PQCNC AIM RPC Spinning Babies

Easier childbirth with
fetal positioning
Presented by Gail Tully
…so many cesareans?
“Worldwide there is an alarming increase in caesarean
section (CS) rates. The medical profession on its own
cannot reverse this trend. Joint actions with governmental
bodies, the health-care insurance industry,
and women’s groups are urgently needed to stop
unnecessary CSs.”
FIGO position paper: how to stop
the caesarean section
Epidemic (2018)
“Money that will become available from lowering CS costs
should be invested in resources,
Better preparation for labour and delivery and better
care, adequate pain relief, practical skills training for
doctors and midwives, and reintroduction of vaginal instrumental deliveries to
reduce the need for CS in the second stage of labour.”
FIGO position paper: how to stop
the caesarean section
Epidemic (2018)
“The World Health Organization states
that the correct cesarean section rate is
between 10% and 15% but ours in the
United States is 38% to 40%.”
Morrison, & Zelop (2018) Time to reduce
cesarean deliveries rates. Contemporary
OB/GYN
Why so many cesareans?
• A loss of medical skills to
confidently and competently
attend a (potentially
difficult) vaginal delivery
• Medico-legal issues
• Incentives in the comfort
of planned daytime delivery
www.thelancet.com Vol 392 October 13, 2018

Why so many cesareans?
“…3 forces largely beyond the
control of the practicing clinician:
1. Patient expectations and
misconceptions regarding
the safety of labor,
2. Medical-legal system, and
3. Limitations in technology.
Clark, et al. "“Doing something” about
the cesarean delivery rate." Am Jour
of Ob Gyn (2018)
ACOGs 5 most common reasons
1. Labor arrest
2. Non-reassuring fht
3. Malpresentation
4. Macrosomia
5. Multiples
-ACOG, 2014
Comparing OA and OP labors
Cesarean in 1st births
73.6% OP vs. 25% OA, P<.001
Cesarean in Multips
38.7% OP vs. 7.5% OA, P<.001
Simpson (2015)
LOT and Flexed OP and extended
Origin unknown
“Safe reduction of the
rate of primary cesarean
deliveries will require
different approaches"
-ACOG
Spinning Babies®
is a different
approach!
What is Spinning Babies®?
•“Spinning” = baby’s rotation

•Facilitate
not manipulate fetal position
•An approach and a brand
•Any setting, any provider
Spinning Babies® Offers A
New View On Birth
New ways to look at birth
anatomy helps resolve
labor dystocia and reduce
cesarean surgery
Muscles, fascia,
and ligaments
(tight or loose)
shape the space in
the uterus
We have
Protocols for:
Top
Bottom
Front
Back
Sides
Balance the Muscles
To help rotation
Balance the Ligaments
The uterus is
supported by the pull
of multiple ligaments
Images courtesy of Dr. Carol Phillips

Balance (Release) the Fascia
Fascia is the
connective tissues
holding everything
together
Breech in a
uterus with a
twist
Torsion shown by
ovarian location
http://www.rb.org.br/det
alhe_artigo.asp?id=2318
Remove torsion and
baby adjusts themselves
3 Sisters of Balance
Rebozo Sifting
Forward Leaning
Inversion Side-lying Release
Contraindications for Inversion
• High Blood Pressure
• Cardiac issues
• Seizures
• Glaucoma, or recent eye surgery
• Heartburn, or after eating
• Or doesn’t want to do it
Adoption of Innovation: Spinning Babies® an Interdisciplinary Labor Support
Program to Mobilize Pregnant Women and Improve Birth Experiences
Leslie Fung MPH1, Michele Helgeson MPH CNM2, Lorenza Holt MPH DONA3, Sylva Yeghiayan PhD DONA3, Jennifer Conti MPH1,Karla Damus PhD MSPH MN RN
FAAN4
1Boston University School of Public Health, 2 Newton-Wellesley Hospital, 3 Spinning Babies®, 4 Boston University School of Medicine
Introduction Results Focus Group Feedback

Spinning Babies® (SpB) is a physiological labor support program 80 L&D nurses participated in one of the six training sessions. 68 Positive Feedback
created by midwife Gail Tully that guides mothers in pregnancy pre tests, 72 post tests, and 52 3-month follow up assessments
and labor to lengthen and release the tension or torsion in their were analyzed. • Higher patient satisfaction
• Improved team dynamic among providers and nurses
soft pelvic tissues. By matching specific birth positions, the Spinning Babies Average Pre and Post Assessment Scores* for 6 Trainings
11-14-17 to 3-28-18, Newton Wellesley Hospital
• Learned technique provides another useful labor tool
diameter of the pelvis can open for the baby to rotate and
Mean Percent Correct Pre Assessment Post Assessment 3-Month • More active labor management approach
descend. 100.0
76.5 85.7
• L&D nurses feel more on the same page with CNMs and
75.3
Despite progress to reverse escalating rates of cesarean 80.0
80.2 80.0 79.1 physicians
70.8
sections, in 2015 about 26% of all deliveries in the US were low 56.8 Constructive Feedback
60.0
risk cesarean births. These major abdominal surgeries have 49.2 49.7 50.0 48.2
51.4
• Research is needed for more physician support
43.9
significant risks for mothers/ newborns, and should be prevented 40.0
39.6
if not medically indicated. • Naming specific techniques is more descriptive than calling it
20.0
SpB
In November 2017, the Spinning Babies Quality Improvement
0.0
project was implemented at Newton-Wellesley Hospital (NWH), Training Dates 11-14-17 12-6-17 12-13-17 1-10-18 1-17-18 3-28-18 Total • Need to address consistent EMR documentation
a community hospital with about 3800 births a year, located in Number of trainee Pre/Post=11
assessments
Pre/Post=17 Pre/Post=14 Pre=15, Post=18 Pre/Post=5 Pre=6, Post=7 Pre=68, Post=72, 3-Mo Post=52
the Greater Boston Area. The goal of the project was to provide *For each training and for the aggregated total, mean Pre/Post Scores are statistically significant at p<0.001 • More support is needed for fidelity of SpB techniques
additional labor support techniques and improve patient care and Mean scores were: pre test 48.2%, post test 79.1%, and 3-month post 51.4%.
• Need to be more sensitive to RNs with many years of L&D
satisfaction. Lessons Learned
experience when teaching and implementing SpB
Frequency Using Specific Spinning Babies Techniques among Nurses in
Project Implementation Method 3-month Post Assessment
Successful implementation and evaluation of SpB in a
Never and Seldom Use Sometimes, Frequent, Always Use
Percent of Nurses
100.0 community hospital setting was facilitated by including team
Labor & Delivery (L&D) and Triage RNs were trained by L.H, a 100.0
SpB approved trainer, on specific techniques: Rebozo Sifting, 84.6 members with research and QI expertise.
80.0
Forward Leaning Inversion, Side Lying Release, Abdominal Lift 71.2
65.4 56.0
Leadership buy-in was essential to launch the project, including
59.2 58.8
and Tuck, Froggy Walchers, Walchers, Internal Rotation of 60.0
funding for all nurses’ trainings and incentives for focus groups.
44.0
Femur. An online module was offered to nurses for pelvic 34.6 40.8 41.2
anatomy review.
40.0
28.9 Positive anecdotal stories from champion nurses helped catalyze
15.4
20.0 support for SpB techniques use among interdisciplinary roles.
A nurse mentor program was established as a resource to the
0.0
0.0
Culture change takes time.
nurses. 14 nurse mentors attended the workshop training twice Rebozo Sifting Forward Leaning
Inversion
Side Lying Release Abdominal Lift and
Tuck
Froggy Walchers Walchers Internal Rotation of
Femur
and have access to the SpB trainer. Spinning Babies Techniques
Next Steps
Grand Rounds on SpB was given to obstetricians and CNMs. Side Lying Release (90.2%) and Internal Rotation of Femur (78.8%) were most frequently
Project Evaluation Method used among nurses. Rebozo use (71.2%) and Abdominal Lift and Tuck (59.2%) were
least used.
Provide ongoing nursing support, refresher trainings, and
Labor Support Survey Analysis by Questions
address questions/concerns to promote sustainability of
program.
Pre and Post tests were conducted with the participants at each Labor Support Survey: Mean*
Question Pre-test 3 Month Offer on-going support for the nurse mentor program.
training. Tests included knowledge assessment, nurse Suggest alternate positions/movements 4.45 4.71
demographics, labor support survey, and feedback of trainings. Provide specific backache relief measures 4.26 4.53
Facilitate the change in culture with leadership support at all
Physiologic comfort measures (backache relief, non-pharmacologic pain relief) 3.82 4.26
A 3-month Post Assessment was conducted to assess Position laboring mothers in a variety of different ways 4.32 4.61 interdisciplinary levels.
Position laboring mothers in systematic ways 4.14 4.61
knowledge retention, perception of confidence/skill level using Have mothers labor out of bed (in a chair, on a birthing ball, walking halls) 4.29 4.54 Conduct evidence based research to determined the impact of
SpB, labor support survey, and feedback of project Provide warm or cool comfort measures for laboring mothers 4.17 4.47
Walk with laboring mothers 3.57 3.93
SpB techniques on patient and provider satisfaction and birth
implementation. Teach support people (partner, friends) how to comfort laboring mothers 4.02 4.37 outcomes.
Advocate to ensure that laboring mothers’ special requests are honored 4.59 4.80 Conclusion
Focus groups were done to collect qualitative feedback about Make suggestions for different pushing techniques (side, squatting) 4.42 4.70
project implementation. Three focus groups were conducted: 1) This quality improvement project has created an opportunity to
Legend for Scores: Yellow: 1=Strongly disagree, 2=Disagree, 3=Nether, 4=Agree,
six MDs and CNMs, 2) five L&D RNs, 3) two Charge Nurses. 5=Strongly agree; Green: 1=Poor, 2=Fair, 3=Good, 4=Very good, 5=Excellent; Blue: strengthen interdisciplinary collaboration and to empower
Nurse mentors were asked to complete a survey about their 1=Never, 2=Seldom, 3=Sometimes, 4=Frequently, 5=Always. pregnant women through increasing mobility and shared
experience. *A third of the 33 questions (11/33) had a statistically significant increase in the 3- month
decision-making during labor. SpB techniques add more labor
post assessment. support and decrease nonmedically indicated interventions.
Appropriate descriptive statistics (frequency, means, medians,
References:
ranges), T-test, and ANOVA were conducted. Statistical
1. Martin JA, Hamilton BE, Osterman MJK, Curtin SC, Mathews TJ. National Vital Statistics Reports Births : Final Data for 2013. Natl Vital Stat Reports. 2015;64(1):1-
For questions or comments please contact Leslie Fung at
significance
104. was set at p<0.05. lescfung@bu.edu
2. Tully G. 2018. Spinning Babies. Retrieved from: https://spinningbabies.com
3. Simkin P, Hanson L, Ancheta R. The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia. 4th ed. John Wiley & Sons, Inc; 2017.
Adoption of Innovation: Spinning Babies®
an Interdisciplinary Labor Support Program to
Mobilize Pregnant Women and
Improve Birth Experiences
Leslie Fung MPH1, Michele Helgeson MPH CNM2,
Lorenza Holt MPH DONA3,
Sylva Yeghiayan PhD DONA3, Jennifer Conti MPH1,
Karla Damus PhD MSPH MN RN FAAN4
1Boston University School of Public Health, 2 Newton-Wellesley Hospital, 3
Spinning Babies®, 4 Boston University School of Medicine
References:
104.
Can nurses learn from

Spinning Babies ® for
Spinning Babies Average Pre and Post Assessment Scores*
? 6 Trainings
11-14-17 to 3-28-18, Newton Wellesley Hospital
Mean Percent Correct Pre Assessment Post Assessment 3-Month
100.0
76.5 75.3 85.7

80.2 80.0 79.1
80.0
70.8
56.8
60.0
49.2 49.7 50.0 51.4
48.2
43.9
39.6
40.0
20.0
0.0
Training Dates 11-14-17 12-6-17 12-13-17 1-10-18 1-17-18 3-28-18 Total
Number of trainee Pre/Post=11 Pre/Post=17 Pre/Post=14 Pre=15, Post=18 Pre/Post=5 Pre=6, Post=7 Pre=68, Post=72, 3-Mo Post=52
assessments
*For each training and for the aggregated total, mean Pre/Post Scores are statistically significant at p<0.001
Mean scores were: pre test 48.2%, post test 79.1%, and 3-month post 51.4%.
References:
1. Martin JA, Hamilton BE, Osterman MJK, Curtin SC, Mathews TJ. National Vital Statistics Reports Births : Final Data for 2013. Natl Vital Stat Reports. 2015;64(1):1-104.
Reults
Do nurses use
Frequency Using Specific Spinning Babies Techniques
® among Nurses in
Spinning Babies
3-month Post Assessment ?
Percent of Nurses Never and Seldom Use Sometimes, Frequent, Always Use
100.0
100.0
84.6
80.0
71.2
65.4 56.0
59.2 58.8
60.0
34.6 44.0
40.8 41.2
40.0
28.9
15.4
20.0
0.0
0.0
Rebozo Sifting Forward Leaning Side Lying Release Abdominal Lift and Froggy Walchers Walchers Internal Rotation of
Inversion Tuck Femur
Side Lying Release (90.2%) and Spinning Babies Techniques

Internal Rotation of Femur (78.8%) were most frequently used among nurses.
Rebozo use (71.2%) and Abdominal Lift and Tuck (59.2%) were least used.
Favorite Techniques
Frequency Frequency
Using Specific SpecificRNs
Using Spinning and Spinning
Spinning
Babies Techniques Babies
Babies Techniques among
among Nurses in Nurses in
ency Using Specific Spinning Babies Techniques
3-month Postamong
3-month Nurses
Post in
Assessment
Assessment
3-month Post Assessment
Percent of Nurses
Percent of Nurses Never
Never and Seldom Useand Seldom Use
Sometimes, Sometimes,
Frequent, Frequent,
Always Use Always Use
Never and Seldom Use Sometimes, Frequent,
100.0 Always Use
100.0
100.0 100.0 100.0
84.6 84.6
84.6
80.0 80.0
71.2 71.2
65.4 65.4
65.4 56.0 56.0
59.2 56.0 59.2 58.8 58.8
60.0 60.0 59.2 58.8
44.0 44.0 44.0

34.6 34.6 34.6
40.8 41.2 40.8 41.2
40.8 41.2
40.0 40.0
28.9 28.9
15.4 15.4 15.4
20.0 20.0
0.0 0.0
0.0
0.0
0.0
Forward Leaning Side Lying Release
Rebozo Sifting Forward Abdominal Lift and Froggy Walchers Walchers FroggyInternal Rotation of Walchers
Inversion Rebozo SiftingLeaning Tuck Side
Forward Lying Release
Leaning Side Abdominal Lift
Lying Release andAbdominal Walchers
Lift and
Femur Froggy Walchers Internal Rotation ofInternal Rotation of
Walchers
Inversion Inversion Tuck Tuck Femur Femur
Spinning Babies Techniques
Spinning
Side-lying Release Babies Techniques
(90.2%) and Babies Techniques
Spinning
Internal Rotation of Femur (78.8%) were most frequently used among nurses.
Rebozo use (71.2%) and Abdominal Lift and Tuck (59.2%) were least used.
Spinning Babies is
the Active part of Patience
Side-lying Release is the Queen of Techniques
100%Spinning
Frequency Using Specific of RNs use it 90%
Babies of the timeamong Nurses in
Techniques
3-month Post Assessment
Percent of Nurses Never and Seldom Use Sometimes, Frequent, Always Use
100.0
100.0
84.6
80.0
71.2
65.4 56.0
59.2 58.8
60.0
44.0
34.6 40.8 41.2
40.0
28.9
15.4
20.0
0.0
0.0
Rebozo Sifting Forward Leaning Side Lying Release Abdominal Lift and Froggy Walchers Walchers Internal Rotation of
Inversion Tuck Femur
Side-lying Release Spinning Babies Techniques
used by all nurses trained in SpB 90.2% three months after training
References:
104.
Spinning Babies® asks a new question
Old Question Spinning Babies® Question
How far dilated Where’s Baby!?
is the cervix?
Old Answer Spinning Babies® Answer

Force open the Let’s make room for
cervix!
the baby!
Anterior and Posterior Fetal Position
Fetal Position
Is proven to be
a valid indicator
of
birth outcomes
Right Left
O = Occiput
A = Anterior
P = Posterior
Pictorial Midwifery
T = Transverse Comyns Berkeley, 1948
Babies get into
the best
position they
can
In the space
they have
available.
Spinning Babies Workshops

www.spinningbabies.com
Occiput Transverse
Pictorial Midwifery
Comyns Berkeley, 1948
ROT and LOT are not mirror images

Compare
ROT and extended LOT and Flexed
“Spectrum of Ease”
Ease is more than

“either - or”
With “Balance”
LOT rotation and descent
Inlet is wider side-to-side
Baby’s head is longer
front-to-back.
After balancing,
we ask,
Where’s Baby?
Inlet
Midpelvis
Outlet
Widest diameters
“Where’s the Baby?”
Open the
diameter of the
pelvis where the
baby is waiting.
Results
Labor Support Survey Analysis by Questions
Labor Support Survey: Mean*

Question Pre-test 3 Month
Suggest alternate positions/movements 4.45 4.71
Provide specific backache relief measures 4.26 4.53
Physiologic comfort measures (backache relief, non-pharmacologic pain relief) 3.82 4.26
Position laboring mothers in a variety of different ways 4.32 4.61
Position laboring mothers in systematic ways 4.14 4.61
Have mothers labor out of bed (in a chair, on a birthing ball, walking halls) 4.29 4.54
Provide warm or cool comfort measures for laboring mothers 4.17 4.47
Walk with laboring mothers 3.57 3.93
Teach support people (partner, friends) how to comfort laboring mothers 4.02 4.37
Advocate to ensure that laboring mothers’ special requests are honored 4.59 4.80
Make suggestions for different pushing techniques (side, squatting) 4.42 4.70
Legend for Scores: Yellow: 1=Strongly disagree, 2=Disagree, 3=Nether, 4=Agree, 5=Strongly agree; Green:
1=Poor, 2=Fair, 3=Good, 4=Very good, 5=Excellent; Blue: 1=Never, 2=Seldom, 3=Sometimes, 4=Frequently,
5=Always.
*A third of the 33 questions (11/33) had a statistically significant increase in the 3- month post assessment.
References:
104.
Baby Engages in the Top Level
Chin tucking helps
Baby enter the pelvis
Inlet
Opens front-
to-back
INLET: Solutions
Flatten the
Posterior lower back
Pelvic Tilt
Open the pelvic brim
to engage baby
during the labor
contractions.
Contra-nutation If High
Opens the
Anterior-
posterior
diameter of
the pelvis.
“Flying Cowgirl” If High
Opens the inlet
6 contractions on
both sides
Congratulations, Baby is Engaged
Baby Turns Through The Middle Level
Baby turns again
to move lower
Pelvic Imbalance
MIDPELVIS: Asynclitism
The pelvic floor
imbalance can
cause
Asynclitism
LOT LOA OA
MIDPELVIS: Transverse Arrest
For the issue of
Transverse Arrest
MIDPELVIS: Solutions
Balance First!
Side-lying Release
Open Midpelvis
MIDPELVIS: Solutions
Running
Start
More
width for
the
bottom of
the pelvis
Cervix? FLI!
• 9 ½ cm or
• “Anterior lip”
Or,
• 10 cm and no descent
• Muscles seem tight (w/ SLR)
Invitations to Act in Labor
⦁ More pain than expected
⦁ Fetal malposition
⦁ Waters released AND no contractions
⦁ Slow labor or labor arrest
⦁ Contractions remain irregular or do not
dilate the cervix (observe labor pattern)
Baby Emerges from the Bottom Level
When baby is low,

open the bottom
Words.
Flexion
Or
Extension
Words.
Flexion
Words.
Extension

Outlet
OUTLET:Solutions
Solutions
Internal
Rotation of
the Femur
Review: Open The Pelvis Where
Baby Is!
For the top For the middle For the bottom
Posterior pelvic Side lunge Anterior
tilt pelvic tilt
Focus Group Feedback
Positive Feedback
• Higher patient satisfaction

• Improved team dynamic among providers and
nurses
• Learned technique provides another useful labor
tool
• More active labor management approach
• L&D nurses feel more on the same page with CNMs and
physicians
References:
104.
Our Welcome gift to
North Carolina Nurses
spinningbabies.com/pqcnc/
You are the Light
of the
Future of Birth

PQCNC AIM RPC Spinning Babies

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Easier childbirth with

www.thelancet.com Vol 392 October 13, 2018

•“Spinning” = baby’s rotation

Images courtesy of Dr. Carol Phillips

Introduction Results Focus Group Feedback

Spinning Babies®, 4 Boston University School of Medicine

Can nurses learn from

76.5 75.3 85.7

Side Lying Release (90.2%) and Spinning Babies Techniques

44.0 44.0 44.0

Old Answer Spinning Babies® Answer

Spinning Babies Workshops

ROT and LOT are not mirror images

Ease is more than

Labor Support Survey: Mean*

Opens the inlet

When baby is low,

Spinning Babies Workshops

• Higher patient satisfaction

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