There are a plethora of clinical skills midwives must master to be safe and effective practitioners for women, and while the #science is complex and extensive, there is also very much an art to practicing midwifery. Often midwives will have an innate instinct or intuition about how best to assist a mom or guide her through pregnancy and childbirth. The practice itself has predated science or evidence, so we are now sort of working in a way that may seem backwards, conducting research to better evaluate the implications of practices which have long been part of the midwife's skill set. The #robozo is one of these ancient art practices for supporting a laboring mom, or more specifically, the position of her baby within the womb.
The Guatemalan Rebozo
Shawls serve many functions in Guatemala. They may be used by a girl or woman to carry small loads to and from the market, or to hold a sleeping baby onto momma's chest or back. They may be used to protect from the wind or sun, and in some cultures, they are used for decorative purposes. Whatever their purpose, they are often close at hand, so it makes sense they were also utilized during the labor process. This midwifery trick-of-the-trade has been passed to midwives here in the state and are becoming increasingly popular as more and more experience the benefits of their use.
Optimal Fetal Positioning
An important distinction between midwives and obstetricians when it comes to managing labor, is that the midwife places a great deal of priority on the position of the fetus during labor. This variable alone can be the difference between a successful vaginal birth or a necessary cesarean. It can also be the difference between what we often call, the "butter birth," where baby slides out like butter, or a fairly long and torturous birthing event.
About half of all babies engage or begin labor in the occiput transverse position with the remainder either facing anteriorly or directly posterior. When babies initiate labor in the posterior position, most (80-90 percent) will rotate to the anterior position before spontaneous or assisted delivery. Spontaneous rotation to the anterior or preferred position often happens later in the second stage of labor, for many. Although when posterior positions are found later in labor, they are more likely to persist, more than 80 percent will rotate to the anterior position. Rotation the opposite way, from anterior to posterior,, is rare once second stage has started.
When the fetus is in what is called a posterior position, a larger passage way is required to successful pass the fetal head, and women often suffer significant "back labor." The incidence of this position in first times mothers is as high as 40 percent, which can be correlated to both use of epidurals and induction of labor. Generally, this position has to be corrected prior to birth which is why this can lengthen the overall duration. Only 4 to 8 percent of babies are successfully birthed in this position without an epidural, and about 13 percent of the time with epidural analgesia.
Due to longer labors and more frequent interventions in effort to advance progress, risks are increased. More women have uterine infections when their fetus presents in this posterior position. Apgar scores are lower. Meconium births are more common, as are perineal lacerations. Postpartum hemorrhage is more frequent, as are #cesarean births. More women suffer post-traumatic stress disorder and more babies are admitted to the neonatal intensive care, with more babies suffering from significant brain damage.
There are a few factors that influence the risk for persistent posterior fetal positioning, including the shape of momma's pelvis, epidural analgesia, number of pregnancies, and race. In my experience, I would argue that a healthy size baby reduces the incidence of poor positioning, as smaller baby heads tend to have the ability to fall a little lopsided since they have the additional room. An anterior placenta also seems to correlate with posterior positioning of the baby, as does maternal obesity.
While a number of midwifery tricks-of-the-trade focus on optimizing fetal positioning, not a lot have demonstrated success in the literature. Women who are able to adopt upright positions and move more freely in the first stages of labor have demonstrated shorter labors, fewer cesarean births, less need for epidural analgesia, and few NICU admissions. However, these studies aren't necessarily specific to the fetal position. Encouraging hands and knees for example, prior to labor or even during labor prior to the pushing phase, have not shown to improve fetal positioning in the literature currently available. Unfortunately, only one intervention has demonstrated success within the literature: manual rotation of the fetus.
Rebozos for Malposition of the Fetus
The traditional practice for using the rebozo for laboring clients in Mexico has a long history. The rebozo itself is somewhat different based on the region. It may vary in color, be made of alternative materials, have a variety of patterns, and it may even be used somewhat differently, but most all utilize the rebozo for acamodada (accommodate) or manteada (body rocking). While there is potentially only one research article on rebozos - the one provided below - the World Health Organization is clear that lack of scientific studies on traditional practices "should not become obstacles to their application and development."
There are a number of techniques for utilizing the rebozo, but to be clear, it is not used to rotate the fetal head in a manual way. Rather, it is thought to relax the pelvis musculature and ligaments, allowing the fetus to move more freely and ultimately complete the necessary cardinal movements for birthing unimpeded. Therefore, the rebozo can be used without fear of causing a fetus to turn from an optimal position to a malposition, in the event the assessment of the fetal positioning is mistaken, which happens about half of the time.
The rebozo technique is also not typically the only intervention offered. Rather, midwives will utilize a plethora of techniques, all working collectively to optimize the fetal positioning for birth. The rebozo is not typically used continuously either, but rather more often, only once or twice during labor to assist in optimizing the fetal position. Contraindications would be concerning fetal status in labor, patient discomfort, breech presentation with rupture of membranes, placenta abruption, abnormal vaginal bleeding, or other contraindications for vaginal birth itself.
Utilizing the Rebozo
Certainly all midwives should discuss the history, use, and potential risks and benefits with her client prior to utilizing the rebozo, but if #consent is obtained, then first, the fetal position via Leopold's maneuver should be evaluated and documented. Midwives have also greeting the fetus to make them aware of the upcoming technique, either through voice or massage of the abdomen. This massage may further help her relax her abdominal muscles as well.
If the mother is lying on her back or side-lying position in labor, a #hospital sheet could be used after being opened completely and folded in fourths along the long edge, and simply slide beneath her so that it covers her lower back and buttocks. This technique can also be used with mother in a hands-and-knees position which allows her to dangle her belly as the procedure is implemented. She may lean over a birth ball, pillows, or a chair relaxing her arms and upper body. Attempt to capture the hip bones in the rebozo, forming a sling. The woman may also stand and lean over onto the bed for support. At all points, of course, assure the woman is comfortable and not experiencing pain or discomfort.
The first maneuver includes a quick tug. The midwife would position themselves on the side of the bed, facing the laboring mother at the level of her abdomen. Reaching over the maternal abdomen, the midwife would grasp one end of the rebozo, holding it close to the maternal abdomen, and pulling up and toward the fetus quickly twice. Repeat this on the other side, grasping the end of the rebozo closest to the midwife. This can be repeated again on both sides, for a total of four times on each side. Again, following the procedure, place your hands on the abdomen to settle the fetus.
The second maneuver includes rocking the hips and abdomen. If she were laying on the floor, the midwife would stand over her, potentially standing in the bed if performing solo, straddling her upper thighs, and bringing both ends of the rebozo up to the level of the midwife's hips. Start by gently pulling up and in on one side, then releasing and pulling up and in on the other side. This would be rhythmic, swaying the mother from side to side, feeling the support of the rebozo on her lower back and buttocks. This midwife has also seen the rebozo utilized with mother in the hands-and-knees position and the midwife placing the rebozo over her bum.
The third maneuver includes having the woman bend her knees and resting her feet on the bed. The midwife would place her palms on her knees and push quickly straight back, the releasing which causes the midwife's hands to bounce on the woman's knees. This maneuver is thought to unlock the fetus from the #pelvis, allowing greater mobility.
These maneuvers are utilized for about five to ten minutes, only once or twice in labor. Greet the fetus once again after all maneuvers are completed, and work to provide the mother comfort. She may prefer an exaggerated Sim's position or right side-lying position.
Implementation within the Hospital Environment
There are always more challenges for implementation of new interventions than one anticipates, even when they are supportive and innovative thinkers. One must consider the durability and strength of the material utilized. Although the traditional rebozo cloth itself is ideal because of its strength, grip, and stretch, it can not easily be cleaned between laboring clients. A sheet is a good replacement, which can be laundered. If women bring in their own rebozo however, this seems to bypass these challenges.
Fetal heart rate monitoring is vital for assuring fetal status, which can be achieved, particularly if risk status supports intermittent monitoring. The shifting position can make continuous fetal monitoring a challenge, but even if continuous monitoring is utilized, if she is able to be released to utilize the restroom, certainly this quick procedure could be supported. If monitoring must maintain continuously, then the laying on the back with a hip tilt is preferred, so that the rebozo doesn't come into contact with the transducer.
While it is often thought that consultations are one way - from midwife to obstetrician - the literature has demonstrated optimal outcomes when obstetricians recognize their inability to successfully transition a woman's labor from first stage into second stage and consult available midwives. The article below shares a case study of an obstetrical case, headed to the operating room for failure to progress, and with only five minutes of rebozo performed by the nurse-midwife, the laboring client successfully birthed her baby vaginally only 27 minutes later. The physician shared that she was "a believer," and was grateful to have consulted the nurse-midwife in this tough case.
Barth, W. H. (2015). Persistent occiput posterior. Obstetrics & Gynecology, 125(3), 695-709.
Cohen, S. R., & Thomas, C. R. (2015). Rebozo technique for fetal malposition in labor. Journal of Midwifery & Women's Health, 60(4), 441-445.