Melbourne Doula

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Supporting a posterior labour

As first time mother, I'm sure you've already heard stories about posterior babies leading to difficulties in labour and eventual ceasareans. Well, here's what I think. The posterior position is just another variation of normal. The breech position is just another variation of normal. What is not normal is the way our system pathologises what is normal, and regards every healthy fit labouring woman as a litigation disaster waiting to happen.

If you are planning a homebirth with a midwife who trusts birth and trusts you, you can have a baby in a posterior or breech position and as long as you are motivated, well-prepared, and willing to do the work, odds are all will be well. However, in a time/money efficiency based institution, where they rarely have the patience to support the average first time mother through the birth process, they are unlikely to make any extra allowances. I've yet to see a hospital where they say, "Oh, she's a first timer and her baby is posterior, so this could take a while, we'll need to give her extra time and trust while her baby rotates."

It is vital, if you do start labour with your baby in a posterior position that you have two things in place: a careprovider who will not pathologise the posterior position, and believes you can do it, and is willing to give you the time you need to support your baby's efforts to rotate - and that you yourself understand that it is *possible* that your labour *might* take longer and need some extra endurance on your part while everyone waits for the baby to rotate. Now - you might have a quick 6 hour first time posterior labour and give birth to your baby sunny-side up - it's possible - but you need to be prepared that it *could* take 40, 50, 60 hours, and pace yourself accordingly.

Through staying fit and active throughout pregnancy, Chiropractic care and Optimal Foetal Positioning, you can optimise the chances of your baby being in an anterior position. This is worth doing if you have a careprovider or birth venue where there is no special attention paid to either first time births or first time posterior births. It can't hurt, and who knows, it could possibly help your baby get lined up for an anterior birth, which is *usually* more straightforward.

Optimal Foetal Positioning

If your baby is RIGHT anterior, you need to be aware of the theory of Rotational Positioning: that *some* right-lying babies, instead of rotating to right anterior and being born that way, like to rotate in a clock-wise direction, right through the posterior position, and round to the left anterior position, before they are born. They go the long way round! And this requires of course a great deal of patience, trust, active positioning and endurance on the part of the birth team - especially the mother.

For this reason, if your baby is right lying, I would suggest that you don't do OFP. Just get in plenty of walking and exercise, and wait to see if your baby shows signs of staying on the right or moving to the left. If s/he *does* move to the left, then start the hands-and-knees OFP. But I see no point in doing OFP with a right-lying baby.

Spinning Babies

Optimal Foetal Positioning

Rotational Positioning - from Childbirth International

The Webster Technique - from Plus Size Pregnancy

Sub Optimal Positions - from Gentle Birth Archives

This is all useful info that *can* be useful tools in our tool box. But just like an epidural can be a useful tool when appropriately used, or something that undermines a birthing woman's power, so too with this info. I think we need to be *aware* of the possible implications for posteror possies, but also avoid PATHOLOGISING a position that is just another perfectly OK version of NORMAL. A comment from the Gentle Birth Archives page:

"I wouldn't be putting any energy at all into turning a primip's baby anterior. This must be very psychologically undermining for her. She's starting out her birth thinking she's broken or something is wrong. I would:
1. Tell her to thank her lucky stars that her baby knew how to get head down
2. Tell her that we (mws, drs, nurses) think we know what way babies are presenting but half the time we are wrong
3. Tell her that when her birth sensations are strong, her uterus will push the baby down and through the pelvis in the easiest way possible.
4. Tell her that she was made to have babies.
What I would be working on is convincing her about is to have her baby at home."

From my own experience I have found that posterior does not mean a problem if a mother is in an environment where there are no protocols, time lines or deadlines, but instead there is a lot of love, a lot of trust, and patience to WAIT. I have supported a couple of first time mama posterior births and although we all had to have trust and patience, and we had to deal with sleep deprivation, the births unfolded over 50-60 hours and gave way to straightforward, 20-30 minutes 2nd stages. All with no intervention. I'm not saying that's *always" possible with *every* sub-optimal position, but if we don't pathologise the normal too much, it *is* possible.

Spinning Babies also points out that if a multi has a posterior possie this is rarely a problem. Even if the babe stays posterior through out the pregnancy and labour, at some point they just kind of follow the trail blazed by their siblings. Reading this reassured me when, despite all my OFP efforts, baby #4 stayed posterior. He turned on the bl**dy perineum! And while that didn't quite make it into my "hilarious, ecstatic, best fun of my life" basket, it was still a normal, ordinary birth with no hassles.

I think there is something to the notion that the "car-couch-computer" lifestyle isn't doing birthing women any favours. We stand, walk and lean forward a lot less than our foremothers even of the 70's and 80's (most of us). So I think encouraging walking, say, an hour a day, is a positive thing, plus plenty of other kinds of exercise like swimming, preggo water aerobics, preggo yoga or pilates etc. It's all good - no matter what possie babies favour. But at the same time, some babies will be posterior if the mother does snow-boarding every day of her pregnancy, so we need the balance of promoting healthy lifestyle and fitness but not pathologising the posterior position too much.

I do think hospitals, as a general rule, need to get much better at supporting the primip labour, especially if a sub-optimal position is a factor. This is where doula care can help. If you know the babe is posterior, supporting the mama to stay home longer and work with that posterior bubba. "To move the baby, move the mother" - physically, AND emotionally. Watch out for the premature pushing urge that occurs sometimes with posterior possies - no she isn't fully, it's just the babe rotating past the bowel, there's bowel pressure that can feel like pushiness.

Also the waters will often stay intact and the head high. I hate to see this pathologised. That water bag is like a cushion for the baby to rotate on! This smart baby is staying high until s/he can wiggle and jiggle round to a better key-in-lock fit! S/he won't descend significantly until the ROTATING part of the journey is complete. So what will happen if we pathologise the high head and decide to "help" the process by breaking the waters and giving syntocinon? "Because you don't want to be here all day and all night and all the next day do you?" No, thinks the exhausted mother. "And long labours aren't good for babies, you don't want to put your baby at risk now do you?" NO, thinks the terrified father. OMG the bl**dy Dead Baby card, thinks the doula.

The next thing you know, that baby is "coffee-plungered" down into the pelvis in a possie all wrong for *that* baby, the baby's birth intentions and planned MO just went down the gurgler .... next minutes they're muttering about Deep Transverse Arrest and Foetal Distress and it's all down-hill to theatre from there. Not the way to support a first-time posterior labour!

Also remember that sterile water injections and TENS can sometimes be useful tools when back labour pain is severe.

In the case of posterior possie and asynclitism as well - very tough gig for a firstie. Yes normal vaginal birth is still possible. But I have seen a couple of cases where we had no progress for a long time (24 hours) despite trying all the usual - mobilising, positions, pelvic manouveres, rest, food, rebozo etc so we transferred. Mama chose epidural and synt over immediate c/s. I felt that (a) she was holding a lot of tension in her hips and was unable to soften/yield there due to the intensity of the labour - and the epi might just be able to help with that; and (b) the epidural might just give her the rest she desperately needed. Thank God, this approach worked. 6 hours later, she was fully and began coached pushing. Of course, the drawback of the epi was now in play - she couldn't use gravity but had to push lying down. A ventouse was necessary in the end. But this is an example of obstetric intervention *helping* a firstie with a tough position on board to achieve a vaginal birth and avoid a c/s (we landed a lovely old-school obstetrician, very experienced). (BTW this particular mama had a straightforward home water birth with #2)

Sometimes right-lying bubbas take the short route and sometimes they like to rotate clockwise round the long way. So make sure a birth that starts ROA does not get pathologised into "Somethings wrong because of how long it's taking" with the entire arsenal thrown at the mother when she's about 6 cm and the baby is POP or LOP and still in the middle of his/her "Long Journey Round". Childbirth International has a good article on this called "Rotational Positioning". As a general rule, an un-medicated, supported mother with a patient, trusting team, who is able to stay active and upright: Walking. Drinking. Eating. Weeing. - and able to move her body instinctively, and has access to deep warm water when/if she wishes, will be able to cope with a long, gradual posterior first time labour, which will take a bit longer while baby is turning, then progress rapidly and reassuringly as long as we don't mess with it prematurely.

Also I notice that posterior labours, especially firstie labours, you don't see text book progress and you don't see text book contraction patterns. Progress is minimal until baby turns and then it's all on at the end - sometimes quite dramatically, and of course this is a wonderful relief. Also you see a pattern of "cluster contractions": very peter-y, non-impressive contractions for a long time. Then clusters of stronger one, 2 or 3 close together, then a long gap - repeat. This is typical of posterior labours and perfect for helping bub turn. Mother stays upright, often leaning forward, often swaying and wiggling her hips - inside, baby is doing the same thing! The Spiralling Concept from Birth As We Know It becomes relevant here.

However what if we pathologise what is normal for a firstie posterior labour? Policy says she must have 3 contractions in 10! Policy says she must dilate 1 cm per hour! What if we string up some synto and get her on the bed and attached to monitors to make sure the baby is OK .... and frog-march her uterus into doing it the way Policy says? Well I ask you. Are women machines? Can we force their bodies to do it the way those misogynists at Dublin hospital say? Fine go ahead, but you're completely stuffing up Nature's pattern for wisely and gently getting a first time mother through a posterior labour, and you're increasing risk for the baby rather than "saving" it.

The posterior position can be a perfectly normal variation for women. If we were better at supporting first time mothers generally, it wouldn't be such a big deal. So, if your babe likes to lie posterior - know that babies DO turn and they know what they need to do, and make sure you have a venue and informed care providers who know how to support and work with a posterior labour.

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