April 19, 2012

Explanation of Fetal Positions; Part 2

Why are some labors long and others quick? One main factor can be the position of the baby at the onset of labor. The ideal position would be with the baby’s back facing the mother’s abdomen, occiput anterior (OA), with the chin tucked in towards its chest. There are, of course, variations of this position. The baby could have its back slightly to the right -ROA (right occiput anterior) or slightly to the left -LOA (left occiput anterior).

Other fetal position variations are:
OT- Occiput Transverse- the baby’s back is to the mother’s side
OP-Occiput Posterior, the baby’s back is towards the mother’s back
ROP- Right Occiput Posterior- the baby’s back is towards the right side of the mother’s back
LOP- Left occiput posterior – the baby’s back is towards the left side of the mother’s back

Any of the OA positions are considered the easiest of fetal positions to facilitate labor progress because when the baby is in an OA position, the smallest part of the baby’s head, the fontanel, is pressing against the mother’s cervix. This pressing causes the cervix to dilate. Since it is the smallest part and molds easily, it is a better fit to push the cervix open. Think about when you put on a turtle neck sweater (the cervix being the turtle neck); if you tuck your chin, the sweater slides over your head easily. If you are looking up towards the opening of the sweater, it is more challenging to slide over your face. The same logic applies to your cervix!

When the baby is in the OP or OT positions, the fontanel is not the presenting part. Instead, it is likely that part of the baby’s un-moldable forehead is pressing up against the cervix. Sometimes the baby’s back is in the anterior position, but the baby’s head is slightly ascyclitic, meaning it is slightly kinked to the side. This is also going to create a bit of problem in pushing the cervix open in a timely manner.

How Do I Know My Baby’s Position?

For some women it can be difficult to feel what is happening internally. In addition to not understanding the movements inside, some mothers are at a further disadvantage by having an anterior placenta (the placenta being adhered to the front of her uterus) making it even harder to feel the baby’s movements. Start to pay attention to where you are feeling kicks and the shapes of your belly. Ideally, if the baby is in an OA position, you will feel kicks on one side of your belly. If your baby is in a posterior position, the kicks will be more towards the front of your belly. Visualize your baby inside your body, if the baby’s back is towards your back, then the feet will be more towards your front.

You can also start to palpate your abdomen. First picture your baby’s body. If the head is vertex, then the landmarks you are looking for are a smooth round back, a hard butt and feet. Ideally, you will feel this along either the left or right side of your belly. If you baby is facing back, then you may not feel this. Your belly will also look a bit different. Picture your baby’s back towards your back. This will leave your belly having a bump at the top- where the legs are tucked in -a small depression around your belly button, and then another bump where the arms are hugging inward.

If you suspect your baby is in a posterior position, there are things prenatally you can do to encourage your baby into a different position. Even if your baby is in an anterior position doing these things will only encourage your baby to stay put.

Be mindful of your posture and the way you position yourself in your daily life. If we know that heaviest part of the baby is the back of the head and their back, put your body into positions where that is encouraged into an anterior position, letting gravity help you and your baby. So instead of coming home and throwing your feet up and sinking into the couch, which will draw your baby towards the hammock shape our your back, lay on your side or rock on a birth ball. Or if you are comfortable, hang out in child’s pose.

Prenatal yoga and swimming are also great activities to help your baby into an optimal fetal position. For one reason, swimming and many of the prenatal yoga poses are belly down, encouraging the baby’s back towards the mama’s belly. Another reason for malposition could be tight, twisted pelvic ligaments and muscles. If the psoas and pelvic ligaments are tight this can restrict the baby from manipulating itself into a good position. In prenatal yoga, we address this issue and incorporate many hip opening poses into class.

What Are The Signs of A Malpositioned Baby?

*One of the biggest indicators of back labor is a tremendous amount of pain in the back, mainly the sacrum area. This is not to be confused with the ordinary amount of back pain a laboring women may experience. Lingering pain on the sacrum area is often secondary to the pain of the contraction itself. This pain is due to the baby’s head pressing up against the boney structure of the pelvis.

*Mothers may also notice a nonlinear labor pattern. In a functional labor, the contractions generally start out about 10 minutes apart lasting 30-60 seconds. As labor progresses, the contractions become closer together, forming a predictable pattern and being consistently 60 seconds long. In a dysfunctional labor, the mother may be having contractions 3 minutes apart with short painful contractions and then dropping back to 10 minutes apart.

*In a “normal” labor, if a mother was having contractions close together, say 3 or 4 minutes apart, it would expected that she was in active labor and her cervix was between 4-7 cm dilated. In a back labor situation, the mother may be experiencing strong, frequent contractions with little progress and slow dilation

*Another telltale sign of a malpostioned baby is the frequent need to urinate during/after contraction. This is because the baby’s forehead is pressing against the mother’s bladder.

*If the cervix is open enough the care provider can feel for the suture lines to determine the position of the baby’s head.

Ways To Help Rotate A Malpositioned Baby During Labor

Once you have identified that the baby is malpositioned, there are ways to help rotate the baby. This often takes patience, time and effort. BUT it can work, so don’t give up hope!

If the baby’s head is not deeply engaged in the pelvis, sometimes it can be as simple as spending time on all 4’s in positions like cat/cow or doing body circles or “shaking the apples”- this is done by placing the mother on all 4’s and jiggling her legs, this will loosen the pelvis. Counterpressure and the “double hip squeeze” can also be useful tools.

If the baby is a bit more stubborn to move, you will likely want to work on positions that open the pelvis allowing for more space to rotate the baby- like lunges. With the hips facing squarely forward, place a stool to the side of the mother and ask her to externally rotate her leg and bring one foot up on the stool. Then have her lean into the lifted leg and then rock away. Keep repeating this action for at least 5 contractions. This will create an asymmetric opening of the pelvis and can help rotate the baby. Walking up and downs stairs will also have the same effect, as well as walking while doing leg lifts with the lifted knee going towards the mother’s arm pit.

If the baby is still not rotating, the baby may be rather engaged in the pelvis and actually need to be disengaged to help it properly rotate. To do this, ask the mother to come into a position where her butt is higher then her shoulders. For example, “butt up child’s pose” or a wide leg forward bend. These poses need to be held for about 45 minutes. Truth be told- it will not be a comfortable position to hold. With the butt up, the is a fair amount of pulling on the round ligaments that hurt during the contractions, but this is an effective way to float the baby’s head out of the pelvis and allow it to reposition itself.

Also keep in mind that a malpositioned baby tends to lead to a longer labor, so offer the laboring mother a resting pose between the hard work of these “butt up” poses. Lay her on her side in a semi-prone position with her bottom leg extended and her top leg elevated on pillows or a bolster. Roll her towards her belly so her top hip is leaning forward. Take into consideration which side the baby’s head is facing. If the baby is ROP (right occiput posterior) then she should be laying on her left side. This will encourage her baby’s back towards her belly.

If the baby is still malpositioned, DO NOT opt for an amniotomy (breaking the water). While it may sound enticing and hopeful that this intervention could possibly move labor along, the water still intact will give some cushioning and more ease in trying to rotate the baby. With the bag broken, head may go further down in the WRONG position.

Sometimes, an epidural can also assist in helping a baby to rotate. If the woman is exhausted and her pelvic muscles are tight and constricted, putting them into a relaxed state can allow the baby to move more easily.

Knowing that malpositioned babies take the longer to dilate, be prepared to push against preconceived ideas of labor progress. Seventy percent of cesareans are due to “failure to progress” which could be from poorly positioned babies. Ask “If mother is ok and baby is ok, can you have more time?” These questions can possibly afford you more time to let your baby maneuver itself into a good position.

On a personal note, I would have been one of the 70% to have a c-section for failure to progress. Luckily, my midwife gave me the time (about 42 hours!) and tools to turn my baby so I could birth him vaginally.



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