral legal) of injecting a solution marked "NOT FOR INJECTION"?

Does it really matter?

I believe it says not for injection because it is sterile water, unbuffered, with nothing else in it.

It seems that there are at least 2 different grades of sterile water, some intended for irrigation and some intended for injection.

Perhaps it's just a matter of a higher level of quality control over the sterile water intended for injection.

Since sterile water intended for injection is available, why not make a point of getting and using that instead of the irrigation sterile water for SWP?

sterile h20 for injection contains a bacteriostatic additive.  sterile h20 for irrigation does not.  either can be safely used for sacral injections as long as you are careful to discard the left over of the large irrigation bottles when you are through.  do not save an opened one from patient to patient because opening it negates its sterility soon.  The bacteriostatic sterile water for injection can remain sterile in the vial with the rubber stopper for up to 30 days after popping the plastic top.

Belly Lifting

There is a technique called "belly lifting" which might have transformed an unstable lie, or a lie over-riding the symphysis, into a longitudinal one which was more favorable for pitocin induction or AROM.

Basically it is a vector analysis of the forces of labor, and has been used for relief of pain of back labor. I have also found it extremely useful for those multips who come in well dilated, head no where near the pelvis, and pendulous abdomen due to lax abdominal musculature.

Mom stands up, flexes knees, bends backwards just slightly, places hands under uterus and tries to align the longitudinal axis of the fetus with the long axis of the mom...ie belly lifting. This is probably the same mechanism of the old Scultetus binder or sandbag techniques for labor. It not only relieves pain of back labor, but assists in descent.

The technique is thus. Have the woman stand, or slight standing squat. (although it implies sitting is ok too.) As the contraction starts, she brings her hands around her belly and pulls up (on the butt) of baby until the back pain goes. If labour is long a helper can do this from behind. It sounds simple, and is along the same lines as much of what we use with hands/knees, duck walk, backward on a chair, etc. The theory is to change to vector (direction of force) of pressure of the presenting part. But one interesting thing was her classification of "types" of women who have back labour. She states that women with a "low rise" (never heard of it) have back labour.

I find myself wondering whether there is somehow stress that is causing the pirformis muscle to spasm, holding the baby in a posterior position.  Lifting the belly would relief some of the stress on the pirformis, I think.

Pain Relief Necessary for Turning Posterior

If you can relieve the back pain, the baby will usually turn. I have had great success with sterile water papules in the sacrum, and as last resort, intrathecal analgesia. Both will relieve the pain and allow her to relax enough to turn the baby, if combined with hands and knees or side lying to get gravity to assist.

Yes.. pain relief can only help! Back labor is another good indication to try a warm tub - -sometimes moms can get on hands an knees in the water, or even a floating squat....

Homeopathics for Posterior

Homeopathic Remedies for Back Labour and Posterior Presentation by Piper Martin, DS Hom. Med. from Midwifery Today's site.

Knee-Chest

Rebozo Technique - using a rebozo to help turn a posterior baby.

Great photos of rebozo use!

"Chunging" to Turn a Posterior Baby

I recently posted on this list about "chunging" a woman with a posterior positioned baby. I was successful! We only recently learned this procedure at an Association of Texas Midwives conference in Galveston.

To the new doctor's amazement...the pregnant woman was placed on the blanket and then thrown into the air by the four men, each at one corner of the blanket, then caught again.

I found the article. It is in The Birth Gazette, March '87 Vol 3 No. 3, page 22. There is a picture of Leo Sorger on the cover.

Ask The Midwife
The following letter comes from Debbie "Chung" Marin, from Coconut Grove, Florida:

I read an article some years ago written by an American obstetrician who had traveled the back country of China, far from civilization. He observed that when a woman was having a long and difficult labor, the midwives would "Chung" the mother. "Chung" means that two or three women would shake the laboring woman very vigorously all over. The obstetrician said it worked every time.

I was attending a woman's birth, and she was having a long and difficult labor. We tried everything: long walks, jeep rides over bumpy roads, blue cohosh tea. Suddenly remembered the article and told everyone there what to "Chung" is. The three of us shook the laboring woman all over as hard and as long as we could while she was standing, leaning over a dresser with her arms braced. I thought it would hurt, since she was having such strong contractions. To our surprise, she said it felt good! We laughed and continued to shake her until our arms were sore. The woman went to 10 centimeters and delivered a 6 lb. 3 oz. boy four hours later. I feel the "Chung" did the trick.

IMG: I have "Chunged" women in labor before, although I never used this word for it, or even knew that anyone else had ever done such a thing. The first birth during which remember using this method was the thirty-sixth birth attended. As with most of the others, this mother was having her first baby. She was a soft spoken person, who usually kept her feelings very much to herself. She was happy about being pregnant and didn't seem very much frightened about going into labor.

It wasn't that her labor took very long. What was a little unusual about it, in my experience, was that she stayed at 4-5 cm for a couple of hours, with her rushes coming stronger each time. She was being very brave, but the intensity was incredible. I deep massaged her legs, working to keep her thigh and calf muscles as relaxed as possible during and between rushes. My husband stopped by to see how the labor was progressing. Noticing how the mother was doing, he suggested that shake her legs instead of squeezing or holding her muscles. Keeping eye contact with her so I could tell easily whether I was helping or hurting, I took one of her thighs between my hands and shook it with a sort of rotary motion as her uterus contracted and she kept up her deep breathing. It was obvious right away that the shaking during a rush made it easier for her to relax. We were soon past the stuck place, and she pushed her baby out with no real trouble.

After that, I found that used this shaking method only now and then. Mostly it seemed useful to help a well muscled woman who was having trouble relaxing the muscles of the pelvic floor. The shaking forces her to give up to it, since the rhythm is insistent and impossible not to notice. She goes with it in the same way you go with the hammock when it's swinging.

Dr. Palmer Findley's "The Story of Childbirth, " published in 1933, contains an interesting reference to shaking the mot her during labor: "Engelmann mentions a peculiar custom practiced by some of our Western Indians in which the woman is tossed in a blanket, the four corners of which are held by four stout men, the idea being to correct any malposition of the baby and shake it out of the womb."

Does anyone else out there ever find "Chunging" useful? If so, let us know when you use it and how.

Trendelenburg position for rotating an OP baby

I am an RN in labor & delivery of a hospital. I also work at a birthing center with a CNM. I love the birthing center and can't wait to work there full time instead of the hospital. Anyway, I wanted to tell you about something I do to help rotate an OP baby. I don't know if you or your readers have tried it, but it works a lot. I put them on their side in Trendelenburg position. I tried it first years ago to get the FHR to come up (bradycardia) and two times in a row, the baby rotated and delivered pretty quick. So I started thinking, that it probably gets the baby's head "unstuck" from the birth canal and helps it rotate easier. It works!! I still turn them from side to side in the trend. position. Most of them can tolerate it better than knee-chest, and it seems to work better. We have a big wedge at the birthing center and put it under the mattress of the bed. Or you can use a bean bag.

Walcher's Position/Arched Back/Lordosis

Some moms with a posterior baby seem to instinctively arch their backs once they begin pushing.  This probably pulls the sacrum away from the occiput and opens up the pelvis a bit more.  Now I think I'll try it during first stage as well.

I was taught the following trick for helping a mom arch her back:    Take a towel or blanket and roll it up.  Then have the mom lie flat on her back with the small of her back directly over the rolled-up towel.  Her back will be arched pretty steeply.  She needs to stah there through at least three contractions, maybe more.  Some women find this very uncomfortable, but some women find it feels better or that the pressure on the sacrum feels great.

There's an old-fashioned position called "Walcher's Position" that was supposed to widen the pelvic inlet and allow borderline CPD babies to engage.  The idea was to get the mom lying on her back with her hips brought forward to the edge and her legs supported but almost dangling.  Apparently this creates a significant arch in the back and changes various pelvic diameters, sometimes for the better.

I used the towel trick last night and it worked beautifully!  What a goddess-send!

For a posterior baby, place a trochanter roll on the bed beneath the place on the spine that corresponds to the iliac crest. The angle of the pelvis increases, therefore increasing hyperextension of the fetal head. This is uncomfortable for the fetus, so he assumes a more comfortable anterior position. Alternate with side lying position at 15 minute intervals (removing the roll) until rotation is complete. This method can be used at any stage of labor.

In transition the method of pushing is contrary to the classical methods. Remove pillows and allow the mother to rear her head back. Legs can either be held up or slightly bent. When rotation occurs classical methods of pushing can be used. -Clara Yochem Zuxley, RN in Midwifery Today's Tricks of the Trade Volume 1

AROM for Posterior

I also find that if you break the water, or if membranes have already ruptured, that you get better traction -- the head is held tighter and doesn't have as much play, and isn't as likely to turn back.  Some midwives believe that not breaking the water allows the head to rotate and become anterior.  They fear breaking the water will allow the baby to be wedged posteriorly, but I think it is the opposite. It gives the head more to pivot on, and it also usually causes harder contractions which also help with the rotation.

I definitely agree with this; I generally wait just long enough to achieve some measure of ‘progressive’ dilation (to confirm adequate contraction pattern) and then AROM to flex/apply the head. Unless you are already augmenting with Pitocin, waiting around with a spontaneous labor and ‘slow’ progress just tires the uterus and the baby.

Comfort for Posterior

I found a very comfortable position when having back labor is standing and rocking from side to side and also stand and doing little squats. It really helps to ease the pain.

Posterior and Epidurals

Changes in fetal position during labor and their association with epidural analgesia.
Lieberman E, Davidson K, Lee-Parritz A, Shearer E.
Obstet Gynecol. 2005 May;105(5):974-82.

CONCLUSION: Fetal position changes are common during labor, with the final fetal position established close to delivery. [Ed. - Yes, the normal mechanism of labor involves twists and turns as the head descends into the pelvis; this is why the baby's head is called the vertex, or turning point.]  Our demonstration of a strong association of epidural with fetal occiput posterior position at delivery represents a mechanism that may contribute to the lower rate of spontaneous vaginal delivery consistently observed with epidural.

In addition to the usual side-to-side, all fours, kneeling with hands above head, standing, etc. a friend  showed me a new one that works well with too heavily-epiduralized patients.  Sit them absolutely straight up with their legs Indian-style, and tie a sheet or towel onto the birthing bar.  Have them rock back and forth from one hip to the other, holding onto the sheet for stabilization (since the bar is usually too far forward to grab onto in this position).  I suspect the alternating weight on one acetablum at a time moves the spines out of direct opposition and  gives the head a little more room. Also seems to work well for asynclitism but not as well in either malposition as all fours.  I can't wait to see what you come up with - this is an area in which I think US hospital-based providers are woefully undereducated.  I've already learned so much about this subject from you smart women on the list - thanks!

Asynclitic Head

Asynclitic Heads by Nancy Wainer Cohen

In pre-labour or latent phase of labour - open knee to chest position to encourage baby to drop slightly out of pelvis and reposition.

If woman has a pendulous abdomen or poor abdo muscle tone, semi sitting position, slightly inclined backwards to move the fetus' centre of gravity towards her back.

Also to try abdominal lifting  with a pelvic tilt during contractions.

During active labour they suggest trying knee-chest position, hands and knees, pelvic rock, lunge, abdo stroking, abdo lifting, walking and movement. Also suggest sitting with one leg raised, standing with one leg elevated, asymmetric kneeling, standing lunge or kneeling lunge.  I have also heard that you can use going up and down stairs to "shake" fetal head into pelvis!

I always have had great success with the old Pancake Flip for asynclitic presentations.  Once you detect the problem, have the mom do 2 contractions each in left lateral, right lateral, H&K's and then knee-chest position. Then re-check.  Usually takes a couple rounds of 8 contractions to correct the position, but it works.  Also I have used hot compresses to the lower abdominal muscles to relax them and aid in the repositioning, as the lower uterine segment gets tight.  You need to back the head off the cervix a bit to allow the repositioning to correct the asynclitism, and the varied positions seems to do the trick.  With a big baby, it may take a few more rounds of 8's, but be persistent.  I have also applied internal pressure to physically back the head off the cervix, but had less success with that than the Pancake Flip.  Same trick works wonders for anterior lips, which basically are caused by another form of malpresentation on the cervix.

But sometimes you get someone whose cont'ns got strong, but then plateaus. At this point, I have no idea how to distinguish this from a "normal" plateau. Except to say that many times, there is not just a plateau but also a slowing down. This seems more common in an asynclitic presentation. The uterus can no longer contract well, gets inco-ordinate. During the VE, if you diagnosis this, we have had success with pushing the head up , or applying gentle but steady pressure to try to turn the head. It doesn't always do it, but usually does. These ladies are more likely to hang up more than once, and occasionally do not progress and need hospital augmentation or even c/s. The asynclitic head may be a sign of CPD. I often also have seen these tikes born with a nuchal arm or something that helped make things miserable for their mums. NOW, if anyone has any ideas for getting these kids to put their arms down, I'd be grateful.

For a baby with an asynclitic head I have the mom walk up stairs, two at a time as long as she is able (which is usually only once or twice each try.) This works well for rocking the head through the tight spot.

I spook with a woman recently who said for an asynclitic head put the mom with her head and knees on the bed and her butt in the air and correct the head bimanually. Any one tried something like this?

Beth, yes I have done this. Four times, I believe. We just don't see it that often. I think I did it one for asynclitic head, and one for unflexed, and twice for a persistent OP that wouldn't turn. It worked well three times and one of the persistent OP went on to c/s when it just wouldn't turn. I think there could be risks associated with this procedure, I could imagine rupture of uterus as one, if one were too rough about it. I got the idea from an old book on midwives handling complications, I think by Valerie Hobbs, (now Appleton) where she suggested turning an OP manually, like dialing a telephone. Tried it but head would not turn, so pushed it up a bit and it did. The three times it worked it was very quick, head went up a bit, came down right, and away we went. At no time did I suspect true CPD in any of the cases, just a poor fit due to fetal head position.

My bag of tricks for asynclitism includes measures to back the baby off the cervix slightly and allow the head to realign properly.  If you push or encourage the head to descend at the improper angle, you can cause the larger diameter of the head to engage.    So, if I am able to feel the asynclitism, or an anterior lip (usually associated with the asynclitism), I encourage the mom to do pancake flips, i.e. two contractions on left side, two on right side, and two on H&K's. After one full pattern, I recheck for head position.  If it persists, try one more set and recheck.  After two sets, try knee chest rather than H&K.  I have had a lot of success resolving the asynclitism with this pattern.  Also doing the baby boogie, swinging the hips wide with the contraction if possible, and the deep squat as the contraction begins, will settle the head into the correct diameter, once it has shifted.

Nuchal Arms or Cord

Don't forget to think about cord. I've had several babies come wrapped in weird bundles because of a cord wrapped around arms or shoulders, causing an arm to be stuck in a certain position. One thing to try is to have the mom recline and use gentle fundal pressure, easing the presenting part into or toward the pelvis. Listen very closely to FHTs to discern if there are any dips as you do the maneuver. If a cord is involved, pulled or pinched it may show up in the FHTs. Never force a baby into the pelvis, use a gentle touch. Good suggestion about checking for breech. One of our midwives recently delivered a baby with both hands over the head. It went well, just a BIGGER stretch. If the little rascal is sucking it's thumb it's unlikely to give it up, it is also hard to pinch enough to make them budge. Get the mom mentally ready to open really big!

Face Presentation

Face Presentation

Face Presentation with Mentum Posterior Birth Story

I've only seen one face presentation, and it was while I was a labor nurse in Oklahoma.

It was a grandmultip who came in fully, or nearly so, with mentum posterior face. While the residents ran around discussing the impossibility of delivery, she preciped in the bed. From the facial bruising, it was clearly a face, and not a brow which converted at the last minute.

If the baby is MP -- mentum posterior -- chin to the back of mom's pelvis -- then attempt to convert the baby to a vertex position. An MP baby is very unlikely to birth, and if you are successful turning it you will end up with an anterior vertex and that's a very good thing!

To convert a face presentation into a vertex takes a little bit of luck, and some gentle persuasion. I tried it once with the only face I had -- which was MT -- but wasn't successful. as labor progressed it was clear the baby would go MA so everything worked out well. rapid easy birth, bruised kid though.

Anyway. here's the info from an old post. But remember the advice; MA=OK , MP =don't let it be! Or: if the baby is looking at you, let it be. if it's looking at mom's back, then think about trying to convert to vertex.

The technique (as described in several old texts) involves two people. the general theory being that the head will be flexed and the fetal pole straightened at the same time.

To help visualize -- a face presentation feels like an S Curve -- the baby's bottom on one side and a sharply curved torso so that what feels like the baby's back is really the baby's chest (except it's on the wrong side!) and the large feeling head is on the same side as the baby's bottom (feels just the opposite of a normal flexed head). You might even think you have twins because of this "extra" feeling head - -- at least I did when I felt a face; until the internal, then it was all very clear).

Anyway.. with one whole hand in the vagina! ... the vaginal hand reaches up to the occiput and "pulls it downward" to flex the head -- you might be able to use a thumb on the sagittal suture and the four fingers behind the occiput to get a good grip. (visualize moving the occiput into position over the cervix). Meanwhile an outside person gently pulls the baby's chest while pushing the opposite way on the breech (pushing both parts towards the center line of mom's abdomen) -- this should straighten out the baby and if the vaginal hand can flex the head, the baby should flex right around and go nicely vertex for you. Or so the books say[Grin]...

PS try not to prolapse the cord.

[from ob-gyn-l]

Totally by coincidence. Yesterday I was on for delivery suite when a primip was admitted from antenatal ward at 42 weeks and at 7cm dilated with intact membranes following two doses of PGE2 for induction post dates.

Midwife thought she could feel a nose. I checked her VE and confirmed D/RMA face at +2cm. She progressed quite quickly to fully and so didn't get the epidural she had wanted. After 1hour of pushing the PP had descended but she was tired and face was still not visible. Gave pudendal & perineal LA. Put on mid-cavity forceps and delivered with 1.5 pulls over a RML episiotomy. Babe had swollen face and some bruising (only apparent after 20mins). Saw both today and mum and her son are fine. Swellings gone and modest bruising. Will watch for peak bilirubin.

Not something I get to do every day - last one was in 1990!

Having used forceps for 37 years I always admire such stories. A totally lost art in our obstetrical culture today. What a shame.

All I can say is wow....

We have a resident in our program that was delivered by forceps from face presentation - we use it to our advantage frequently :)

That makes two of us - I had two faces in the same week this summer. The last one before that was in 91.

Our most experienced resident was amazed when he realised what I was planning to do, couldn't imagine anything other than a CS. Subsequently I asked to of my respected and experienced colleagues. One felt he'd never do a forceps for a face, other said only in a multip. A third colleague who always admits to being more of a gyn than a ob told me he knew that the diameter was consistent with vaginal birth and that he was sure it was right to deliver vaginally. But he had no experience so would probably have opted for CS too!

Worries me a bit. Much easier delivery to do than rotational forceps or delivering an OP position as face to pubes!

It must be high season for face presentations.

The wake-up call came at 4:00 am last night from a panicked house doctor. A full-term para 3 with no prenatal care came in fully dilated at direct MA/+2 station. A quick sono in the DR showed no neck masses and the fetal chest directly to the left of the maternal midline.

I called for general anesthesia and placed her in steep Trendelenburg, disengaged the face, slipped my fingers around the occiput and simultaneously flexed the head and pressed upon the fetal chest (I believe it's called the Baudelocque maneuver). The vertex came down quite easily, I applied the vacuum and delivered the infant without difficulty.

3,400 gram female, 9&10 apgars... with a face only a mother could love.

Interesting. Why not deliver it from face presentation? Was labor arrested? I have delivered two face babies, but never seen or heard of the above maneuver. Will file it in my database, however!

Very snazzy maneuver, but why did you have to do it? Was she unable to push the baby out under her own power? How long did she try? Were the FHTs nonreassuring?

Both of the forceps deliveries of face presentation cases discussed on this list were having difficulty effecting the delivery. I've seen faces deliver spontaneously, without significant difficulty for mom or babe.

This manouevre sounds really impressive! However it's a lot of manouevre and needs a GA. Does it have any advantage over simply putting forks on a pulling. After all your then converting it to a vertex OP, or worse risk getting stuck half way with a brow.