Malpositioning

HOW CAN MY BABY BE IN THE BEST POSITION?

PREVENTING POSTERIOR PRESENTATIONS WHEN YOU ARE PREGNANT

By Claire MacDonald

Previously published in Birth Issues, Fall 2012

Fiddle Leaf Photography

Fiddle Leaf Photography

Over the past decade I have accompanied many women during the births of their babies. I am now starting to attend the births of their 3rd children. As I have become more experienced, there is one thing that sticks out, when a baby is in an optimal position, labour is shorter.

A labour under 12 hours is everyone’s dream. It’s easier on the labouring mom because it is less tiring physically, mentally and emotionally. She has a higher chance of achieving a natural, unmedicated birth and feeling more empowered in the process. She is less tired after the birth, and thus has more energy to devote to her newborn and their breastfeeding relationship. She is less likely to have to deal with any emotional trauma, which can come from medical interventions after a long birth, or by the feeling that she could have done better.

So, all in all it is a win-win situation to have a birth that isn’t long. The question I had for years was: How do we do it? Of course there is no simple answer in obstetrics, yet one thought I had was: “How about getting the baby in an optimal position during pregnancy?”

When I started teaching prenatal education I became very interested in anatomy and physiology. The more I studied the drawings of women giving birth, the more I came to realize that in an ideal world I would want a baby to be head down, facing the sacrum1, chin tucked tightly against her chest, baby’s back making the nice curve of mom’s belly, limbs tucked nicely beside mom’s spine, and head engaged deep into the pelvis by the pubic bone. That would allow the baby to corkscrew easily, the head to apply maximum pressure on the cervix, the head to present its smallest part, all enabling a short pushing stage.

If labour starts without a baby in this optimal position, many hours of seemingly non-progressing contractions (because cervical dilation may not be increasing) may be spent helping a baby realign. Achieving this optimal positioning prenatally would minimize the need for the head to mold or for the body to reposition itself°™ which would translate to less time needed to reposition baby, thus less time spent in labour. It would also mean that your body would not need to contract for a long time to push baby deep into your pelvis°™ which would translate to less time needed to push your baby out2.

As I realized this I started being very pro-active with my clients, insisting and almost ‘preaching’ to them about the benefits of making sure their babies were in an optimal position.

I have to be honest, not all were able to share my enthusiasm. But those that did, I noticed a significant difference. My proudest contribution was at a birth last summer of a mom who had had 2 previous cesarean sections. She had never given birth vaginally, despite all her efforts. She had a doctor the first time, a midwife and a doula the second time that didn’t help achieve a vaginal birth. When she hired me I asked her about her previous births. She said that she had never dilated past 4 cm, that her babies were high in her pelvis (minus 2 station3), she had epidurals and her bag of water artificially ruptured4 each time. Her contractions had also been augmented5, but she was never able to get past those 4 cm and her baby was never able to go past the minus stations—which is far from the pubic bone. She also told me, and this was confirmed to me by her caregivers, that she had a cesarean because she had “failed to progress.” Her pelvis was deemed too small for the size of her babies.

This “failure to progress” diagnosis is the leading cause of cesarean sections. The diagnosis is a catch-all for “We don’t know why but her labour did not progress at the rate that seemed right and baby started sounding poor so we proposed a cesarean.” Research has shown that not all women who have had this diagnosis actually needed to have a cesarean section6. Under certain circumstances they could have achieved a vaginal birth.

Knowing this, both her husband and she were motivated to achieve a vaginal birth. They innately knew they could do it and were hoping that the 3rd time would be the charm.

So I said, “Lets do what you have not done before.” This is the same advice I would give to any woman out there; take responsibility, be physically active, relax, and address your fears. Although we were designed to give birth, that does not give us a license not to take charge of how it will happen.

Take responsibility

This is your pregnancy, your body, your baby. Do not give your responsibility away to your doctor, midwife, nurse, or the hospital. Educate yourself, look for mom groups, go to ASAC meetings, take an advanced prenatal class series (as listed at the back of this magazine), and talk to moms who have experienced natural childbirth. Surround yourself with people who are positive and believe in your ability to give birth. Stay away from nay-sayers and fear-mongers. It’s tough enough to feel positive anyway, so no need to be reminded that it’s work.

Don’t hide behind excuses such as: I’m too busy, I have to work, I’m too tired, I have another child to take care of, I believe my body is designed to give birth, I’m freaked out, I can’t handle pain, I’m terrified. Okay, remember that pregnancy is your first step into motherhood. The day you conceive is when motherhood starts. What is going to be? Are you going to be the kind of mother who engages in her role as an engaged steward of her offspring, or as a blind mother who has no idea what is coming at her?

Taking responsibility means taking responsibility. If you want to be able to criticize others, for their lack of support or their interventions, you too have to do your homework. It is very difficult for me to say this, but I have seen many women who are quick to accuse their doctors and midwives while they are not willing to look at their own shortcomings. This does not mean that women have it all wrong. No no no. And this does not mean that women are lazy and stupid either. It just means that women have a measure of responsibility, and just like doctors, nurses, and midwives need to stay humble. We need to let go of ego and be willing to look at what we could have done differently or better.

For some this may mean that they have to change caregivers. Maybe they need a different doctor or choose to have a midwife instead. Maybe they need to give birth in a hospital that does not have high cesarean section and epidural rates or they may want to seriously consider having a home birth. Question yourself, question your assumptions, open yourself to new ideas. At the very least allow yourself to explore the idea. It may be exactly what you needed after all.

Be active

We live in an interesting contradiction. Our lifestyle is exhausting yet inactive. When I spoke with my client who had had 2 cesareans we spoke about the fact that we drive our cars to work, sit all day at a desk, drive our car back home, eat, watch television and go to bed. Our lives have very limited walking or physical activities. We rarely truly actively walk, which means walking for at least 30 minutes at a fast pace. You cannot get into a stride when you walk at the mall or around the house. There is minimal physical exertion in our modern lives. Yet we feel so tired at the end of our days!

The lack of physical engagement is an issue for a pregnant woman. Physical activity, especially for a first time mom, allows her baby to descend deep into her pelvis by the pubic bone and to be positioned in the most optimal way. Plain and simple.
Being active means walking briskly, or doing physical activities every week. You can go to the gym, run, swim non-stop for half an hour, do yoga, dance, spin classes or any cardio you like. During your last trimester it’s okay to slow down, but that does not mean stopping all activities. It may mean just doing prenatal yoga or swimming or cycling or speed walking on the treadmill.

Apart from physical exertion, being active also means adopting positions that are engaged. Rather than sitting passively, think of positions that engage your body and pelvis. For example, sit on your kitchen chairs as if you were horseback riding. You don’t lean back on the chair, rather you turn it around and lean on the back. This forward position opens your pelvis wider thus allowing your baby to move deeper into it. It also stretches your lower back which may be tired at the end of the day. Other forward leaning positions include sitting or kneeling on the floor. A great way to do this is when you are playing with children, or if you have a dog. It gives you more mobility in your hips and allows, again, your baby to sink deep into your pelvis.
The most passive position of all is on the sofa. Not only is it completely inactive (our pelvis is not moving and not engaged) but also we tend to put our feet up. This position tilts our pelvis, which prevents babies from entering deeply into the pelvis.
Baby will actually float quite high up. It also tends to put baby in a posterior presentation. Think of it this way, if mom is lying back with her feet up so is baby! Baby is not going to face your spine, or else their faces would be smooched into it. It is much cozier for baby to be laying the same way you do. Stay away from lying back, putting your feet up, and having your ankles higher than your pelvis, even slightly. If you really need to be on the couch, then at least use a more neutral position, such as lying sideways and upward propped up on pillows (or your spouse). This way gravity is doing some work.

Relax

Interestingly while our lifestyle is often physically inactive our mental and emotional side is quite active. Our minds are busy bees. We have a variety of stressors whether financial, work, or family. We drive around getting things done and collapse at home.
We so need to laugh and relax. I truly believe in the importance of appropriate relaxation. Relaxation of the body and mind is absolutely paramount. Without it, you would become a little ball of tight nerves. Your back would be aching, your muscles and ligaments in knots, and your mind would become depressed. That is not the state in which I want you to start labour.

Although the television and the sofa are not recommended when you are pregnant, other wonderful things are. I guarantee you will have a smile very soon. Equal parts active, equal parts relaxation. That means I want you to find the things that ‘physically’ and ‘mentally’ relax you. I highly encourage you to get together with your friends and have tea, got out for a long walk, and go to the spa to get massages and your nails done. All this will relax you and get rid of all the tightness in your body.

Another way to get rid of muscle and ligament tightness (and aches) is to go to regular appointments with an acupuncturist, chiropractor and massage therapist. If you can, do all three, please do one a week. If you can only afford one, then do one a month. When you get to 37 weeks of pregnancy, and your prenatal appointments switch to every week, start going every week to the modality that works best for you.

This is something that the mom who had 2 caesarean sections had not done before. She was very diligent about it, had both an acupuncturist and chiropractor, and it made a huge difference for her as you will find out at the end of this article.
The reason why I insist on making these appointments a regular part of your weekly routine, is not just because it relaxes your mind but because it relaxes your body. You may not realize how much tension you are experiencing. Oh, you know, you may have aches; but these aches are the tip of the iceberg. They are the manifestations of very tight ligaments and muscles that are pulling your structure in all directions. This can put, and keep, your baby in a position that is not optimal. After all, our bodies are amazing and they are able to give birth to babies in all kinds of ways. However, if you want to have it easier, then you might as well relax those tight spots so that baby can be placed in the best position possible.

Address your fears

We also have a number of fears. The first one being about birth. We live in a culture that teaches us from a very young age that childbirth is hard, scary, and dangerous. Watch any movie that depicts a scene with childbirth, and your adrenaline starts pumping! You may also have fears and doubts about your ability to cope and to handle childbirth. You may not be sure about what to do and who to trust. You may have had an abusive relationship, or an abusive past. All this can cause you to have tight ligaments and muscle groups, which as you now know, can put your baby in a posterior position and may not allow your baby to descend deep into your pelvis.

Some women may have so much fear that they are unable to think about childbirth. I have met some women who are so stressed that I would say they are already experiencing signs of trauma. Unfortunately, I could almost place bets on the type of birth they will have. This is no laughing matter, as it can be so stressful that they leave the planning for their birth to the last minute, which is as good as doing nothing. No marathon runner is able to run a marathon without training.

I have noticed that in those cases, regular visits with a psychologist during pregnancy are very helpful and empowering. They can give you the tools you need to feel in control. If you have experienced traumas, physical or psychological, this can affect your ability to believe in yourself or to advocate for yourself. You may have fears and anger that could prevent you from being able to cope with the intensity of childbirth. With appropriate counselling, with a loving and caring professional, it is amazing how the past does not have to determine your future. Do go and see a psychologist. You are worth it.

Hypnotherapy classes are also excellent additions to dealing with fears. They give you tools that also help a woman feel in control.

Whether this is your first baby or your third, whether you have had cesareans or not, it’s all the same. Doing this will make a world of difference and will allow you to feel you have done everything you could to give yourself and your baby the best chances before labour starts. The more active and loose you are the better.

I am proud to say that the mom who had 2 cesareans had a vaginal birth. It did not come easily, but when we arrived at the hospital she was already past 4 cm dilation and her baby was in plus one station in her pelvis. She took an epidural at 5 cm dilation, and 2 hours later she started pushing. Her baby arrived in 30 minutes of pushing, before her obstetrician could make it. He was so happy for her and impressed, “Wow you are a first time pusher, wow, well done!” You should have seen the mom and father’s faces. “I’m not broken, I did it” She said. Yes, her pelvis was not too small after all; she just needed to be more pro-active when pregnant. It still makes me weepy. I hope that more women get a chance to experience a birth, and feel proud of their bodies.

Claire MacDonald is not currently physically active and has a past with physical and emotional traumas. She is actively dealing with her past and getting into shape so that she can have the birth she has always dreamed of. She finds it hard work, but she knows it is worth it. Sometimes though she allows herself to sit in the sun like a lazy lizard!

Notes:

1. The sacrum is the lowest part of the spine. It creates a joint with the hip bones forming the back side of the pelvis and ends at the tail bone.
2. Senecal, Xiong, and Fraser. “Effect of fetal position on second-stage duration and labor outcome”. Obstetrics and Gynecology, Vol. 105, No. 4 (April 2005): 763-772.

3. A station is a measurement that describes how low the baby’s presenting part (usually the top of the head) is in the mother’s pelvis. When the baby’s head has not moved down into the bowl of her pelvis yet, it is said to be floating and is at a minus 5 station. Each station is 1 cm lower than the previous. Zero station is half way down. At plus 5 station the head is past the lowest part of the pelvis and you can see the head starting to show.

4. The artificial rupture of membranes (AROM) is when a caregiver artificially breaks the bag of water, which is the thin membrane surrounding your baby in utero, during a vaginal exam (using fingers or a hook). Because AROM can increase the risk of infections, as well as impact the rhythm of contractions, some women prefer to keep their membranes intact as long as possible, or to squat during a contraction to naturally break their own membranes.

5. If a labour is not progressing at a certain pace, if you are showing signs of exhaustion, and if baby is showing signs of exhaustion, some caregivers may suggest help to get your labour moving faster. It is usually a medical intervention, which involves a ‘drip’, which administers the synthetic form of oxytocin (called either pitocin, syntocinon or oxytocin) via an IV. Your caregiver may also suggest breaking your bag of water and accepting epidural analgesia.

6. Ellice Lieberman, Karen Davidson, Aviva Lee-Parritz, and Elizabeth Shearer. “Changes in Fetal Position During Labor and Their Association With Epidural Analgesia”. Obstetrics and Gynecology, Vol. 105, No. 5 (May 2005): 974-982.

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