In the previous post I explained some of the basics about baby positions and how they can affect labour.
One of the things I didn’t address is why malpositions are common and why they can be such a problem in labour.
Although I believe our bodies have evolved to give birth successfully the majority of the time, there will be some for whom labour is more difficult, especially with a baby which is not in the optimal position for their pelvis.
Remember, we are all on a continuum of 4 basic pelvic shapes and some of these are a shape that need a baby to be posterior or asynclitic to engage or fit through the pelvis, so there is no one optimum baby position. Problems occur when a baby cannot get into the position it needs to engage or fit through the pelvis.
Why might this occur?
Whilst our bodies have evolved to give birth, they have also evolved to work best when we follow a paleolithic type diet, and exercise (like a hunter gather society) with walking at least 5-10 miles a day and frequent squatting. Many of us do not eat this sort of diet or manage to exercise like this.
Even if we do some yoga and sit on a birth ball in an evening, this does not necessarily correct the issues caused by working in an office all day and lots of driving. For women that also do not stretch and exercise regularly or who are obese, it can be even harder for a baby to get into an optimum position (for lots more info see http://www.plus-size-pregnancy.org/malpositions.htm)
Labour is a complex process
Like the flight of a bumblebee the complex process that starts labour and how it progresses normally is still not completely understood, but it is a complex process that involves physical (including hormonal) processes and also emotional and spiritual.
If women are evolved to have straightforward births, they are also evolved to have undisturbed and unmedicated births, which begin without interference, where they can allow their neo-cortex to relax so the hormones of labour, oxytocin and endorphins can do their work.
Some anthropologists have argued that society evolved to have women companions during the birth to give comfort and physical support to women in labour. Many indigenous cultures have birth customs that involve women being upright and movement, and also water, whether immersion in or squatting over steam baths.
In our current medical model of birth which has a rhetoric of choice, but is bound by a risk and intervention based protocol, it can be very difficult for women to go into labour naturally and to make the kind of instinctive movements (nesting in a warm, dark, private space) which can help babies negotiate the passage from inside her to the outside world.
If women are induced, they will have drips and monitors which mean they may labour on their back. An epidural as pain relief means most women cannot mobilise and make a posterior position more likely.
Some women can easily birth babies in whatever position they are in, without needing to mobilise. Others may need to do lots of work, either in pregnancy or in labour (like this! http://www.youtube.com/watch?v=mXmwtpJ6Lb8) to help their babies to be born without intervention (and it is these women that are most affected by time limits, and limits to mobility in labour)
I believe that this complex birth process is effected by a huge range of possible scenario’s. It is wrong to imply to women that if they trust enough that their labour will progress easily. For some women this may be the case, but for those whose labour does not progress, it is not the ‘fault’ of their mind (not relaxing enough to let go), their spirit/emotions or body but a result of the circumstances we find ourselves in today. Diet and exercise can be dictated by society and circumstance and also the level of deprivation in the local environment.
Research needs to be carried out so that the best ways to prepare women for labour and support them in labour are at the heart of birth protocols in our hospitals to give women the best chance of going in to labour naturally and allow their babies to be born without unnecessary and harmful interventions. Women with babies in non typical positions may have a different labour pattern to that which is typically expected on a labour progress chart but that does not mean with time, freedom to move and good support in labour that their babies cannot be born without assistance.
In summary, a babies position during pregnancy is governed by a whole host of factors and whether this affects the progress of labour and the interventions a woman has during birth also depends on the circumstances she finds herself in, however there are ways to prepare for birth and gather a support around yourself for labourand this can make all the difference between being able to birth without interventions which can have long term implications to the health of mothers and babies.
I have been interested in malpresentation (babies that present in a non typical position like posterior, brow, face, asynclitic) since my first baby was born stargazing (persistent posterior).
Babies can be found in non typical positions during pregnancy but as babies can change position frequently until relatively late in pregnancy (although most are head down by 32 weeks) so health professionals are usually only worried about babies that are presenting breech (bottom down) or transverse (lying across the uterus) later in the pregnancy.
Women that have babies that are still breech or transverse after 35-36 are offered ECV (External cephalic version) where doctors try to turn the baby to head down through the uterus wall (see here for more info http://www.breechbirth.org.uk/ecvchoice.html)
Other non typical presentations that are head down but can be associated with more interventions include posterior (back to back) but many babies will rotate to an anterior position either before labour starts or during labour so women may not be told about their babies position or are told it is not a concern so they don’t spend their pregnancy worrying.
What’s the problem?
- Can have longer labours
- Stalls in labour
- Longer second stage
- Augmentation (drip) more common
- Assisted delivery more common
- More episiotomies and tears
- Gardberg (2011) found 65% of first time mothers with any malpresentation gave birth by CS
Quite often if I hear a woman’s difficult birth story, it seems likely that the cascade of interventions that occur are often set off because babies are in a difficult position (labour is overdue or slow to start, waters may break without contractions, labours have unusually intense pain from early on which leads to the use of pharmacological pain relief (diamorphine, pethidine or epidural), this then effects mobility, stalls in active labour lead to augmentation (drip to speed up contractions), second stage is much longer than usual or women have no urge to push, may have a cervical lip) leading to episiotomy, ventouse, forceps or emergency cesarean section.
But malosittion isn’t always a problem, some pelvic shapes make a non typical position more likely and may require the baby to be in a non typical position to engage.and for labour to start.
Women will be on a continuum of 4 basic pelvic shapes- Gynecoid (pear shaped body), Android (boyish shape, no obvious waist. Anthropoid (more common in non white women, larger bottoms) Platypelloid pelvis are rare (tend to carry a lot of weight in the lower abdomen). A family history of difficult labours may point towards a pelvic shape that makes a labour non typical in pattern.
Whether a malposition is a problem will depend on many factors-
- Pelvis shape
- Pelvis size
- Baby size
- Baby position (this can also encompass flexion (chin tucking) and arms above the head
- Mothers health in pregnancy (diet and exercise)
- Mothers mobility in labour
- Mothers pain relief in labour (epidural use is associated with babies turning OP in labour)
Sometimes women that are very fit and healthy can have problems too, especially those that have very tight abdominal muscles like athletes and dancers and can benefit from exercises to relax the uterine ligaments.
Recognising malpresentation in pregnancy
- Belly mapping (spinning babies see http://www.spinningbabies.com/products/belly-mapping-workbook)
- Kicks around the belly button area
- Wiggles in the front, bladder area
- Forehead overlapping brim ~(can be felt by mother when laying on her back)
- Pain in one or other hip, hip sticks out more on one side than another
- Dip seen in belly button area
Recognising malposition in labour
- SROM- at start of labour and/or without contractions
- Stop/Start labour
- Long latent phase
- Irregular contractions
- Stalls in active labour
- Long second stage or no descent
There is very little research to show what works to help prevent or resolve malpostion. Often midwives may not tell women their baby is in a non optimal position, and in labour it is rare that health professionals suggest anything to help reposition babies except to treat the symptoms (drugs for pain or drips to speed up stalled contractions) although suggestions for position changes like all fours or use of a birth ball may be given.
What can be done?
The most comprehensive website about malposition with exercises that can be done in pregnancy and labour is Spinning Babies (http://www.spinningbabies.com/).it includes exercises that relax and untwist the ligaments that hold the uterus in place (e.g. rebozo sifting and inversions) and that can move babies in non optimal positions (like breech and transverse) or can be used if labour stalls (e.g. lunge, hip press, dangle).
Other work may be necessary if a baby does not move easily or if there is a previous difficult position.
seeing a bodyworker like a chiropractor might help.
Good support in labour can make a real difference so consider a doula. (http://doula.org.uk/)
Forewarned is forearmed!
If you know your baby is in a non typical position towards the end of the pregnancy or you have had a previous difficult birth or a family history of difficulty then there are many things that can be done to make labour easier and intervention less likely.
Why bother if not all women have a problem?
It is not always easy to tell who will have problems when a baby is in a non typical position. You may be lucky enough not to have problems if you’re baby is in a different position but doing some preparation work in pregnancy wont cause any harm and may be a big help!
I did a workshop with midwife Gail Tully from Spinning babies in 2012 and have been using these techniques with women in pregnancy and labour since 2007.
You can see my using a hip press at this homebirth
I offer a range of services in the UK to support women and birth professionals to help prevent and resolve malpresentations including
- Learn a routine of simple exercises to relax and balance you’re uterus so your baby can settle into the best position for an easy and gentle birth. Includes a relaxing rebozo session
Overdue Support or PROM (waters gone but no contractions)
- A personalised session incorporating, birth planning, massage, acupressure, rebozo and positioning work, belly dancing, releasing fears and techniques to help you relax, release fears and tension and gently encourage labour to start.
Birth partner one to one sessions
- learn skills to help a baby into an optimum position for an easier and faster birth, get labour started if over due date or waters break, movements that can progress stalled labour, comfort measures that really work (especially with a back labour)
Workshops for doulas, midwives and students
- Learn ways to recognise the signs of malosition in pregnancy and labour and techniques to resolve issues and to help prevent intervention.
- Practice techniques to use in pregnancy and labour including Manteada (rebozo)
- Includes tips to resolve many common and uncommon positioning problems (asyncliticsm, lack of engagement, posterior presentation, nuchal arm, cervical lip)