-Tips from a Midwife: A Good Position

-The Dance of Labor

-First Positions

-The Webster Technique

One of the factors that sets the stage for a productive labor and normal vaginal birth is a baby in a good position at the end of pregnancy, especially at the time labor begins. At or around 32 weeks of pregnancy, most babies will have adopted a longitudinal lie (most head-down, some breech (bottom down) in the mother’s womb. Near the end of pregnancy as baby grows and has less room to move around, he tends to settle into a position with his back on either the mother’s right or left side. Ideally for most mama-baby pairs, a baby enters its mother’s pelvis head-down with its chin tucked toward its chest and its back on her left side. This is typically called optimal fetal positioning.

As midwives, we pay close attention to a baby’s position during prenatal visits. At every visit in the third trimester we use our hands to palpate the mother’s belly, feeling for the baby’s head, back, bottom and limbs.

If at 32 weeks we determine a baby is in a breech or other non-vertex (non-head down) position, we suggest a variety of techniques to our clients that they can practice on their own or with the help of other providers, such as a chiropractor or acupuncturist, to encourage the baby to turn while it is still small and has room to do so easily. Most babies will stay head-down once they switch, but some like to keep us on our toes until the very last minute! If by 36 weeks of pregnancy a baby has persistently remained in a non-vertex position despite efforts to help it turn, we counsel our clients about the risks and benefits of undergoing an external cephalic version. This is a procedure performed in hospital, under ultrasound guidance, with or without various medications for the mother, in which a doctor manually rotates the baby from the outside into a head-down position. Depending on a variety of factors, the overall success rate of this procedure is around 50%. It is usually performed at or after 37 weeks of pregnancy due to the chance of the baby reverting back to a non-vertex position while it may still have room, and also due to the small risk of the need for emergency Cesarean delivery if there is a problem during the procedure. If a baby continues to present non-vertex, her parents decide whether to try for a vaginal birth, or to consent to an elective Cesarean delivery, which is the standard of care at most area hospitals.

A more subtle determination is the position of the vertex baby’s head in the mother’s pelvis. Ideally the baby has its chin tucked toward its chest with its back easily felt along mom’s left side. Carrying a baby in this position at the end of pregnancy provides the greatest chance for a straightforward labor with either no or minimal medical intervention. If a baby persistently presents its back on the mother’s right side or towards her back, she is more likely to present occiput posterior, or “OP.” Mothers with babies presenting in OP have a greater likelihood of the pregnancy going late (possibly needing to induce labor), and of the mother experiencing the dreaded back labor.

Between 15-30% of babies are positioned OP at the time labor begins. This fetal position is associated with longer and more painful labors, increased need for medical intervention such as pitocin augmentation, vacuum or forceps-assisted delivery, 3^rd and 4^th degree perineal/anal lacerations and Cesarean section. There is also a correlation between the use of epidural anesthesia in labor and having a baby in a persistent OP position, and its attendant risks.

As midwives we are skilled in recognizing the dysfunctional labor patterns that often happen when a baby is presenting in a sub-optimal position, such as OP, asynclitic (baby’s head crooked) or de-flexed (baby’s chin not tucked toward chest). Throughout the course of prenatal care, we suggest ways our clients can encourage their babies to adopt an optimal position at the end of pregnancy. We use a variety of techniques including maternal postures and movements, manual rotation/flexion of the baby’s head, homeopathy, nutritional support and IV therapy to help avoid maternal exhaustion if indicated. We are also skilled in working with these mama-baby pairs to support them through a potentially longer, more painful labor and to help correct the baby’s malpresentation, thereby reducing the need for the medical interventions described above.

A baby in a suboptimal position at some point in labor is common and can happen to anyone. If you educate yourself, live a healthy, active lifestyle and build a skilled, supportive birth team, you will be in a good position to have a great birth.

–Michelle Edgar, LM, Nicole Sellers, LM and Ellah Ray, LM

East Bay Homebirth Midwifery

www.eastbayhomebirth.com

None of the information in this column is intended to be used for medical diagnosis or treatment.  Talk with your healthcare provider about any questions you may have regarding a medical condition.

What if you could just smile and dance your baby out, even through the most difficult parts of labor? How powerful would it be to focus on the tools you inherently possess as a birthing mother to move your baby out, instead of relying on drugs or outside interventions? How can pregnant mothers be set up and supported to give birth in ways that were proven optimal for healthy mother-baby outcomes as well as improve the mother’s birthing experience?

There are specific posture and movements in pregnancy that prepare the mother’s body and encourage the baby’s positioning for a positive birth experience. Dance and maternal movement are powerful tools to use in pregnancy and birth, because labor is a dance. The baby’s and mother’s body “combine to create unique circumstances that influence the way baby will actually move during descent”(1). Simple movements enable the birthing mother to move her baby into an optimal position in her birth canal so the baby can move out through her vagina. In labor, movement is vital just like in pregnancy.

The main movements of the baby are:

1. Descent, when the baby moves downward onto the cervix,

2. Flexion of the head (degree of the baby’s chin tucked against her chest to pass through the pelvis),

2. Engagement of the head into the pelvis,

3. Internal rotation of the baby’s head & body occurring in a downward spiral motion through the pelvis and birth canal.

Mothers’ bodies are designed to create, grow, and sustain a life, just as they are designed intricately, yet so simple to give birth. The hormones of oxytocin, endorphins, and adrenaline are released through dance and movement in birth and pregnancy, giving the birthing mother the energy for the physical experience as well as giving her a euphoric emotional feeling. As the laboring mother moves her body, the blood flows and circulates to the uterus and placenta, allowing the baby to receive more oxygen-rich blood and the muscles to relax. This optimal uterine function is connecting the movement of breath pattern with the rhythmic pattern of the uterus.

In Pregnancy

During pregnancy, the mother’s posture affects the habitual positioning of the baby. As the baby grows and settles in the mother’s body, it takes physical cues from how the mother uses her body. During labor, the uterus is moving the baby down with each rhythmic contraction, where the baby is moving in a spiral down the woman’s body.

In Labor

The birthing mama in labor wants to open the pelvic area and put pressure on the cervix, to ensure dilation. As the uterus is moving the baby down with each rhythmic contraction, the baby is moving in a spiral down the woman’s body. When a baby is in an optimal fetal position, there is greatest ease of descent for both mother and baby. Most problems in labor can be easily mitigated through maternal movement. In many cases, the “problem” is the angle of the baby’s head, not the cervix. A stalled labor or ”failure to progress” is when the baby is jammed in a position. It’s the fetus’s positioning that can determine the progress of the labor.

Hospital Protocol

Instead of fear of back labor and fear of failure to progress, mothers can feel full of confidence as they move their baby into an optimal position for an easier labor for both mother and baby. Mothers want and need to feel more as an active participant in their labor experience. Because the medical system sets up birthing mothers with fear, along with the hospital’s diagnosis of “failure of progress”, mothers are turning to interventions as the way to birth their baby and giving away so much of their power. ”Failure to progress is estimated to account for approximately 60 percent of American C-sections. While it is known that upright positions, dim lights, eating, and drinking, and fewer vaginal exams speed women’s labor, none are encouraged in a hospital….women are defacto coerced into surgery or other interventions they don’t need” (2). It appears that hospital procedure leaves women with little choice for a natural birth. While technology and outside interventions have become the focus of birth, it hasn’t produced better outcomes or better birthing experiences. Instead of birthing mothers coming into the birth with fear of failure, it is possible can set up a framework of celebration and belief, where we bring power back into the birthing mother’s hands.

When so many women suffer with post-traumatic stress disorder (PTSD) years and decades after their birth, even when their children appear healthy, we must see how the way a woman feels about her birth affects her for the rest of her life and answer the question of how women can stand in their power with internal tools for birth.

We can reframe birth as a dance, where they mother and baby are working together as they figure out how their process will unfold. Optimal fetal positioning is connecting the mother and baby as a unit of movement in which the baby is positioning in the mother’s body in a way that is most optimal to the mother’s unique body. It is this dance that aligns the physical and emotional systems of the mother-baby unit that imprints the couple for life.

Birth is this memory, a framework and visionary inquiry into the depths of our birthing selves to innovate and participate with the process of life. Movement is a basic human right and is vital in the birth process. We must look at the current protocols in hospitals and reframe them so mothers are really able to use the tools they possess to birth their babies in a peaceful and connected way. Having a satisfying experience to a birthing mother is being an active participant in your own experience, and not giving away your power. Having access to this internal knowingness (knowledge), allows birthing mothers to have the tools for a healthy and empowering pregnancy and birthing experience, where mothers can awaken to the intelligence inherent in their own bodies. This is accessing female inherent power.

Caroline’s victory story

While laboring at Alta Bates the doctor talked about cesarean because the baby was not positioned properly and she was taking a while to progress, but Caroline was determined to have a natural vaginal birth. Her doula reminded her of what Caroline practiced in the movement class she had taken during pregnancy. They immediately began pelvic spirals and Caroline began to move her baby into a more optimal position and was able to have a vaginal birth!

Essential Movement Tools for Birth:

• Rocking the hips- helps settle baby’s head into the pelvic area
• Leaning- helps to move the baby’s back to another direction
• Straddling, Squatting- opens pelvic area, gives legs and muscles some rest, puts pressure on the cervix
• Sitting on all fours rotates the baby back forward, relieving pressure of quick moving labor, and relieves strain of back labor.
• Spirals- balances the pressure on all sides of the cervix during dilation

–Gingi Allen

www.theartofmothering.com

Gingi Allen is a mother, Doula, Student Midwife, Pregnancy Movement Dance Teacher, Womb Wellness Educator and founder of The Art of Mothering. Gingi has full trust in women’s ability to birth their babies, as they use intuition to guide them. She envisions a world where birth and family wellness is the highest priority for every mother, father, community member, politician, and society at large – when women are healed, the world reflects this healing. Her role as a Goodbirth Keeper is to educate mothers about procedures, their choices, and support them in having the birth they desire no matter their external environment.

Sources:

1.  Holistic Midwifery Vol II Care during Labor and Birth, by Anne Fry, p.76.

2.  Baskin and the Battle for at-Home Births -NYTimes.com,www.nytime.com/2012/05/27/magaine/ina-may-gaskin-andthebab.

Before both my children were born, I wondered who they were and who they would be. In retrospect, my first physical experiences of them in utero and during birth gave me more of a connection with the individuals soon to come into my life than I could have guessed. Their birth was the first step in the dance of knowing and love.

I.

I could not escape or writhe away from the intense and non-relenting pain. It was my first time birthing and I kept waiting for that little break of contractions where I could catch a resting breath. I looked up in a moment of panic and asked Susan, my midwife,”Isn’t there supposed to be a break between these things?” She was leaning against the wall, quietly watching and hanging back; she shrugged, “apparently not.”

My midwife was not one to sugarcoat and I was surprised how much I loved her for it. The most support I could get from my husband, mother and midwife was as witnesses to the labor I was doing. Even in my fairly frantic state of wishing the whole thing was over, I found Susan’s dry tone somehow funny and perfect; She was right, there would be no breaks, there was no escaping this labor as this labor was meant to be: back labor.

Sofia, my first baby, was in a great fetal position until her eighth month when I made the ambitious decision to tile my kitchen floor. The bustle of activity right before her birth had to do with buying a very old and rundown house two months before she was conceived and then realizing that if we didn’t finish fixing things up before she was born, it was likely we wouldn’t ever have time to fix it up because we would be too busy with a baby. Somewhere between laying down the hardy-backer and smoothing out the mortar, something changed and I couldn’t put my finger on the sensation. From a quiet first eight months to the last month of bustle before birth, it seems Sofia got curious about what was going on out there. During my next examination, the midwife looked puzzled and then explained why I was feeling a difference: Sofia was still head down, but she was facing out. I did some shifting of my pelvis, some gentle stretching and wiggling of my hips, trying to move her around, but she persistently stayed facing outward. Without a true understanding of the importance of fetal position and how it could affect outcomes in labor and birth, I didn’t think much more about it.  I felt ready and hung curtains, nesting and practicing breathing and relaxation with pre-labor contractions.

My water broke at five in the morning, and after a day of waiting and hoping things progressed so I could have a homebirth, labor really began when everyone had finally gone to bed. I awoke and everything was different and intense as active labor can be. Seven hours later, Sofia was born. No one really told me or could tell me what back labor was going to be like: being my first labor I wasn’t able to distinguish how intense back labor is until my second birth. For my back labor, there was intense pressure and pain in my back where the baby’s skull was trying to move past my back bone while simultaneously working with the contractions of the uterus in the front of my body. There was a sensation of being squeezed from the front and the back and the back pain didn’t cease until Sofia had moved down and twisted to face my back as she entered my vagina. After seven hours of serious work, I gave birth to Sofia squatting over a birth stool with a favorite piece of sarong clutched like a rope between my hands, my husband pulling the rope as a counter pressure and the midwife down on the floor ready to catch Sofia as she came. As soon as she was out, I held her while still in a crouched position. The relief of holding her was an instant balm against the pain and exhaustion and I melted into bliss.

From birth on, Sofia was calm and observant, opening one eye like a pirate as she peered at us. Almost immediately, her favorite positions were looking over our shoulders, being held up outwards against our chest by our forearms and once I got a little help figuring out the Maya sling at three months, she was happy for hours in a cross-legged, outward sitting style where she could see everything and get plenty of interaction from the safety and height of my arms. Her birth position and the positions she was most comfortable with for the first two years were very similar.

I draw a connection between observing the eight year old Sofia as she joins different activities and her time in utero and babyhood: I see her circling the group, then finding a spot where she can observe before she joins in. Time passes before she looks comfortable, but then she works to master the skills with intense concentration. She inspires me. Part of me wishes she could just jump into a situation and not hang back as long as she does and maybe have more fun, but recognizing the essence of her and seeing her as a unique person is the part of me that I try to honor more. My wishes to change her for my own comfort level began our dance together and accepting how she would come into this world and be in it will continue to be the acceptance that is part of a mother’s lifelong work.

II.

The one stretch mark I have from birth is exactly where Oli tended to push his head down slightly to the left of my lower belly and do a lot of stretching against my ribs. He didn’t like to be curled up at all and his stretches were a big part of his expression before birth. Oli’s birth position was great throughout pregnancy and labor was typical of a second birth: fast and at night as the midwives had cautioned me might happen, while the first child is still sleeping. Sofia had drawn many pictures of a baby in my tummy. Early on I had requested them all to be upside down babies, preferably with just a little face showing: after all, why take chances on another back labor? She used face paints and painted a picture of him on my 38 week belly, a smiling baby, looking ready to play.

The birth records say there was a four hour labor, but really there was only about an hour and a half where I was lost in the work of labor. As soon as everything was more or less set, I had stripped off my clothes, put my glasses on a shelf and let the labor really begin. Instead of trying to avoid the pain and intensity of the contractions of my lower body, I backed and lay myself into them, willing myself to open and accept it. Thus, I opened and was ready for transition fairly quickly, but without back labor, the sensations of uterine movement were more intense sensation rather than pain and I did get those little breathing spaces I had been looking for in my first labor. When it was time, I pushed Oli out while standing, knee deep in a hot tub, one leg slung up on the rim. Once out, I took him in my arms and sunk down into the hot water relieving the muscles in my legs. It was fast and fairly furious and the way that he was meant to be born. The image I had as he was born was a giraffe that births her young to the ground and gets him moving right away. It is Oli’s essence: a moving, strong creature ready to begin right away. The midwives said he was hearty enough at the first Apgar check that if there was an Apgar score above ten, they could have given him an eleven or twelve, he surely deserved it.

Oli’s birth position has also translated to a picture of who he is in the world. After birth, he really didn’t like being rolled up into a sling and did all the familiar pushes to get out of it that he had done inside me. His strong neck and head pushes in utero are a mirror of all the movements he makes today: he tends to be a headstrong personality, he pushes with his head when he’s upset and he has given me more bumped lips, noses and head bruises than I can count as he plays like a wild animal.

He is delightful in this physicality though it can be painful to play with him as he learns physical control and responsibility for his actions. That is the work set out for me: helping him harness his innate strength and physical determination for his greater good and to make the world a better place because he can help push and pull it together. I continue to accept him and his physicality easier when I reflect on that strong, rosy baby already wildly sucking at his first nursing, his fists trying to make it into his mouth as he worked to take in life as much as possible.

Labor with both my children was my first experience of their physical expressions and the first step of the parenting dance to which I am constantly learning the next steps, just so I can keep up. I continue to create a connection with who they are and how to parent them through my memory of their births.

Gillian Gillette is a writer and mother who lives in the Bay Area.

The female human body is beautifully designed to grow, nourish, and birth babies. There is an innate intelligence within that has shaped the structure, organized the function, and allows for the divine gift of bringing life into the world.

Babies also have an innate intelligence that begins in utero, which intimately communicates with the mother’s body and allows for neurological development and the initiation of pre-programmed instincts to prepare for birth and life outside of the womb.

During the late stages of pregnancy, it is these instincts that encourage baby to turn head-down, or vertex, in what is considered an optimal position, in order to prepare for the journey of birth.

Why is having the baby in a vertex position considered optimal? There are a few reasons:

During pregnancy, when baby is head down with the back of his head (the occiput) facing towards the front of mothers body, there is decreased stress on his spine and developing nervous system. During the labor process itself, the pressure of baby’s round head is what encourages cervical dilation and effacement (thinning). If the presenting part of the baby is a foot, a knee, or the buttocks (known as breech presentation), it can be challenging for the cervix to open efficiently and can increase the risk of dystocia (a longer and potentially difficult birth). It is possible for babies to be born if breech or transverse, but there is increased risk of complications to both mother and baby, and this is one of the most common reasons for cesarean section.

So why is it that some babies assume a breech or transverse (side-lying)  presentation?

Is it because the baby did not receive the innate programming to know what do? Surely not: rather, something is interfering with the natural rhythm and progression. In some cases, a less-than optimal presentation of the baby is due to structural and neuromuscular misalignments, torque, and tension (chiropractors use the term Subluxation) in the mother’s body, specifically her pelvis and sacrum.

How does subluxation happen?

Subluxations typically arise from a combination of past trauma and injury or from accumulated life stresses over time. Before and during pregnancy, the mother may experience physical, chemical and mental/emotional stress that creates tension patterns within her body. Muscles, ligaments and fascia respond to this stress, and as a result, pull and misalign the bones of the spine, pelvis and sacrum.

The spine and pelvis are home to the central nervous system which is the orchestrator of the innate intelligence within. Subluxations can decrease overall nervous system function, thus affecting the messages being received by the body from the brain, and by the brain from the body.

Subluxations specific to the pelvis and sacrum can have a direct affect on the uterus and its position within the mother’s pelvic bowl. The position of the uterus can therefore be a determining factor as to what position the baby assumes, as he will have to accommodate for the space that is available to him.

The uterus is an exquisite organ suspended within  the mother’s pelvic bowl by a number of strong, muscular-containing ligaments. The broad ligaments attach to the front of the sacrum, wrap around the sides of the uterus, and encapsulate the round ligaments at the front, offering stability and support. The two round ligaments are vertically oriented and attach to the front of the pubic bone, and are the foundation of uterine orientation, constant balancing, and dynamic equilibrium. The utero-sacral and posterior ligaments attach to the front of the sacrum and tailbone to the back of the uterus and cervix, creating a stable anchor.

When the mother’s pelvis is subluxated, these ligaments respond to the tension and create distortion within the uterus itself. This is known as intrauterine constraint, and in some cases is the cause of breech or transverse positioning of the baby. Although the baby will continue to receive the innate messages to move himself into a vertex position during late pregnancy, he simply may not have enough space, or doing so may be uncomfortable for him.

However, there is hope, including options that work with  the mother’s body in a gentle and holistic way to help encourage a more favorable position for baby. Dr. Larry Webster, a Chiropractic pioneer who founded the International Chiropractic Pediatrics Association (ICPA) noticed the relationship to pelvic and sacral subluxations and the position of the baby in utero. In the late 1970′ s he developed a gentle and effective method of restoring balance and freeing subluxations to the sacrum and pelvis known as the Webster Technique. This technique allowed babies to turn vertex on their own. Unlike an external cephalic version which is a procedure that OBGYN’s use to externally rotate babies from a breech to a vertex position, the Webster Technique is less invasive, and instead works with the mother’s body, rather than manually moving the baby which can be uncomfortable and has about a 58% success rate.

The theory and technique are simple; adjust subluxations within the structure of  the mother’s pelvis, sacrum and surrounding ligaments, bringing freedom to the uterus so that it will suspend itself in a more balanced way within the pelvic bowl. The adjustment is typically done on comfortable pregnancy support pillows in which the mother can lie face down and the sacral ligaments and structure is gently and non-forcefully adjusted. The mother is then placed for a short time on her back if it is comfortable, and uterine ligaments and anterior pelvic structures are released by the chiropractor based on her individual pelvic presentation. Increased space is created for the baby, and he will have the opportunity to be innately guided to assume a comfortable vertex position.

The Webster Technique is not a baby-turning technique, and uses no direct external forces on the baby. It is extremely gentle, safe, and effective.

According to the Journal of Manipulative and Physiological Therapeutics (2002), an 82% success rate is seen by Webster Technique Certified Chiropractors who work with mothers with babies presenting breech or transverse.

The Webster Technique works best if administered as early as possible, as it typically takes several sessions to free subluxations and allow the mother’s nervous system to adapt to its new way of being. Having at least 4 weeks before baby is due will increase the success of baby turning. Starting the process in the 38th week of pregnancy and later is not the best approach. However, if mother is in the final weeks it is still a good idea to see a Chiropractor certified in the Webster Technique for more frequent visits to at least try and create as much space as possible to allow for an easier labor and birth process.

The Webster Technique, and chiropractic care in general, is an important option to maintain freedom of movement and optimal nervous system function during pregnancy. Subluxations corrected before and during early pregnancy can prevent uterine constraint and less-than optimal positioning of the baby, and keep the mother’s nervous system and innate intelligence free to flow. Baby will likewise receive clear messages from mother and within his own being to help promote optimal nervous system development. If the mother has a balanced body and clear nervous system, stress load for both her and baby is decreased, which typically allows for an easier and more comfortable pregnancy and birth process.

In support of the continuum of life,

Kacie Flegal D.C.

Elements of Being Chiropractic Center

5545 Claremont Ave. Oakland, CA 94618

Dr. Kacie is a professional member of the International Chiropractic Pediatrics Association and Certified in the Webster Technique. She specializes in pre/post natal care and pediatrics and is a Certified Doula with the Natural Birth Institute. As a Vitalistic Family Chiropractor, she is dedicated to optimal development, health and well living from the very beginning of life!

Please visit www.elementsofbeing.com to learn more about Dr. Kacie and her practice in the Oakland/Rockridge area.

For more information about the Webster Technique and chiropractic care for pregnancy and children, or to find a Certified Chiropractor in your area, visitwww.icpa4kids.org