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Optimal Maternal Positioning

My niece and nephew, Eve and Richie Kessner in "Polar Bear" position for optimal maternal positioning during labor.

There continues to be much discussion about optimal fetal positioning, and rightfully so - it is often the key to obtaining healthy vaginal births. The subject of ‘which way the baby’s face is facing’ and how it can impact labor, has been documented in the medical literature over the centuries by midwives and doctors alike. If the baby's face is up, or at mom's symphysis pubis, it often is cited as a reason for doing a c section. An equally important concept, which has a direct impact on optimal fetal positioning, is what I call optimal maternal positioning. This perspective holds the mother’s position accountable, both physically and emotionally, and not her baby’s. Once she learns how to be a team player and position her baby, she will have the best chance of turning her baby anterior, so the back of baby’s head is facing front at the mom’s pubis symphysis, making for a swifter delivery.

As a midwife I am mindful of how I broach the subject, if at all, with my clients as to not raise concern. Regardless of baby’s position, here’s my spin, “During labor, while the uterus is at work, we may use a variety of positions to help rotate the baby.” I believe a mother should not worry about the position of her baby before labor starts as she has enough on her mind with eating healthy foods, hydrating well, and staying healthy. However moms do need guidance from their provider, so they will be able to take direction and get into what might seem like extreme labor positions. My mentor Valerie El Halta taught me the art of rotating the posterior. The late midwife Osaka Roy taught midwives and doctors about the extreme left lateral side lying position to turn the OP, and in her memoirs Mother and child were saved, midwife Catharina Schrader discussed techniques back in the 1700’s, with reference to “buttocks” in the air to turn the baby.

For optimal maternal positioning, I tell my clients:

1. Do not lie on your back. This position promotes baby to lie on his or her back, becoming face up or posterior. It also reduces circulation to the baby

2. Do not be a couch potato and lean back. Sit forward on your chair and do not sit or stand in one position for longer for than one hour

3. If medically approved, sexual relations should be on your side or on all fours, not on your back for long periods of time

4. Get chiropractic adjustments to help align the baby in your pelvis

5. Be open to getting into different positions in case I need you to turn your baby

If you do ‘everything‘ by the book and your baby remains face or sunny side up, so be it. The baby is not at fault. I have delivered many babies in the OP position. Some pelvises are deep and wide which allow baby more room to play around. While cervical dilation may initially be fast with OP as the face slides into the pelvis or mid pelvis, the diameter of the OP may not allow for the head to fit through and labor progress seems to stall. Fifteen to thirty percent of babies present face up with their backs facing their mom’s sacrum at the onset of labor. According to Oxhorn and Foot, authors of Human Labor & Birth, most babies turn on their own during labor, “often undiagnosed.” The baby’s head, hands and elbows can create delays during labor including lack of dilation or descent. A provider should identify the baby’s anterior and posterior fontanels (membranous spaces between the infant’s skull bones) to shift the baby’s position. The time to begin positioning is when a woman is having frequent, strong contractions. Doulas and nurses can also help with their expertise. Moms may be asked to turn over on all fours, hold a knee chest or ‘polar bear’ position, rock their hips and torso, belly dance, spin the baby with a rebozo, sway on an exercise ball, climb steps, alternate with chair and floor lunges, or lie in an extreme left lateral position with pillows supporting her top right leg.

My niece Eve Lynn Kessner, one of my favorite repeat clients, popular SoulCycle Instructor and Wellness Coach, shares her experience of optimal maternal positioning: “I think it's human nature to assume your second birth will be similar to your first. Having been through it you feel like you know what you are getting back into. For me, this wasn't the case! My first came after a long labor into a long delivery. She was a double cord wrap and I figured having been through that, the second could not be worse. I was very mistaken! With my second, after some 4 hours of laboring without any significant dilating, I learned that she was posterior (hence the crazy back pain). Luckily Risa was somewhat of a magician here and knew exactly what to do! It was NOT easy, but she saved me from a c-section by positioning me in what she called a polar bear pose for an hour that felt like a day, but, upon coming out of my inversion, my daughter fundamentally fell out! It was the easiest delivery I could have imagined after the craziest labor. I am forever grateful to Risa for saving me from the knife and taking such amazing care of both me and my baby”!

Many women come to me for a VBAC (vaginal birth after cesarean) because their provider missed classic signs of a posterior before or during labor including: slow dilation, rapid dilation then a slow go forward, mom feeling lots of limbs in front during her pregnancy, or continuous back ache during labor. A busy provider who doesn’t palpate a client’s abdomen, may not feel or notice the classic concave presentation in the lower abdomen weeks before labor begins.

Optimal Foetal Positioning” a handbook by New Zealander’s Jean Sutton and Pauline Scott, has been teaching birth attendants and childbirth educators for many years, to understand how the baby moves during labor, which positions to avoid, and which positions help turn a posterior baby. Tips such as not sitting in the bucket seat of a car for too long are given, however mom’s willingness to follow suit is essential.

Birth care providers should palpate their clients’ abdomens at every prenatal visit and teach them where their baby’s spine, feet, and head are positioned. This helps a woman to be more cognizant of when her baby rotates out of OP during labor. Without understanding of optimal maternal positioning, labor can slow down, or take a while to advance, and that can trigger other insecurities, fears, exhaustion, and interventions for mom and baby. Even with bold measures to reposition an OP baby, a medically indicated c section is appropriate if there is unresolved fetal distress due to a true disproportion between the baby’s size and the diameter of mom’s pelvis.

Birth is about movement, and with courage and realistic discussions ahead of time about optimal maternal positioning, we have more likely instances of safer vaginal deliveries.

I hope you found this useful.

What kind of optimal position did you use or learn about?

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