Malposition-…more questions than answers
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)