To help baby into position for the easiest birth… BEFORE LABOR

IF AT ALL TIMES…

the mother will cooperate with gravity, baby has an excellent chance to ideally position ‘himself’ during the final 6 weeks before the expected due date.

· Regularly use forward leaning positions.

Keep her belly as a hammock
Keep her tummy lower than her spine
Keep her knees lower than her hips
Keep persistent!

· Use a birth ball, or pregnancy rocker (put a Swedish or ergonomic chair on rockers) as much as possible.

· When sitting on a sofa, an armchair or in a bucket type seat, place a firm cushion or pillow under mother’s bottom and lower back in order to sit more upright. Use tailor sitting.

· Watch TV or read while sitting on a dining room chair, or facing backwards on a dining room type chair, or kneeling on the floor leaning over an ottoman, coffee table, stack of floor cushions, birth ball, or a bean bag, or kneeling on a sofa or chair leaning over its arm or back.

· When resting or sleeping, mother can lie on her side. *NOTE: Gravity effects are different when mother is in pure side lying or semi-prone (exaggerated Sims’)*. If side lying with baby in Occipito-Posterior, lie so that baby’s back is toward the bed 15-30 minutes, then change to kneeling and leaning forward for 15-30 minutes. If semi-prone, lie so that baby’s back is toward the ceiling, for at least 15-30 minutes. (Labor Progress Handbook pages 126-130) A water bed is ideal for helping a persistent occipito-posterior baby rotate because it allows mother more comfort sleeping in this position.

In Addition:

Spend at least 20 minutes 3X/day on all fours pelvic rocking or hula.
Perhaps assume an open knee chest position (inversion postures) 20 minutes with pelvic movement 3X/day. Perhaps lie on a slant board as with a breech 30 minutes several times/day.
Scrub the floor, crawl, or do other tasks that require being on all-fours a lot, during the last 2 weeks prior to labor (not just for a few minutes, for 20-30 minutes at a time at least).
Swim, belly down, using breast stroke.
Take warm baths and gently encourage baby to “roll over”. Have mother visualize baby in the correct position and talk to baby telling it to move.
Resolve emotional fear and trauma, and constrictions.
Acupuncture, acupressure, chiropractic care, homeopathy, myofascial (diaphragmatic) release, rebozo, and yoga type exercise may be used as needed. Only modified squatting may be used during the last 6 weeks prior to labor.

AVOID:

· Long trips in cars with bucket type seats, semi-reclining positions, allowing knees higher than hips, (if at all, baby will likely enter pelvis in occipital-posterior mal-position)

· Sitting with legs crossed (decreases the amount of space in front part of pelvis, combined with semi-reclining, baby “has no alternative but to lie towards the back or posterior of her pelvis…it is probable that her baby will remain Occipito-Posterior and enter the pelvic brim in this position.”)

Deep squatting (may encourage baby to engage in pelvis in mal-position)

Prepared 2005 by JoAnne King CD 303.426.5845 joanne@doula4birth.com www.doula4birth.com

To help baby get into position for the easiest birth…DURING Labor:

Remember, in order to move the Baby, move the Mother!

Continually remind the mother to give her baby the space it needs, where it needs it, when it is needed.

Let her move instinctively, continuing to change positions. (Epidurals impede instinctive movement.)

Keep membranes intact. Keep the pelvis brim open.

Use gravity and motion to shift the baby, and to bring the baby down.

· Knee-chest position (rear end in the air) angle at hip greater than 90^o for at least 30-45 minutes; before engagement it allows repositioning of the baby’s head, gravity allows baby to back out of pelvis, rotate and flex before re-entering.

· NOTE: Gravity effects are different when mother is in pure side lying or semi-prone. (Labor Progress Handbook pages 126-130)

· Standing and leaning forward; enlarges pelvic inlet, aligns baby with pelvic inlet, may promote flexion of baby’s head, may enhance rotation especially when combined with swaying

· Kneeling, leaning forward with support of bed, ball, partner; aligns baby with pelvic inlet

· Pelvic rocking, write the baby's name with pelvis; helps dislodge head to enable rotation, encourages rotation

· Birth ball: lean on it, or sit on it, rotating hips and lean on bed; changes pelvic alignment and uses gravity

· Lunge, asymmetrical standing, kneeling, sitting; increases pelvic diameter, elevated femur acts as a lever creating more space on that side of the pelvis for baby to rotate

· Slow dancing; repeated change in pelvic joints encourages baby to rotate and descend

· Dangle; elongates mother’s trunk giving baby more room to renegotiate angle of head in pelvis, allows more mobility in pelvis

· Abdominal lifting; to help align long axis of the baby with the axis of the pelvic inlet

· Rebozo, or stroke the mother's belly while she is on all fours, in the direction you want the baby's back to go; increases likelihood that baby will rotate

· Double hip squeeze; sit or stand behind mother, place both hands on back of each pelvis iliac crest and squeeze upward and inward, causes mid pelvis and outlet to widen, added room may allow rotation and descent

· Walking and stair climbing, sideways or two stairs at a time; changes alignment of pelvic joints

· Crawl backward and forward; gravity and changes alignment of pelvis

· Acupressure; fingernail pressure on outer edge of little toenail (could also turn breech)

· Rocking, swaying, stomp-squat, and other rhythmic movements; may alter relationships between baby, pelvis, and gravity helping rotation and descent. A rhythmic move seems to occur when mother is coping well in labor.

When Epidural is Used

· Delay epidural until at least 5 cm dilation. Given earlier may cause internal pelvic musculature to relax so much that baby is deprived of a firm pelvic floor against which to rotate. When unable to rotate out of the Occipito-Posterior or Occipito-Transverse position, the force of the contractions push baby deeper into the pelvis in mal-position, risking ‘failure to progress.’ Care provider may use two fingers, during vaginal exam, against baby’s head, forming a false floor on which baby may rotate to more favorable occipital-anterior position.

· Care provider may try manual internal rotation (Valerie El Halta – see Midwifery Today Issue 36). Caution: This may invoke negative memories for women with a history of sexual abuse.

· Stay off back, and avoid semi-reclining.

· Pan caking: Turn mother from left side to right side, and back, each 30 minutes. It is long enough to allow gravity to help with baby’s rotation while allowing epidural to continue to give good pain relief.

· Texas tilts: Similar to pan caking but at each 30 minute interval, at mid-turn, two support persons each standing on either side of mother opposite one another, reach under mother’s pelvis and grasp one another’s wrists, and lift her pelvis up and down 10 times then continue to turn her to lie on the other side .

· Hands and knees position is possible with plenty support, pillows, and conscientious care that her joints maintain proper alignment.

· Supported dangle-squat: Set up bed like a birth chair, use stirrups as hand holds or to support forearms. Keep hip angle 90^o to 120^o in order to maintain open pelvic brim.

· Keep membranes intact. Rupture of membranes could allow baby to wedge permanently into the Occipito-Posterior or Occipito-Transverse position, preventing rotation.

Prepared 2005 by JoAnne King CD 303.426.5845 joanne@doula4birth.com www.doula4birth.com

Helping Baby during Second (Pushing) Stage

At complete dilation and effacement:

· Keep mother upright and mobile. If standing she will need something solid higher than her waist in front of her to hold.

· Allow time for uterus to retone and baby’s shoulders to finish rotating into transverse in order to clear the pelvis brim, until then his head cannot descend further.

· Keep her pubic symphasis below her coccyx, keeping baby’s weight in the front part of the ichial spines (sit bones) of her pelvis.

· Keep legs well below hips away from body, angle at hips must be open 120^o

· Mothers arms must be above waist level, in front of her shoulders

It is thought that if mother remains upright and baby is properly aligned, the back of baby’s neck triggers the movement of the mother’s rhombus. (Epidural anesthesia may interfere with nerve communication preventing this reflex action.) The Rhombus of Michaelis moves backward up to 2 cm. pushing the wings of the ilia outward. The mother reaches to find something solid to hold. She allows her body to sag and her knees to rotate outward. The mother moves her body, thrusting her hips forward the baby begins to come. Her spine lifts out of the way, her coccyx higher than her pubic symphasis as her back arches. The baby’s head is out; his shoulders rotate into the AP diameter. The anterior shoulder is seen first but uses the pubic bone as a fulcrum, as the posterior shoulder is born. The anterior shoulder then comes and baby comes out face down onto whatever surface is beneath the mother. Lying in the left lateral position is a good compromise to upright positions. If allowed to happen this way, less than 5% of baby’s will need help. This is different than what is traditionally done in the western hemisphere.

References

The Labor Progress Handbook ~Simkin/Ancheta

Let Birth Be Born Again Rediscovering and Reclaiming our Midwifery Heritage ~Sutton

Sit Up and Take Notice! Positioning Yourself for a Better Birth ~Scott

Understanding and Teaching Optimal Foetal Positioning ~Sutton/Scott

Posterior Labor-A Pain in the Back! It’s Prevention and Cure ~El Halta

Obstet Gynecol 2003

Midwifery Today

www.empoweredchildbirth.co.uk

Comparative statistics for persistent occiput posterior (OP) fetal position and occiput anterior (OA) include:

	OP	OA		OP	OA
labor longer than 12 hours	49.7%	26.2%	0 to 6 1-minute Apgar	12.4%	7.1%
length of stage 2 greater than 2 hours	53.3%	18.1%	7 to 10 1-minute Apgar	87.6%	92.9%
spontaneous delivery	37.7%	83.9%	0 to 6 5-minute Apgar	0.6%	0.9%
assisted vaginal delivery	24.6%	9.4%	7 to 10 5-minute Apgar	99.4%	99.2%
cesarean delivery	37.7%	6.6%	shoulder dystocia	0.8%	2.1%
third- or fourth-degree tear	18.2%	6.7%	nuchal cord	18.6%	21.6%

— Persistent fetal occiput posterior position: obstetric outcomes. Obstet Gynecol 2003

For in depth explanation and demonstration contact JoAnne King. Class available

The following illustrations show a variety of useful positions, remember to keep the hip angle 90^o or greater.

Prepared 2005 by JoAnne King CD 303.426.5845 joanne@doula4birth.com www.doula4birth.com

Upright positions useful for labor and birth

The laboring woman can make the most of these positions by combining them with movement, chanting, natural breathing, visualization and massage. However, she should be able to rest whenever she feels like it, particularly in early labor. Encourage her to follow her inner urges. Her instinct and intuition will guide her when she allows her body's wisdom to take over.

Standing and Walking - Stimulates contractions. The downward force of gravity assists the baby's head to descend which in turn helps to dilate the cervix. Will also help to increase the efficiency of contractions and lessens discomfort, particularly when she leans forward with each contraction.

Helpful in early labor when the baby is in a good position - sometimes used for most of the labor.

Sitting upright and leaning forward on a firm chair, stool or toilet seat. Can be very comfortable. Her body is well supported while upright; good downward force. A nice position for being massaged because the back is so accessible.

To relax and to be in control with minimum effort.

Kneeling - An instinctive position particular in active labor when contractions are strong. Gives a sense of being literally on top of the contractions. A way of increasing privacy and concentration. Helps to feel centered. Easy to relax forward over a pile of cushions, a beanbag or a chair; makes it easy to change into different positions like standing, half kneeling - half squatting, squatting and all fours.

Helpful when labor starts in the night or when the woman is tired, needs privacy or seeks comfort.

Induces a feeling of control and release. Can be helpful for internals.

Particularly useful for active labor or for helping a posterior baby rotate.

www.empoweredchildbirth.co.uk

All fours - lessens the force of gravity, thus reducing the speed of descent while providing the baby with enough space to move on; lessens the intensity of the contractions; allows for a wide range of movement, facilitates the ability to produce low noises and helps to feel centered; helpful in rotating a posterior baby.

Induces a feeling of control, makes breathing easy and gives privacy. Good when suffering from vulval or varicose veins.

Knee - Chest - Takes pressure off the back. Slows down a violent or extremely fast birth, thus helps to cope. Helps to create a time-out when needed. Extremely valuable in helping a baby to turn to a better birth position and to heal a swelling on the cervix⁽⁴⁾.

Least pressure. Good for focusing and privacy or to take some time out. Can relieve pressure on the baby. Best position for an anterior lip to go down.

Lying on Side - If labour is progressing well she may choose this position for comfort and a slow, gentle birth. Good resting position for a long birth. Take care that she rolls fully to the left side into the recovery position with cushions to prop up her head, right leg and under her right arm; use a small cushion as a wedge under her left hip.

Make her comfortable with big cushions in her back, to rest her arm on. Keeping her left leg long while the right leg is bent and flops right over to the left as in the recovery position, put a small wedge under her left hip.