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POSTERIOR LABOR

WHAT EVERYONE MUST KNOW ABOUT POSTERIOR LABORS

This information is compiled from a workshop on POSTERIOR LABOR by midwife Tricia Anderson. I recommend it to be read alongside the notes from the workshop PROLONGED LABOR with midwives Jill Cohen and Sara Liebling, as some issues overlap.

 

AN IMPORTANT CAVEAT in the subject of Optimal Fetal Positioning and Posterior presentation. As we (teachers, doulas, women) become more educated, we must not let OFP become yet another stressor for pregnant women! There are things they can do to influence their baby’s position** but we must be careful not to create more fear. 

 

In addition to taking more responsibility for our own pregnancies, it is time for women to develop higher expectations of their caregivers’ skills and expertise. (see Diagnosis and Care During Pregnancy). If the U.S. is a long sad way away from returning to Midwifery Care, perhaps it’s time to require more from our Obstetricians. I personally do not see this kind of extensive knowledge applied at the majority of my students’ prenatal care and births. Usually after a c-section there is a surprised: “oh, the baby’s head was posterior!”  (Admittedly there are cases, such as a recent posterior along with an Android pelvis, where the best option is a cesarean. But not every posterior labor!)

 

Signs of the Classic Posterior Labor:

 

A normal, healthy, in-shape (even athletic) woman. Near term, she starts getting backache; at 40 weeks she may have 3 days of painful contractions that fizzle out. She starts getting fed up. Sometimes the water may rupture. In labor, the baby’s head stays high. Her backache gets excruciating. Hospital may make her lie down, may give her an IV, may limit her movement with fetal monitoring. She gets demoralized by back pain that feels crushing. Nothing helps, even if support people are applying as much counter pressure as possible. The contractions may be erratic, 2 strong, 2 weak. Finally she feels rectal pressure, but the exam finds her at 5 cm. Everyone agrees to a much-deserved epidural for the atypical pain and distress. Relief! The contractions slow, leading to administration of Pitocin. After a few more hours, the fetal heart rate may go up. A few more hours, the FHR is still up. She is at 7 cm and baby is still high. Discussion begins regarding risks to the baby, poor prognosis of descent. A c-section is performed (the baby is often under 8 lb).

 

As birthing women and birth professionals, our Greatest Challenges are these approximately 20%%  of labors that begin with the baby in a posterior position. About 6.5% are will be posterior at delivery; 13% for the moms with epidurals.* Sometimes our tricks can help; sometimes not. 

 

Occiput - the back of the baby’s head

OA - Occiput Anterior (to front)

OT - Occiput Transverse (sideways)

OP - Occiput Posterior (to back)

R - Right  L- Left

FLEXED - baby’s chin to its chest

DEFLEXED - baby’s chin up/not to chest

 

Babies that start labor / engage in the pelvis in the ROA position (on mom's right side) are more likely to turn posterior than those that begin in LOA (on mom's left side). 

 

CAUSES of OP Position [Is OP increasing? ]:

 

1. Soft sofas, chairs (which used to be hard), too much lounging & car driving. Soft surfaces encourage the heaviest part of the baby to swing to the back.

(see suggestions for moms, below)**

2. Our culture of flat stomachs and tight abs is a disaster for pregnancy. Exercises like crunches aim toward corset-like abdominal muscles, which then hold the baby up & high. The baby needs to hang forward

3. The shape of her pelvis. *

4. An anterior placenta

 

* (the below, most commonly used representations of the four pelvic types come from autopsies done on approximately 100 women in the 1920s. It is considered flawed and outdated data, but it’s what we have!)

 

Gynecoid (most common) - ROUND brim, wide angles, transverse diameter of 10+ cm. No obstacles, LOA baby has lots of room to rotate.

Anthropoid - OVAL brim, long transverse diameter (sometimes common in tall, African, Caribbean women)

Android - TRIANGLE brim. Male pelvis. Deep, straight sacrum, narrow arch (baby must go way down to get under). Outlet may be funneled. Baby can’t get in anteriorly. May engage (drop in) in transverse / lateral position.

Platypelloid - LETTERBOX brim, flattened. Narrow at inlet & outlet. Baby will engage in transverse, may be hard to rotate.

 

(Note- Many obstetricians will say that pelvimetry, a general assessment of her pelvic shape, is impossible. Many midwives will laugh at this statement.)

http://www.youtube.com/watch?v=qwOqQjIrI7w

 

BUT A WOMAN’S PELVIS IS AN AMAZING, FLEXIBLE STRUCTURE. INCREDIBLE, EVEN VISIBLE, MOVEMENT CAN OCCUR, IN THE RIGHT ENVIRONMENT.

 

The occiput anterior baby is like an egg sitting in an egg cup. The occiput posterior baby is like a sideways egg sitting in/on an egg cup. 

The poor fit triggers several false starts to labor, especially in her back. These bouts of “entering pains” (British term for this period of the baby trying to get down) sets off contractions that start & stop for days. Mom may get tired, discouraged, maybe dehydrated. 

Labor may have an irregular pattern such as two big, two small contractions, long but far apart contractions, or short but close together contractions. Baby’s head is usually deflexed, thus a longer diameter is presenting, causing an erratic feedback loop of cervical pressure.

 

The cervix does NOT dilate in centered round circles, like the texts show. It dilates from the os in an elliptical shape (especially after 3 cm), expanding forward, based on the presenting part of the baby, which is usually appling the most pressure in the front (with well-flexed head)  

 

THIS IS WHY WE EXPECT A PLATEAU in the posterior labor at around 5-7 cm. (How many times have doulas been at a birth where the OB comes in at this point and tells the mom that her labor is not progressing normally and needs Pitocin). Normal pressure works well until about 5 cm but then, when the baby is in an OP position, she won’t dilate until the baby descends, flexes, rotates and puts pressure again on the FRONT of the cervix.  MANY labors, not just posterior, plateau at this point, when the baby still needs to descend or turn. Friedman’s Curve does not allow for these different types of labor.

 

 

5 KEY PRINCIPLES OF CARE FOR THE OP LABOR

 

1. Use Maternal Positions to aid rotation.

Forward leaning (moms instinctively will do on their own), backwards on toilet or chair, hands & knees, pelvic rocking, stairs down or sideways, deep knee chest (baby disengages, then can turn), butt circles, gentle pelvic presses IN during contraction. With lunges & lying down, it’s good to know which side the baby is on.

 

2. Techniques to Maximize Contractions

Hydrate with calcium (banana milkshake!), walk, stimulate erotic spots, kiss, nipple stimulation, CREATE AN OXYTOCIN ENVIRONMENT, water (surge of oxytocin), remove anxiety, annoyance, inhibitions. Facilitate warmth, comfort, intimacy.

Don’t use Pitocin or rupture membranes in an OP labor. The fluid helps the baby rotate. 

Last resort - with proper skill/training, midwife can manually flex the baby’s head and rotate it while mom is in hands & knees position

 

3. Deal with back pain

 

4. Give Adequate Time. 

Expect a long prodromal phase (before active labor). Expect a stall around 6 cm. Expect a longer pushing stage.

 

5. Plenty of support for all; food, rest, breaks. Team effort.

 

[In OP labors the mom may have a blocked bladder, may need catheter or help peeing. She may have an early urge to push, due to occiput pressure on the rectum.

Frequent exams in this type of labor also raise risks of infection.]

 

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DIAGNOSIS AND CARE DURING PREGNANCY

 

How a Skilled Care Provider can Diagnose:

 

1. how she walks (experienced midwive can tell!)

2. shape of belly

3. palpation (lots of limbs in front)

4. no curve of baby’s back (or way to the side)

5. feeling the head (occiput = flexed head; sinciput = deflexed head)

6. heart beat not in usual, anterior place

7. if vaginal check, head high

8. different shape of bulging membranes

9. location of sutures/fontanels.  

 

SUGGESTIONS FOR PREGNANCY

 

1. Moms can learn to identify the baby’s position

http://www.yourmidwife.com.au/bellymap.pdf 

http://spinningbabies.com/products/belly-mapping-workbook

** 2. Lifestyle in the 9th month - no reclining! Moms should sit with their knees below their hips (can use a cushion). Sleep on left side (encourages baby’s back to fall to the left front). Forward leaning. Floor activities.  Swim (belly hangs). Moms should do hands & knees projects on the floor during last weeks of pregnancy.

3. Exercises & techniques to loosen & balance pelvic ligaments. Alignment, release (chiropractic, osteopath, acupuncture, pulsatilla).

http://spinningbabies.com/techniques/activities-for-fetal-positioning

 

 

Other sources:

Frye, Holistic Midwifery, Vol. II

Myles Textbook for Midwives

Oxorn, Human Labor & Birth

* Simkin, http://www.pennysimkin.com/articles/op%20article.pdf

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