POSTERIOR BABIES, BACK LABOUR, AND HOW TO PREVENT HAVING A CESAREAN

By Jen McKinnon

Previously published in Birth Issues Fall 2012

Many pregnant women hear about the horrors of back labour from friends, family and even from strangers at the grocery store. I know that I have contributed to this unfair treatment of fellow women, sharing my experiences with back labour. I am hoping that I can make amends for my contribution to this phenomenon by giving some real information about back labour.

A posterior position is the most common cause of back labour that many women complain about. Back labour is when you feel discomfort in your lower back or around your sacrum (which is the back of your pelvis). It is difficult to say whether or not back pain is mild or intense because every woman will tolerate discomfort differently. The consensus, however, is that it makes us less relaxed.

I would like to start by saying that if you have back pain that does not mean that your baby is presenting posterior. You may be relieved, or not, to hear that sensations in your back can be due to labour itself.

Some of the reasons for this are physiological. Did you know that your uterus is attached to your pelvis in four different areas? There are two ligaments in the front of the uterus attached to the pubic bone area and two in the back of the uterus attached to your sacrum. When the uterus contracts it also contracts the four uterine ligaments. This causes a chain reaction—the ligaments pull on the pelvic areas where they are attached. Back pain, and even pubic pain, can be due to that constant strain.

Another physiological reason is that your pelvis is very flexible at the end of pregnancy. You must have noticed that by the end of the day your back aches. It’s from the weight of your uterus pushing you forward but also from the fact your pelvis is not tightly fastened as it usually is. It is usually fused in one spot in the front and in two spots in the back. But during pregnancy that gets loosened and your suddenly experience the Penguin wobble! That’s a good thing during labour because that gives more room for baby, but it also causes a lot of strain on the ligaments because the structure is loose, which causes them to be constantly pulled around…a little like holding the hands of 2 children instead of having them in a stroller.

There are emotional and psychological causes to back pain. You may be one of these women who normally get back pain when she is anxious, stressed, or scared. Labour can also trigger those emotions and therefore trigger that area to feel pain. If you have any traumas from your past, you may also carry, and bury, them in your back.

Finally, if a woman has had injuries in her back, or has certain health conditions, her back pain may be increased.

Now that all this has been said, let’s talk about back pain caused by a baby who is in a posterior presentation. Most babies are born in an anterior position, which means that the baby is head down and faces moms back and baby’s back is against mom’s belly (sunny-side-up). Posterior positioning is when baby is also head down but faces moms belly and baby’s back is against mom’s back (back-to-back).

So why do posterior presentations hurt our lower backs?

You may have already guessed by now. Posterior positioning means that baby’s head is pressing against mom’s sacrum. The hard head is pressing against the hard sacrum. It would not hurt as much if the soft face was pressed against the hard sacrum, at least for mom (baby may not like it that much though). This hard pressure creates back pain.

To make matters worse, the pain often does not last only during contractions. It also continues in between contractions. As labour progresses baby is negotiating a tighter and tighter space and is putting increased pressure on the sacrum.

And to top it off, the posterior baby’s head is bigger than the anterior baby’s head. What I mean by that is that the part presenting is not the same size if it is anterior or posterior. It’s hard to visualize, but let’s try. Imagine a baby’s head tucked into her chest. Visualize the top of the head: there is the flat part directly at the top. Imagine your hand caressing your baby’s head. Slide your hand forward, you will find it slides down over a ‘ridge’ onto the forehead. Okay so the anterior baby will present the part that is above the forehead when you slide your hand over the ‘ridge’. The posterior baby will present the part that is just before the ‘ridge’. Although this may seem insignificant, inside the pelvis it makes a huge difference. It is a matter of one extra inch. That’s a lot.

This will mean that with a posterior baby you will have to dilate that much more to give birth to your baby. You will need to have enough patience to allow baby’s head to mold to fit and you will need extra time to allow your baby to corkscrew herself and re-position in a position that is not so posterior. If you hear the words “direct OP” it means that the back of your baby’s head is directly against your sacrum. You can have a posterior baby that is only slightly posterior because her head is partly against your sacrum. In any case, that extra inch will increase the length of your labour and the time you have with back pain.

How do I know I have a posterior baby?

If you experience all of the following things, you have a posterior baby.

(1) When you are in labour, your caregiver can do a vaginal exam and check how the head is presenting. This is a deeper vaginal exam, but it is information which can help your caregiver give you advice as to which positions to adopt to help rotate your baby.

(2) Your contraction patters. In an anterior position, your contractions come at (usually) a regular time with a rest in between. Contractions will come closer together and last longer, until you feel like pushing. There is a clear pattern. But in a posterior position there is no pattern, or perhaps it does. It has a start-and-stop stop-and-go pattern. It will start slowly, often over several days. You will think you are in labour and then after hours of labour contractions will space apart and stop only to start again the next day or during the night! This is not active labour this is a long early labour stage. If your caregiver checked you, you would probably be under 4 cm dilation even after several days of this pattern.

(3) Contractions don’t seem to ease up. They can often feel unusually long and intense followed by a smaller contraction. However, stress and anxiety can also cause this.

(4) You are experiencing constant back-ache that continues during the entire labour. It does not ease up in between contractions like it would normally with an anterior baby. The feeling can range from a dull but uncomfortable ache to a significant pain. This constant aching/pain can be extremely tiring.

Why is the contraction pattern like this?

It may surprise you but if unmanaged the contraction pattern is very efficient. It will eventually result in you going into active labour like any woman and giving birth naturally. The reason for this pattern is because the uterus is helping the baby rotate and reposition itself. It is also helping put pressure to help with the molding of the head. It would be way too hard to do that in one go. Both you and baby would find it too intense. The uterus is protecting you and baby by taking breaks. Work work work… break. Work work work… break. Work work work… break. Eventually, your baby is in a position that is optimal for birthing.

So, what can i do to have a vaginal birth when I have a posterior baby?

Although difficult, posterior positioning is a variation of normal. It is still a form of natural childbirth and is not something to be feared. Many women have ssuccessfully given birth vaginally, unmedicated or medicated, and have found the experience both empowering and life-changing.

There are many things that a mom and her birth team can do to help give her relief if she has a posterior baby. Many things can significantly impact a posterior labour such as patience, collaboration, encouragement, distraction, interventions, and positioning.

(1) Patience

There are three main reasons for not being able to have a vaginal birth: baby’s heart tones are poor, mom’s life is in danger, and mom quits. You can have the best team in the world, the best prenatal education, the best hospital, the best home environment, the best labour, the best health, and the best fetal heart tones; but without patience those things will do you no good. Just like any Olympic athlete, or long-distance runner, you need to keep emotionally stable and mentally focused. To achieve this state, patience is needed.

There are far too many situations when a woman has a caesarean section not because her life or the baby’s was in danger but because someone on the team quit; because they felt it was taking too long. For example, mom was patient and focused, but after hours of active labour and no cervical dilation her team put pressure on her to accept interventions or to get things moving more quickly. Or all was moving along well, and the mom suddenly declares she doesn’t want to do it anymore. I have seen both situations occur. In the first example, a woman will feel that no one believes in her ability to give birth within her own time. She may feel isolated, and it is a burden too heavy to bear at the height of labour, or after a long labour, and she will give up. After all she is in a fragile and suggestible space. It’s tough to have to advocate for yourself when you are emotionally exhausted and are barely holding it together. In the second example, the medical team as well as the spouse or doula will be absolutely encouraging but to no avail. The mom has made a decision and she won’t budge, even though one may think that if she could refocus she would have the ability to give birth without interventions. In both cases, a feeling of doom descends on the team and all that can be done is often a forceps, vacuum or caesarean delivery.

To prevent this situation the team; mom, doctor, midwife, nurse, spouse, family, doula, etc. all need to be patient. The mom also needs to be patient with herself and the process. Not to get discouraged by the stop-and-go pattern, the perceived lack of progress, the back pain, the length of her labour, the when and the why. Expectations can cause lots of sorrow. Each birth experience is unique and special. I have heard pregnant women say that they feel expected to ‘perform’ during birth in a certain way and the moms feel unsure that they will be able to do it. Trust yourself and trust your baby. Let go of all of that baggage. This is your birth. Do it your way. If you allow yourself, it is amazing how babies do get into proper positioning and are born without interventions.

(2) Collaborative care

Every woman has a birth team. Who will be on your team is up to you. One of the most important aspects of a birth team is collaborative care. Working as a team and being collaborative means that you, the mom, are very involved. It is necessary to ask questions and make decisions. Talk to your spouse and your doctor about what you want. Where do you want to give birth? What kinds of interventions are you comfortable with, if any, and what are you not comfortable with? This is where an involved spouse is vital because when mom needs all of her strength to focus on labouring—her spouse is available to answer questions to the staff and to ask the questions about what is happening.

To make this happen, you want to make sure that you and your spouse are supportive of each other, and that you are on the same wave-link. Of course you want that from your caregivers too. Make sure you choose your caregiver wisely and in case your caregiver is not on call when you go into labour, be sure to show them your birth plan. Be pleasant and polite. Firmness and confidence about your choices are not out of place. Be honest too. Make sure you do listen to medical advice and make your decision based on your health, goals, and values. Everyone wants to be appreciated. Honest collaboration allows a healthy work and birthing environment.

So this means that the mom accepts responsibility and that medical providers relinquish it. You will need to work together in a way that allows you to have a satisfying birth experience while maintaining safety. This balance is often difficult to achieve as caregivers have pressures that may impinge on their ability to let go of control (e.g. colleagues, College, hospitals, insurance companies, etc). Our current obstetrical environment is a real challenge in this regard. But it is possible and as consumers we need to be aware and to encourage this new paradigm.

(3) Encouragement

It takes a woman’s full attention and energy to give birth to a baby so it is very important to say encouraging words and to help verbally guide her through the process. Always be positive. Praise her for what she has accomplished. Remind her that she has already done it before and she can do it again (if she has given birth previously). Tell her you understand. Validate her feelings, even when she is discouraged and at a loss. Hear her. Never scold her or lose it. Nothing she says is personal…

If a mom is giving birth in a hospital, help mom to tune out the sounds of the hospital (monitor, pumps, people coming and going outside her room, discussions in her room, etc.) and to focus on her body and baby. She needs to turn off her brain and enter her body like an animal would.

Help her to visualize her baby moving into, through and out of the birth canal. Encourage her to visualize opening and dilating as well as concentrating on her breathing which should be slow and relaxed, filling her lungs each time with oxygen to fuel herself and her baby. Try to ignore everything else and just be completely present for her.

(4) Distraction

It is common to go into the hospital early but research shows that the longer you are at the hospital, the higher your chances are of having interventions. There is no need for that. So stay home and attempt to move labour along while in the comfort of your own home. In early labour, have a nap, take a bath or a shower, play with your children, make dinner, or watch television. In early labour you don’t need to concentrate as much. You may feel uncomfortable, but you are still quite chatty and able to communicate in between contractions. It may be several days… so take it easy! Once you are in active labour, also resist the urge to go to the hospital or to have your midwife with you (although she may come for a check and leave). You will need to concentrate more but keep distracting yourself. You will probably need your spouse, mother or doula to help you. Walk around the block, walk your stairs, rock your hips while on all fours on the floor or on your bed, take another bath or shower or even cry! All of these activities help to distract you from the labour and also from the time going by.

(5) Interventions

If you are planning a hospital birth you may feel stressed about when to go. Again; research has shown that the chances for interventions are increased the longer you are at the hospital. If you arrive in early labour, at 3 or 4 cm dilation, statistically speaking, you have a higher chance of medical management. Once you are at the hospital, you enter a system, not that it is evil or out there to get to you, but it does have a life of its own. It has its own rules and goals. So ignore that you are in labour and distract yourself as long as you can.

Sheila Kitzinger in her book, The Complete Book of Pregnancy & Childbirth states, “If the baby is posterior, there are some good reasons that the membranes should not be ruptured artificially. It is much easier for the baby to rotate if it is still floating free. When membranes are ruptured, the baby often drops down into the pelvis in a posterior position and is fixed rather like a cork stuck in a bottle.”

Keeping this in mind, it is imperative that a couple be educated about all the pros and cons for any intervention—as they may start a cascade of unexpected effects, which may lead to more interventions. Knowing about the effects of laughing gas, morphine, epidural analgesia, synthetic oxytocin (Pitocin, Syntocinon, Oxytocin), breaking the bag of water, augmenting labour, induction, forceps, vacuum, and cesarean sections, can help you decide how you want to proceed and what choices you want to make. This is what we call making an informed decision. Without it you don’t know what you are accepting. It would be like signing a contract without reading it beforehand.

On that note, knowing your rights is important. The hospital is not a prison and you are not an inmate. If a medical provider tells you, “Oh no we can’t do that, that’s not protocol”, “That’s not the way we do things”, “We have to do a vaginal exam every 4 hours”, or more disturbing “The doctor ordered it and you have to do it.” I have heard these in hospitals and they are false. You don’t have to do anything. Medical providers are bound by protocols and by their profession, but you are not. They will assume consent unless you state refusal and unless you say no. Because it is rare that a patient refuses the course of care advised by her team, do not be surprised that you may experience resistance if not contempt. Sometimes even bullying. Things are changing however in hospitals all across Alberta. Change needs to happen with moms first though. Like I said earlier, this is your birth so do it your way.

(6) Positioning

Earlier we spoke about the fact that a posterior baby presents a larger part of her head. Also they can rotate into anterior presentations. These two facts mean that a woman needs to concentrate on proper positioning. Positions that take advantage of gravity or widen the pelvis are especially helpful and will enable her to achieve a vaginal birth. Here is a list of several positions that are recommended during contractions:

Kneeling: Kneeling on all fours on the floor or on the bed with a wide stance widens the pelvis giving baby extra space to turn. It also takes the pressure off the sacrum, because baby falls on the belly. It may also encourage baby to turn as she is now flat on her face.

Lunges: Raise a leg onto a chair, stair, stool, or even toolbox (one foot high is enough) and lean into the lunge during each contraction. Do not go back and forth, stay into the lunge during the whole contraction. You can switch sides after each contraction, or do 5 on one side and then 5 on the other. Your support person can move the stool or toolbox. This position also helps widen the pelvis while also using gravity to bring baby down or rotate further into the birth canal. If you see a mom in labour who leans forward while standing and slightly twist one of her legs and feet (or raises a foot), this may mean she is intuitively trying to rotate her baby in a more optimal position. This is your definitive cue to put the stool under her foot.

Squatting: Works the same as lunges but widens the pelvis even more. You can squat by dangling on a person, from your kitchen sink, ramp, bed (bring hospital bed up), and furniture. Keep your feet flat on your floor and have someone hold you in your back. Once you are done, someone can help you up. Squat as a contraction starts and then take a rest position between contractions. This is the best position to use however squatting can be tiring so be aware to manage your energy. You may also feel more pressure and that increased intensity may be difficult to manage. Think of doing 1 squat and 2 contractions standing, then 1 squat in 2, and eventually only squats.

Double-Hip Squeeze: Using a flat hand a birth partner or nurse can press on the flat paddles of the hip-bones during a contraction. The pressure pushes the meat of the bum together, so think that you are trying to press your hands together. It requires the person who is doing it to be quite close to the mom’s body. It flares the pelvis at the pubic joint which creates more space for baby to turn. It also very efficient at alleviating back pain. It is one of any labouring mom’s favourite.

Pelvic rocking: Rock your pelvis continuously during contractions. It can be done on a birth ball, on all fours or even while slow dancing with your partner. It helps the rotation of your baby’s body and distracts you. Remember that a baby is not sliding out, she is rotating out. By rotating your hips, you are accompanying the natural movement of your baby by allowing your hips to open in a rhythmic manner. It is not that easy to remember to move your hips, so your birth team can be behind you and slightly press on one side and then the other of your hips to remind you to move.

These positions will not hurt baby if baby is in an anterior position but will significantly increase your chances of baby turning if indeed baby is posterior.

Giving birth to a baby can have many faces and posterior positioning is just one of those faces. Knowing your body, understanding the progression of labour and having the support necessary are all the tools you need to complete your journey into motherhood.

Jen McKinnon lives in Cochrane with her husband, four children and her dog. Jen homeschools her four kids, is a writer and a doula.

Notes:

Sheila Kitzinger, The Complete Book of Pregnancy and Childbirth, Alfred A. Knopf, NY: 2011

Henci Goer, The Thinking Womens Guide to a Better Birth, Berkley Group, NY: 1999

Elizabeth Davis, Heart & Hands; A Midwives Guide to Pregnancy and Birth. Berkley Group, NY: 2004