A Pain in the Back!
by Valerie El Halta, The Birth Center
Valerie El Halta is a Certified Professional Midwife with NARM (North American Registry of midwives). She has been practising midwifery for 20 years and has helped birth over 2,500 babies. She is co-director of the Birth Center in Dearborn, Michigan.
I have become increasingly frustrated and angered that posterior presentation (back of the baby's head toward the mother's back) and its ensuing complications in labour and delivery have accounted for an inordinate number of cesarean sections. Many of the women who come to us desiring VBAC’s have suffered a previous cesarean for "failure to progress" and "CPD" (cephalo-pelvic disproportion) and yet, when we review the woman's records, the postoperative diagnosis usually confirms the posterior lie. It is my experience that with appropriate diagnosis and minimal intervention this condition can be corrected by assisting the baby to rotate as soon as it is diagnosed. Many times the position is not diagnosed until labour is advanced and progress arrested. Even when it is diagnosed, care providers offer comfort measures only, believing that the posterior position will eventually resolve, or can be corrected in second stage after progress is arrested.
Labour and delivery nurses are often untrained in diagnosing posterior, and the woman usually doesn't see her physician until near the end of labour. Even if the physician were present and an early diagnosis made, generally he/she would do nothing to correct the position. "en progress is slow, often the first action taken is to break the amniotic sac, followed by pitocin augmentation. This is the worst thing that can be done in a posterior labour, since when the waters are broken and contractions are enhanced, the baby's head will descend, only worsening the situation. In order to become anterior, it is necessary for the head to go through a long rotation of up to I80 degrees. (Normal rotation requires a 90 degree turn or less). If the head descends too deeply before rotation is accomplished, the risk if a deep transverse arrest increases, greatly reducing the chances for successful vaginal delivery. If the position is not adequately diagnosed until late in labour, the only recourse may be to offer a para-cervical block or an epidural anesthesia as it is almost impossible for the mother to relax enough to all. How the deep muscles of the pelvic floor to relax sufficiently to allow the baby to turn.
Nothing can prepare a mother for the severe unremitting pain that accompanies labour when the baby is in a posterior position. Often, labour begins with short, painful yet irregular contractions which are often shrugged off by caregivers as "false labour”. It may not be productive as the ill-fitting posterior head is not properly applied to the cervix, but the mother IS experiencing discomfort! She is often sent home to wait for 'real labour' to begin but is unable to sleep and often unable to cat, sometimes for several days. So, adding to the stress of a painful back labour, we begin with a mother who is already tired out! I have heard women describe the pain as "it felt as though someone were sawing my back in half' or, III couldn't oven tell when I was having contractions because my back hurt so much!". All attempts to case the pain have little effect and the labour is a long, hard exercise in determination.
Many midwives attending out of hospital births have not been taught to help correct a posterior presentation, and despite their best efforts are forced to transport the woman to the hospital when confronted with a mother begging for pain relief or after several hours of pushing have resulted in little progress or a large caput has formed. Then there is the mother who finally delivers her baby after a 36-hour labour and is so exhausted by the ordeal that she has difficulty bonding with the baby, postpartum involution is delayed and she may suffer from urinary tract infections due to the pressure upon and swelling of the anterior vaginal wall. Did I fail to mention those nifty lacerations up top? I would love to see this picture changed. As a midwife it is my goal to do everything that I can to help the mother achieve an optimum birth outcome, to use my skills to alleviate unnecessary pain and suffering and to help a new family begin in safety, peace and joy. Hence the purpose of this article.
The incidence of a posterior presentation occurring at the onset of labour is I5 to 30 percent, and many such babies rotate spontaneously to an anterior position. "en the pelvis is adequate, a posterior baby may be born face up with little or no difficulty, as if saying, "Surprise! it's my little face!" On one such occasion, as a woman was delivering precipitously here in our center, my daughter, (who was assisting at the mother's side) said, "Mom, the baby's ear is upside down!" just before the rest of her head came out, with the baby looking straight up at her mother. There are, however, many cesarean sections done for persistent posterior labours when failure to progress occurs, or when maternal exhaustion or a transverse arrest makes vaginal delivery either very traumatic or impossible. As we are unable to guess at the onset of labour what the possible outcome will be, I feel it imperative that every effort be made to avoid both a long and difficult labour and possible necessary operative intervention by early diagnosis and correction of the position.
We see our clients weekly during the last month of pregnancy. One of the things we are careful to assess is the baby's presentation and position. An ROA position is watched expectantly, statistically ROA is much more likely to become posterior than LOA. if the baby is posterior, we give the mother exercises to try to help the baby turn. Having the mother do pelvic rocking three times daily in sets of twenty often assists the baby to assume a more favourable position. it may also be helpful to have the mother assume a knee-chest position for twenty minutes three times a day, or to utilize a slant board as with a breech baby to help disengage the baby, allowing gravity to assist in the rotation. At the onset of labour, the position is re-evaluated and if the exercises have not helped to change the presentation, we encourage her to come into the birth center in early labour. It is relatively simple to assist the rotation of the baby when the mother is in early labour, and very difficult once labour has become advanced.
There are some women who seem to be more at risk for a posterior position. The woman who has an android or an anthropoid pelvis, or a woman who has a narrow inlet is more prone to have this as well as other abnormal positions. Certainly, the woman who has had a previous posterior labour is much more likely to suffer a repeat. Remember to keep a watchful eye on ROA.
Diagnosis of Position Prenatally
Assisting in Anterior Rotation Prenatally
Diagnosis of Posterior in Labour
Assisting Anterior Rotation During Labour
If labour is more advanced when the posterior is identified, say 4-5 cm, if may be helpful while the mother is in the knee-chest position for the attendant to place her hand in the mother’s vagina and gently lift the head, somewhat disengaging the head and allowing it to turn to anterior.
If the posterior has not been discovered until complete dilation, or if the above methods have not been applied in early labour, the baby’s head may still be turned to make delivery more likely. Again, placing the mother in the knee-chest position, with knees slightly apart, the midwife may place her hand into the woman's vagina (remember, your hand is smaller than the baby's head!). Attempt to lift the head up by grasping the head firmly, waiting for a contraction and turning the baby into an anterior position. As soon as the head is corrected, hold on tight and when the uterus contracts again, urge the mother to push very hard! If the amniotic sac has not previously ruptured, rupture it now. This will assure that the position remains fixed and the baby will usually be born very rapidly. This procedure is both safe and sane, yet it must be acknowledged that it will take some physical strength to turn this recalcitrant little head against the force of a good contraction.
I have addressed this article to the prevention of complications which may result when early diagnosis and correction has not been made of the posterior position, and to offer some suggestions for assisting anterior rotation. Placing the woman in a knee-chest position and lifting the head is also an effective aid in correcting military, brow and asynclitic positions.
It is my hope that through early diagnosis and appropriate intervention, many women might be liberated not only from long and difficult labours, but from complications of such labours leading to inevitable cesarean section. I have used these techniques with very favourable results for many years. To date I have had to transfer only one woman (in I977) for transverse arrest due to my inexperience at that time in diagnosing her posterior baby. Even a woman birthing in the hospital could help herself if she is having excruciating back pain or if she is told that her baby is posterior by assuming a knee-chest position until she feels relief from the back pain or for at least half an hour.
For those of us assisting VBAC moms who have had a posterior labour leading to cesarean or rooms who previously have had vaginal deliveries after long posterior labours, a word of caution: In my experience, when a subsequent baby is not in a posterior position the women are often very advanced in labour before they realise that they are in labour. This has led to many amusing situations!
I again assert that to refrain from acting in the interest of the mother in early labour when it is both non-interventive and safe, is to inflict needless pain and suffering upon the mother and her baby, and may lead to a much higher level of intervention: i.e. drugs, episiotomy, forceps, cesarean section.
Used with permission, Valerie el Halta 1996.
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