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

	During the prenatal exam, the mother often exclaims that the baby has too many hands and feet, and the moving limbs may be easily felt and seen.
	The mother often complains of frequency of urination due to the baby’s brow pressing against her bladder. Sometimes she will also be incontinent, not being able to feel an urgency to urinate as the baby’s head presses out urine.
	The mother may exhibit signs of a urinary tract infection, with the above frequency of micturition, a feeling of constant pressure at the symphysis (above the pubic bone), and an attendant lower backache. (In this case, it is always appropriate to test the urine for bacteria, as UTI’s are more likely when the bladder is not completely emptied).
	It may be difficult to ausultate fetal heart tones, or the tones may be indistinct. When it is suspected that the baby is posterior, have the mother roll to the side and the heart tones will be more easily heard.
	While the breech is easily palpated at the fundus, it may be difficult or impossible to feel the outline of the baby’s back and the head will appear to be engage.

Assisting in Anterior Rotation Prenatally

	Have the mother do the “pelvic rock” exercise at least three times a day.
	She may assume a knee-chest position for twenty minutes, three times a day.
	Have the mother lie on a slant board (as with a breech position) several times a day for thirty minutes at a time.
	Have the mother take warm baths and gently encourage her baby to “roll over”. We have found it very effective for the mother to visualize her baby in the correct position and to talk to her baby, telling it to move as well. One time we had a particularly stubborn baby, who liked the way he was lying just fine. The mother had suffered with previous posterior labour and was very anxious that this not be a repeat performance. She had tried in vain to get this kid to cooperate, so I called the dad in and said, “Show this baby who’s the boss!” Dad said, “Turn over, baby!” and he did.

Diagnosis of Posterior in Labour

	Early labour may be marked by a long period of irregular uterine contractions with little or no dilation. Contractions may be more frequent yet of short duration than desirable or expected in early labour, e.g. every three minutes, but lasting only 30 seconds. This due to inadequate application of the presenting part.
	Palpation of the baby’s position abdominally is not sufficient as it is possible that the deeply engaged head may remain posterior even though the baby’s body appears to be aligned as in an ROA or LOA position.
	Auscultation of fetal heart tones is not a reliable method of assessing fetal position, as they may be heard through the baby’s chest as well as through his back.
	The mother usually complains of a persistent backache, which even in early labour may be severe enough that the pain of contractions are secondary. As a backache may be present even in normal anterior presentation, it is important that a vaginal examination be done to correctly assess the baby’s position by the fontanels.
	In the ROP position, the sagittal suture line will be felt obliquely, (from one o’clock to 7 o’clock) and it will be possible to feel the bregma (larger front fontanel) at the top and to the side of the pubic bone (by one o’clock). It may be possible to feel the top of the baby’s ear as well.
	Assuming that the mother’s cervix is soft and a little dilated, a finger must be inserted through the cervical opening in order to accurately determine the direction of the suture lines and to find the anterior fontanel. If the head is in a posterior position, you will find it between 12 and 3 o’clock on the fetal skull. Courage! This exam may not be pleasant for either you or the mother, but when you consider that you may be saving her endless hours of an extremely painful labour, with no guaranteed outcome, your task will be easier. If you are not able to find the anterior fontanel, the baby is probably in the correct position, as when the head is LOA or ROA, the posterior fontanel usually cannot be felt unless the head is assuming a military position, which is another story!

Assisting Anterior Rotation During Labour

	When it is verified that the baby is in a posterior position, the first thing that I do is have the mother assume and maintain a knee-chest position for approximately 45 minutes. Although this position is not the most comfortable one for the mother, it is very effective as it allows the baby more room in which to rotate. I find that the mother tolerates this position well if she is not in advanced labour. We make sure that she is well-supported by lots of pillows and giver her lots of encouragement and emotional support. Often, while in the knee-chest position the contractions become more regular and more effective, which also assists the baby’s rotation.
	If the mother cannot tolerate the knee-chest position for as long as necessary to turn the baby, we alternate by placing her in an exaggerated Simm’s position (lying on left side, two pillows under the right knee, which is jack-knifed, left leg straight out and toward the back).
	Every effort should be made to avoid rupturing the membranes, as the “pillow” offered by the forewaters gives a cushion on which the baby’s head may spin more easily. Furthermore, if the waters break before the baby has rotated to the anterior, it is possible that sudden descent of the fetal skull will result in a deep transverse arrest!

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.

TERMS

	Caput a swelling under the fetal scalp.
	ROA right occiput anterior (baby positioned in the right side of the uterus, facing the mother’s spine).
	LOA left occiput anterior (baby positioned in the left side of the uterus, facing the mother’s spine).

Used with permission, Valerie el Halta 1996.

Copyright © 1997-2007 Mother Care. All photos © Mother Care & Terri McKinney Photography. All rights reserved.