There are many comfort measures that can be taken when a woman is experiencing back labor, that particularly intense labor when Baby is prepared to be born "sunny side up," and his spine is against Mama's spine. As helpful as counter pressure and bathtub laboring may be, the best solution to the distresses of back labor is getting Baby to rotate while Mama is laboring.
"If you can't move the baby, move the mother!"
even During Labor
In other words, if baby’s position is off and doesn’t move easily, use shifts in the mother’s position to help the baby disengage and re-align more favorably in the mother’s pelvis. However, in order for this to take place most easily, it is important the bag of waters still be intact. Avoid Breaking the Waters
Techniques to Turn the Baby
Not only is important to keep the bag of waters intact if at all possible, it is also vitally important for the mother to be off of her back or bottom if malposition is suspected. The mother needs to make more room in the pelvis for her baby to turn, and traditional lying and semi-sitting positions force the tailbone inwards and constrict the space available. Making more room in the pelvis can be done by:
altering the level of the mother’s hips (swaying or dancing, circling the hips, belly dancing)
rocking from side to side
kneeling on one knee, raising one foot
an exaggerated ‘marching’ step
marching up and down stairs (with exaggerated lifting of the knees)
going up and down the stairs sideways
stepping on and off a stool
asymmetric labor positions (lunged to the side, or with one leg bent and up, etc.)
side lunges, done over and over again
‘double hip squeeze’ (a helper squeezes together the upper part of the woman’s pelvis from behind) (with thanks to http://www.plus-size-pregnancy.org/ for original)
The following is from a Childbirth International handout created by Nikki MacFarlane that details how to encourage Baby to rotate into a better position while the mother is laboring.
1. Most babies that become posterior begin labour at ROA
2. Babies prefer to turn clockwise
3. Gravity aids rotation
4. The faster a baby rotates, the lower the incidence of complications
5. The baby will continue to turn until it finds a position where the head can comfortably descend through the pelvis - babies do not consciously move to an anterior position! They are simply rotating until they fit comfortably into ther pelvis and can descend. If there is enough space for the baby to fit when in a posterior position, that is how it will be born. If not, it will continue to rotate until there is enough space.
IMPORTANT: Remember that you are using positioning with the consideration of gravity. Always work WITH gravity so the work for the baby is easier.
Ask the mother where she thinks the baby is lying. In most cases, she is more aware than anyone else. If she is unsure, ask her where she is feeling the baby kick. If the baby is kicking on the left side of her belly or just left of her bellybutton, it is probably lying on the right.
Stand in front of the mother a few feet away when her belly is exposed. Look at each side and see if you can notice whether one side is more pronounced than the other.
Stand behind the mother with your hands on her hips. Close your eyes and feel the hips. Does one side seem to protrude more than the other?
If you are still unable to assess and there is no caregiver available to palpate the mother's belly and determine the position of the baby, look at the nature of her labor. Were the contractions regular and strong and now have spaced out or reduced in intensity? Could this be because she is simply exhausted and needs to rest? When was the last time she ate or drank anything? Contractions that become less regular could simply be her body's way of taking a break if she is exhausted or low on energy.
Is she experiencing back pain? Is it constant or only there at the peak of contractions? If it is constant the baby is probably posterior. If she lies on her back, is there a dip in the center of her belly - if so, the baby is probably already posterior. If you think the baby is already posterior, go straight to step 4.
The next step is to encourage the baby to move towards the right hip, using gravity to the baby's advantage. Suggest that the mother lie on her right side. If the baby is near the hip this may be uncomfortable. Ask her to try this position for at least 3 contractions - at this point it seems to become less uncomfortable and many women will start to drift asleep between contractions.
While the mother is lying on her right side, you can make her as comfortable as possible with pillows and apply counterpressure on her left hip with downwards pressure. This seems to work a little like the double-hip squeeze and can be very helpful during contractions.
Heat or ice packs placed just behind the right hip also help to ease any discomfort. If she needs to get up and move around, it may be helpful to apply strong countrerpressure to the right hip while she is standing.
If the mother is awake, it is important to get her up every 30-60 minutes to determine if the baby is rotating. This allows the woman to stretch and rock her pelvis and empty her bladder regularly. It also allows you to see if there has been any rotation taking place. if the woman is sleeping, the rest at this stage is more important than any observations. Leave her sleeping! In most cases, the mother will drift in and out of sleep, waking for contractions.
Many woman are initially reluctant to lie on their right side. This may be because they have been told or read throughout pregnancy that it is better to lie on the left side to optimize oxygen flow to the baby. Or it may be because the position is initially uncomfortable. However, if she remains on her left or in a forward position such as all fours, and the baby is trying to rotate clockwise, progress is significantly slowed down. Reassuring the mother that resting during labor is as beneficial as upright positions is improtant here. if the mother has not taken any food or drink for some time, it is also important to ensure this is available if she wants it. Her body is working hard and denying her of energy when this is such hard work is unnecessary and more likely to lead to problems later.
Signs of rotation at this stage are:
increasing discomfort in the right hip as the baby moves past it
the right hip bulging significantly - you can feel this when she gets up to the bathroom and you place both hands on her hips and close your eyes to really feel what is happening
mother needs to left or stretch her right leg when she gets up or comments on pain down the leg - this is due to compression of the sciatic nerve as the baby moves towards the back of the pelvis
you can feel a bulge in the back of the pelvis on the right as the baby rotates
the mother notices that the baby's kicks are now closer to her bellybutton or moving towards the right of her belly
looking at the mother from the front you notice that the right side is no longer more prominent than the left side
Do not expect to see any change in the contractions frequency or intensity at this stage. remind the mother that as the baby rotates she may begin to experience back pain. You cannot avoid this if it is going to happen - but knowing about it and knowing it can be dealt with makes it much easier to manage.
Continue with this until you notice that the baby has moved completely past the hip. It is important not to move to step 4 until the baby is at the back of the pelvis. In most cases, the most significant sign is the starting of back pain but have a good feel of the mother's hips before you move to the next stage. If you have already felt the right hip bulging and now it is the same as the left hip, and the back pain has started, the baby is probably now lying in a posterior position and you are ready to move on. Let the mother know what fantastic progress she is making. If she is aware of how the baby is moving around and rotating through her pelvis she is alot less liekly to become despondent.
Once the baby has rotated past the right hip it is now lying in a posterior position. This tends to be the most challenging part of the labor. Consider gravity again - the baby is now trying to move clockwise, towards the left hip. The most effective way to achieve this is for the mother to move to a left side lying position.
The signs to look out for to indicate the baby has rotated to a posterior position are:
constant or intermittent back pain
right hip moves back to a normal position once the baby has rotated fully past the right hip
if the mother has a vaginal examination at this stage, the baby may still be high, or found to have a deflexed or asynclitic head
as the baby moves towards a direct posterior position, the sacrum begins to move outwards
a reddish line appearing on the buttocks - a continuation of the crack of the bottom, moving upwards a few centimeters (half an inch - one inch)
One of the most prominent signs of a posterior baby is a dip in the mother's belly. If she lies on her back this is usually clearly seen as a slight depression around the bellybutton, or just below it. It may look almost like a donut shape.
The line appearing on the bottom is what is usually seen at the end of labor, as the baby moves down through the pelvis in second stage.
At the same time as the line appears, the mother begins to feel a lot of pressure in her rectum and may have some slight pushing urge. This is all due to the head pressing against the bowel and pushing out the sacrum. The sacrum is the triangular shaped bones at the base of the spine - you can feel the sacrum move outwards as the baby moves past it. if the mother is feeling an urge to push, you can ask her if it is irresistable and throughout the whole contraction, or only at the peak. If she can resist the urge to push at this stage it is probably only the head pressing on the rectum and not because she is advancing quickly through labor and already in the second stage.
Ask yourself if there are any other signs of second stage. has she been through a transition like state? Are the contractions lasting for 90 seconds? Has she had any significant show?
One of the very unusual things we have noticed at this point is that if you place your hand on the mother's sacrum, with your finger tips pointing towards her feet, your middle finger lies about where the coccyx, or tailbone, is. If you concentrate you can often feel the baby's pulse here in your middle finger. We can only assume this is because the pulse is transmitted through the bone as the baby's fontanels lie directly below the coccyx. When the baby is postereior remember the baby's head is more likely to be extended than flexed. This means that the rear fontanel lies closer to the coccyx than it would if the head was flexed.
IMPORTANT: If at all possible, it is important to avoid positions where the mother is foward, such as all fours, until the baby has fully rotated to an LOP position, behind the left hip. Also, avoid rupture of membranes if possible as the waters make it easier for the baby to rotate.
Remember to have the mother lying on her left side at this stage. As the baby continues to rotate through the posterior positions, she will probably be experiencing constant or intermittent back pain. Strong, firm pressure to the sacrum in addition to heat or ice packs can significantly reduce the discomfort. If the mother has had an epidural, you help her move from her right side to her left side once the baby rotates past the right hip. If she wants to be in water it is better to be in the bath rather than a shower as it is easier to lie down in a bath and utilize gravity to help rotate the baby. While water will help relieve discomfort it is more difficult to get the full advantage of gravity encouraging the rotation fo the baby and also very difficult to apply any counterpressure.
You can determine when the baby has rotated by asking the mother what she is feeling. Have the baby's kicked moved to the right side of her bellybutton? Are the contractions being felt anywhere differently from earlier? Often, as the baby moves to a direct posterior position the contractions are only felt in the back but as the baby moves towards the left hip they begin to also be felt in the front.
Once the baby has moved to behind the left hip, the mother can now move to a forward position to encourage the baby to move to LOA. LOA is the best position for the baby to be born from as it provides the greatest amount of space. The most effective position at this stage is all fours, or hands and knees. Another position to get the baby past the left hip is lunges or asymmetric positions, where the left leg is higher or more extended than the right leg. This can adjust the pelvis slightly to provide a little more room on the right and enable the baby to pass over the hip.
While the mother is on all fours it is helpful to have someone lie beneath her and firmly massage her belly with single strokes from her left to her right. This helps encourage the baby to rotate the last part of the way. These strokes should only be done between contractions and stop during them as they can be very uncofmortable if the mother is contracting.
In most cases, once the baby moves to an LOA position, contractions increase in intensity and frequency as the baby's head becomes more flexed and the head makes more consistent and even pressure on the cervix, increasing the feedback mechanism. Up until this stage in primips (first time moms) the mother may not dilate past 4cm. However, once the baby rotates to LOA dilatation may be rapid. In a multip (second or subsequent baby) the mother may continue to dilate regularly despite the posterior positioning.
While the baby is rotating past the left hip, the mother may feel a lot of discomfort in the hip or down her left leg. As was the case on the right side, this is due to compression of the sciatic nerves on the left side of the pelvis. Hot or cold compresses placed just behind the hip can be helpful. Also firm counterpressure on the left hip can be helpful.
As the baby makes the final part of the rotation, the contractions will most likely begin to be felt wholly in the front and the back pain will ease or disappear altogether.
If the mother is not comfortable on all fours, standing in the shower and leaning forward, or rocking on a birth ball can be helpful. She could also move to the bath at this stage if one is available. Adopting a position in the bath such as kneeling forwards will help encourage the rotation as well as easing any discomfort the mother is feeling. If the motehr is on the bed, moving her to an all fours position or kneeling over the back of the bed will help.
If the mother has had an epidural, this can be more challenging. If it is possible and the mother is willing, the epidural can be turned down slightly to give her some additional feeling in her legs. This can then enable her to move to all fours wioth support from a person on either side. If you place a birth ball on the bed she can lean over that and rest on it between contractions.
Rotational PositioningTM appears to be effective when a baby is attempting to rotate in a clockwise direction during labor. At this point, there is no research to support this technique, but the anecdotal evidence from doulas and midwives using the technique is extremely positive.
Rotaional PositioningTM will not always be effective and is not helpful at all during pregnancy. It may still be helpful to use techniques such as Optimal Fetal Positioning(OFP) in late pregnancy to encourage anterior positions. However, our experience has been that this is only effective if the baby is already posterior, and preferably on the left of the pelvis. When a baby is ROA OFP simply encourages the baby to stay there.
Rotational PositioningTM is most effective for primps (first time moms). In second or subsequent pregnancies, babies seem to either rotate much more rapidly on their own, or may even rotate across the front of the pelvis.
A few things to remember:
picture the baby trying to rotate and use gravity to assist
explain the progress to the mother to provide encourage and motivate her
do not expect consistent rates of progress - throw away the curves!
focus on rest and conserving energy for the majority of the time that you are using Rotational PositioningTM>, ensuring the mother is eating if she is hungry and remaining well hydrated
avoid rupture of membranes and oxytocics to speed up labor wherever possible
Finally, we would love to hear your experiences of Rotational PositioningTM. If you use it in a labor and find it works, or was ineffective, please use the discussion group on the main page to share your experiences. We would like to see research being carried out on this technique, but in the meantime, perhaps accumulating people's experiences will help us to refine the technique and determine how it can be used most effectively.
To help baby into position for the easiest birth… BEFORE LABOR
IF AT ALL TIMES…
the mother will cooperate with gravity, baby has an excellent chance to ideally position ‘himself’ during the final 6 weeks before the expected due date.
· Muscles, ligaments and joints MUST remain balanced!
· Use a birth ball, or pregnancy rocker (put a Swedish or ergonomic chair on rockers) as much as possible.
· When sitting on a sofa, an armchair or in a bucket type seat, place a firm cushion or pillow under mother’s bottom and lower back in order to sit more upright. Use tailor sitting.
· Watch TV or read while sitting on a dining room chair, or facing backwards on a dining room type chair, or kneeling on the floor leaning over an ottoman, coffee table, stack of floor cushions, birth ball, or a bean bag, or kneeling on a sofa or chair leaning over its arm or back.
· When resting or sleeping, mother can lie on her side. *NOTE: Gravity effects are different when mother is in pure side lying or semi-prone (exaggerated Sims’)*. If side lying with baby in Occipito-Posterior, lie so that baby’s back is toward the bed 15-30 minutes, then change to kneeling and leaning forward for 15-30 minutes. If semi-prone, lie so that baby’s back is toward the ceiling, for at least 15-30 minutes. (Labor Progress Handbook pages 126-130) A water bed is ideal for helping a persistent occipito-posterior baby rotate because it allows mother more comfort sleeping in this position.
· Long trips in cars with bucket type seats, semi-reclining positions, allowing knees higher than hips, (if at all, baby will likely enter pelvis in occipital-posterior mal-position)
· Sitting with legs crossed (decreases the amount of space in front part of pelvis, combined with semi-reclining, baby “has no alternative but to lie towards the back or posterior of her pelvis…it is probable that her baby will remain Occipito-Posterior and enter the pelvic brim in this position.”)
To help baby get into position for the easiest birth…DURING Labor:
Remember, in order to move the Baby, move the Mother! Use Hands of Love info!
Continually remind the mother to give her baby the space it needs, where it needs it, when it is needed.
Let her move instinctively, continuing to change positions. (Epidurals impede instinctive movement.)
Keep membranes intact. Keep the pelvis brim open.
Use gravity and motion to shift the baby, and to bring the baby down.
· Knee-chest position (rear end in the air) angle at hip greater than 90o for at least 30-45 minutes; before engagement it allows repositioning of the baby’s head, gravity allows baby to back out of pelvis, rotate and flex before re-entering.
· NOTE: Gravity effects are different when mother is in pure side lying or semi-prone. (Labor Progress Handbook pages 126-130)
· Standing and leaning forward; enlarges pelvic inlet, aligns baby with pelvic inlet, may promote flexion of baby’s head, may enhance rotation especially when combined with swaying
· Kneel, leaning forward with support of bed, ball, partner; aligns baby with pelvic inlet
· Pelvic rocking, write the baby's name with pelvis; helps dislodge head to enable rotation, encourages rotation
· Birth ball: lean on it, or sit on it, rotating hips and lean on bed; changes pelvic alignment and uses gravity
· Lunge, asymmetrical standing, kneeling, and sitting; increases pelvic diameter, elevated femur acts as a lever creating more space on that side of the pelvis for baby to rotate
· Slow dancing; repeated change in pelvic joints encourages baby to rotate and descend
· Dangle; elongates mother’s trunk giving baby more room to renegotiate angle of head in pelvis, allows more mobility in pelvis
· Abdominal lifting; to help align long axis of the baby with the axis of the pelvic inlet
· Rebozo, or stroke the mother's belly while she is on all fours, in the direction you want the baby's back to go; increases likelihood that baby will rotate
· Double hip squeeze; sit or stand behind mother, place both hands on back of each pelvis iliac crest and squeeze upward and inward, causes mid pelvis and outlet to widen, added room may allow rotation and descent
· Walking and stair climbing, sideways or two stairs at a time; changes alignment of pelvic joints
· Crawl backward and forward; gravity and changes alignment of pelvis
· Acupressure; fingernail pressure on outer edge of little toenail (could also turn breech)
· Rocking, swaying, stomp-squat, and other rhythmic movements; may alter relationships between baby, pelvis, and gravity helping rotation and descent. A rhythmic move seems to occur when mother is coping well in labor.
When Epidural is Used
· Delay epidural until at least 5 cm dilation. Earlier it may cause internal pelvic musculature to relax so much that baby is deprived of firm pelvic floor muscles which help baby to rotate. When unable to rotate out of the Occipito-Posterior or Occipito-Transverse position, the force of the contractions push baby deeper into the pelvis in mal-position, risking ‘failure to progress.’ Care provider may use two fingers, during vaginal exam, against baby’s head, forming a false floor on which baby may rotate to more favorable occipital-anterior position.
· Care provider may try manual internal rotation (Valerie El Halta – see Midwifery Today Issue 36). Caution: This may invoke negative memories for women with a history of sexual abuse.
· Mother should avoid lying on her back and avoid semi-reclining.
· Pan caking: Turn mother from left side to right side, and back, each 30 minutes. It is long enough to allow gravity to help with baby’s rotation while allowing epidural to continue to give good pain relief.
· Texas tilts: Similar to pan caking but at each 30 minute interval, at mid-turn, two support persons each standing on either side of mother opposite one another, reach under mother’s pelvis and grasp one another’s wrists, and lift her pelvis up and down 10 times then continue to turn her to lie on the other side .
· Hands and knees position is possible with plenty support, pillows, and conscientious care that her joints maintain proper alignment.
· Supported dangle-squat: Set up bed like a birth chair, use stirrups as hand holds or to support forearms. Keep hip angle 90o to 120o in order to maintain open pelvic brim.
· Keep membranes intact. Rupture of membranes could allow baby to wedge permanently into the Occipito-Posterior or Occipito-Transverse position, preventing rotation.
Helping Baby during Second (Pushing) Stage
At complete dilation and effacement:
· Keep mother upright and mobile. If standing she will need something solid higher than her waist in front of her to hold.
· Allow time for uterus to retone and baby’s shoulders to finish rotating into transverse in order to clear the pelvis brim, until then his head cannot descend further.
· Keep her pubic symphysis below her coccyx, keeping baby’s weight in the front part of the ichial spines (sit bones) of her pelvis.
· Keep legs well below hips away from body, angle at hips must be open 120o
· Mothers arms must be above waist level, in front of her shoulders
It is thought that if mother remains upright and baby is properly aligned, the back of baby’s neck triggers the movement of the mother’s rhombus. (Epidural anesthesia may interfere with nerve communication preventing this reflex action.) The Rhombus of Michaelis moves backward up to 2 cm. pushing the wings of the ilia outward. The mother reaches to find something solid to hold. She allows her body to sag and her knees to rotate outward. The mother moves her body, thrusting her hips forward the baby begins to come. Her spine lifts out of the way, her coccyx higher than her pubic symphysis as her back arches. The baby’s head is out; his shoulders rotate into the AP diameter. The anterior shoulder is seen first but uses the pubic bone as a fulcrum, as the posterior shoulder is born. The anterior shoulder then comes and baby comes out face down onto whatever surface is beneath the mother. Lying in the left lateral position is a good compromise to upright positions. If allowed to happen this way, less than 5% of baby’s will need help. This is different than what is traditionally done in the western hemisphere.
Watch for new additional information explaining how the mother’s pelvic ligaments and muscles work with the baby’s reflexes to bring the baby into alignment for most efficient and easy birth. Coming soon!
The Labor Progress Handbook ~Simkin/Ancheta
Let Birth Be Born Again Rediscovering and Reclaiming our Midwifery Heritage ~Sutton
Sit Up and Take Notice! Positioning Yourself for a Better Birth ~Scott
Understanding and Teaching Optimal Foetal Positioning ~Sutton/Scott
Posterior Labor-A Pain in the Back! It’s Prevention and Cure ~El Halta
Obstet Gynecol 2003
Comparative statistics for persistent occiput posterior (OP) fetal position and occiput anterior (OA) include:
|labor longer than 12 hours||49.7%||26.2%||0 to 6 1-minute Apgar||12.4%||7.1%|
|length of stage 2 greater than 2 hours||53.3%||18.1%||7 to 10 1-minute Apgar||87.6%||92.9%|
|spontaneous delivery||37.7%||83.9%||0 to 6 5-minute Apgar||0.6%||0.9%|
|assisted vaginal delivery||24.6%||9.4%||7 to 10 5-minute Apgar||99.4%||99.2%|
|cesarean delivery||37.7%||6.6%||shoulder dystocia||0.8%||2.1%|
|third- or fourth-degree tear||18.2%||6.7%||nuchal cord||18.6%||21.6%|
Persistent fetal occiput posterior position: obstetric outcomes. Obstet Gynecol 2003
For in depth explanation and demonstration contact JoAnne King. Classes available 10/2006
The following illustrations show a variety of useful positions, remember to keep the hip angle 90o or greater.
© 2004 Kassandra Clemens - Design by Flipside
The laboring woman can make the most of these positions by combining them with movement, chanting, natural breathing, visualization and massage. However, she should be able to rest whenever she feels like it, particularly in early labor. Encourage her to follow her inner urges. Her instinct and intuition will guide her when she allows her body's wisdom to take over.
Standing and Walking - Stimulates contractions. The downward force of gravity assists the baby's head to descend which in turn helps to dilate the cervix. Will also help to increase the efficiency of contractions and lessens discomfort, particularly when she leans forward with each contraction.
Helpful in early labor when the baby is in a good position - sometimes used for most of the labor.
Sitting upright and leaning forward on a firm chair, stool or toilet seat. Can be very comfortable. Her body is well supported while upright; good downward force. A nice position for being massaged because the back is so accessible.
To relax and to be in control with minimum effort.
Kneeling - An instinctive position particular in active labor when contractions are strong. Gives a sense of being literally on top of the contractions. A way of increasing privacy and concentration. Helps to feel centered. Easy to relax forward over a pile of cushions, a beanbag or a chair; makes it easy to change into different positions like standing, half kneeling - half squatting, squatting and all fours.
Helpful when labor starts in the night or when the woman is tired, needs privacy or seeks comfort.
Induces a feeling of control and release. Can be helpful for internals.
Particularly useful for active labor or for helping a posterior baby rotate.
All fours - lessens the force of gravity, thus reducing the speed of descent while providing the baby with enough space to move on; lessens the intensity of the contractions; allows for a wide range of movement, facilitates the ability to produce low noises and helps to feel centered; helpful in rotating a posterior baby.
Induces a feeling of control, makes breathing easy and gives privacy. Good when suffering from vulval or varicose veins.
Knee - Chest - Takes pressure off the back. Slows down a violent or extremely fast birth, thus helps to cope. Helps to create a time-out when needed. Extremely valuable in helping a baby to turn to a better birth position and to heal a swelling on the cervix (4).
Least pressure. Good for focusing and privacy or to take some time out. Can relieve pressure on the baby. Best position for an anterior lip to go down
Lying on Side - If labour is progressing well she may choose this position for comfort and a slow, gentle birth. Good resting position for a long birth. Take care that she rolls fully to the left side into the recovery position with cushions to prop up her head, right leg and under her right arm; use a small cushion as a wedge under her left hip.
Make her comfortable with big cushions in her back, to rest her arm on. Keeping her left leg long while the right leg is bent and flops right over to the left as in the recovery position, put a small wedge under her left hip.
© 2004 Kassandra Clemens - Design by Flipside
from Diana Johnson's website:
"There is an excellent way to change persistent posterior babies that has worked every time I have used it. It may need to be done several times in late pregnancy, but it will turn the baby every time. It is a chiropractic technique called a diaphramatic release. It is non-manipulative and easy to learn. I learned it from Dr. Carol Phillips, who teaches chiropractic care for pregnant mothers and newborns. Every midwife should know this technique. I no longer have any posterior babies. Neither my mothers nor I miss those long hard back labors!!
It is easy to recognize a persistent posterior baby. You cannot feel the back on palpation, rather only little lumps and bumps of limbs. To do a diaphragmatic release, it is best to have the mother lie on her back. If she is in advanced pregnancy and this makes her very uncomfortable, you can have her lie in a recliner or semi-sitting position. If you use that position, place a small pillow or adequate support behind her lower back.
One hand will go horizontally across her lower back where the uterine ligaments attach. This is where you would put lower back pressure during labor. You do not need to press, as just the pressure of the mother lying on your hand will be sufficient. (Be sure you take off any rings you may be wearing, for your hand's sake!)
The top hand will go on top of the abdomen, horizontally just above the pubic bone with the thumb upward. Just rest it lightly on the abdomen, no pressure. Then all you have to do is wait. Things may start right away or it may take several minutes before you feel anything. What you will feel is a motion beneath your hands. For the hand in back it will feel much like it does when there is a contraction taking place during labor as you feel the muscles tighten and contract beneath your hand and release. For the top hand it will be either a waving motion or a circular motion under your hand. At first you will think you are just imagining it, but you are not.
The best description I can give is that it feels as if the mother has a tennis ball in her abdomen that is being bounced back and forth between your hands. As it hits one hand it will roll across it or around underneath it and then bounce back to the other hand. Sometimes the motion is so great that it will actually make your hand wave on the abdomen. Sometimes the mother will feel things inside, sometimes not. What she feels may not be located where your hand is located.
The movement under your top hand may stay all in one place or move around. If it moves, try to gently follow it with your top hand to keep it centrally located under your hand. Do not move the back hand. Sometimes it will move around in a circle, sometimes off to one side, or even clear down to a hip. It all depends on the muscles that are involved and the type of injury that precipitated all the spasm of abdominal muscles.
Our muscles really only know how to contract and shorten, not how to relax and lengthen. They depend on another counter muscle to contract and pull the first one out of contraction. Abdominal muscles do not have as many counter muscles, so this technique allows the muscles to relax.
If you go back into the mother's history, you will almost always find a history of a car accident (especially with a seat belt on, where there has been a twisting of the abdominal muscles because we use only one-shoulder restraints) or severe fall. However, I have had a mother cause it simply by doing too much hoeing in the garden.
You continue the diaphragmatic release as long as you feel motion under your hand. Usually it will just fade away and you will no longer feel it. Sometimes, if you end up over a bony prominence, it will end with a vibration. The process takes some time, often at least 20-45 minutes. But if you consider the time you save in labor, it is well worth it. You may need to repeat the process over several visits. I usually start at about the 6th month unless I have a mother with a history of car accident or several prior posterior babies.
This procedure has also been used this technique to turn breech babies. I use it for transverse but find it less effective for breech. I usually use a tilt board for breech and then do a diaphragmatic release after the baby turns. It works marvelously well for posteriors. I have never done one where the baby did not turn to anterior. However, on some occasions, after a few days the baby will turn back to posterior and you will need to repeat the process more than once. The more severe the history, the more likely you will need to do it several times before the baby will stay anterior.
Posterior babies use to be the worst problem I had in births. The long hard back labors wore us all out and occasionally ended in transfers for maternal exhaustion. I am thrilled not to have these any more. Now my biggest problem is cervical lips! But I am working on a solution for that also, using evening primrose oil!
I do believe every midwife should have this valuable tool, the diaphragmatic release, in her bag of tricks. It is so easy and non-interventive. It is much better than other suggestions I have seen of putting your fingers in the baby's suture lines and trying to turn the head!"
OP: Prevention is Key, but remember ... Babies Come Out!
Karen Webster, CPM
Encourage all women to see a chiropractor throughout pregnancy, in order to normalize position and optimize the mama's health, rather than to correct a malpresentation. Women who regularly see a chiropractor have easier labors!
The baby's back is the heaviest part of its body, and will gravitate towards the lowest part of the mom's abdomen. So if your belly is lower than your back, for instance if you are sitting on a chair or birth ball leaning forward, your baby's back will swing towards the front of your belly. Likewise, if you're leaning back on a sofa or chair, your baby's back is more likely to swing back towards your spine.
Throughout your pregnancy, see a chiropractor who is experienced with adjusting pregnant women and who also knows the Webster Technique, which specifically releases the pelvic ligaments in order to allow the baby to assume a position in which the baby's axis is aligned with the mother's spine.
Optimal Fetal Position:
During the last six weeks of pregnancy, avoid positions that encourage your baby to face out towards your tummy. Don't sit reclining in chairs, or in cars leaning back, or any position where your knees are level with or higher than your pelvis. Instead, spend lots of time kneeling or sitting upright, or on your hands and knees; when you sit in a chair, make sure your knees are lower than your pelvis, with your belly tilted forward!
• Watch TV or read while kneeling on the floor, draped over a beanbag or birth ball, tailor sitting is great
• Tailor sit with knees out and soles of feet together
• Don't cross your knees, this closes up the front of the pelvis
• Don't recline with feet up, lie on your side
• Avoid deep squatting, but sit on a low stool, upright, not leaning forward
• Swimming belly down is great
• All 4's, cat/cow is good, wiggling hips from side to side
If you have an OP baby --- Don't panic, do what you can:
• See your chiropractor for the Webster maneuver; also ask about diaphragmatic release, another Chiropractic technique that is said to help babies turn
• Avoid deep squatting
• Sway your hips while in hands and knees position
• Crawl on the floor
• Try to sleep on your tummy, with lots of pillows for support
• Talk to your baby and visualize the baby turning
Dealing with/turning OP babies in labor:
During Labor, if baby is found to be OP - Don't Panic! The majority of babies who present OP in labor, turn, but even if yours doesn't turn, babies come out!
First, avoid drugs for pain relief! You need to be mobile and active!
• Lie on your back with a rolled towel in the small of your back; this is uncomfortable for baby and will encourage the baby to turn
• Lie on a slant board (ironing board works well) at a steep angle, for at least 15 -30 minutes. This can disengage the baby's head and encourage head to rotate and descend in OA position; you may try having the mama drink some valerian or skullcap tea to help relax her muscles
• Assume a deep knee chest position for 30-45 minutes, use pillows for Apply a warm compress on the lower abdomen with ice pack on the small of the back
• Try a belly band or belly lift to change the direction/angle of the baby's head and the force of the contractions, if the mama has a pendulous belly
• Do exaggerated lunges to the left and right between contractions; also have the mama "duck walk" up and down the stairs a couple of times
• If mama is very tired, have her lie on L side for 3, contractions, in exaggerated lunge, with R knee held up and supported over belly, L leg straight and towards the back, alternate this with R side lying, same position; Then have her do 3 ctx on all 4's, then 3 in knee chest
• If you have a big tub or birth pool, have mama lay on one side then the other, alternating every 3-4 ctx.
• Midwife can try to manually rotate the baby, have mom lie on back with hips slightly elevated, knees wide (sort of McRoberts position) midwife can then use fingers to push the baby up off the cervix and attempt to rotate the baby's head in the direction she feels it will turn the easiest. When the baby rotates, you can lower the hips and have mom push if she's complete, or have her flip over on hands and knees
• Sometimes, when all else fails and baby just won't turn, you can try the "Alley OOP" or McRoberts position and that will often give a persistent posterior baby room to come under the pubic arch and be born!
Hands and Knees position
Homeopathic Remedies to try:
Use at least a 200c potency
My favorite for OP babies, Kali Carb - this one is for excruciating back pain, as if her back is breaking. She wants constant, hard pressure on her back, may feel chilly and tremble, touchy, both mentally and physically, doesn't want to be touched, stroked.
Gelsemium - Baby appears to ascend rather than descend during ctx; pains go up the back or into hips; nervous & weak, chills up the back; heavy lids, flushed face, puffy eyes, drowsy and listless, wants to sleep; may have reverse dilation, performance anxiety
Cimicifuga - think of this one when there is a lack of progress at any stage of labor or ineffective, incoordinate ctx. - misplaced labor pains, felt in hips back, legs; pains may shoot up and down thighs or across pelvis; Cramps in large muscles; Fear that something bad will happen, hysteria, talking incessantly, sensitive to noise and is worse when cold
By Karen Webster, CPM