Optimal Foetal Position makes a labour of difference
Chapter Seventeen- From A Labour of Love II
Optimal Foetal Positioning Makes a Labour of Difference!
Any of my aqua-specific class participants will tell you what a stickler I have become for getting women to acknowledge where their baby is sitting inside their body and just what they can do to assist their baby into a favourable position for birth. This acknowledgement and push came after reading, Understanding and Teaching Optimal Foetal Positioning by Jean Sutton and Pauline Scott who live and work in New Zealand. They suggest due to our Westernised/sedentary lifestyles, women are no longer leaning forward at all throughout their day due to not having to perform tasks and skills of manual labour around the house, like chopping wood or scrubbing the floors. The cause and effect being we are witnessing more and more babies being in a posterior position or OP (Occipito Posterior) as it is technically referred to, where the baby’s spine is to the mother’s spine and back of the pelvis.
Jean and Pauline, like myself, believe it is of utmost importance to get a baby into the optimal foetal position as early on in the pregnancy as thirty weeks, for this is when a baby is starting to rotate around and is settling into the pelvis in readiness to be born.
Having run aquatic and fitball pregnancy specific classes for many years, optimal foetal positioning was something I was always aware of and it was always at the back of my mind, however until I read Understanding and Teaching Optimal Foetal Positioning, I did not consciously tune in to just how important optimal foetal positioning is in relation to birthing outcomes. That wake up call came to me about five years ago when I was noticing so many women coming to me with posterior positioned babies who would literally endure these long hard drawn out labours as their body tried to turn their baby with the contractions to the anterior position in labour, or they birthed their baby in a posterior facing position with intense back pain.
It is for this very reason that I now encourage women to do some fundamental activities from thirty weeks through to the baby’s birth day once they know they have a baby head down. The three things I get women to do are what I call:
- Tummy time (between 30 to 40 plus weeks)
- Ball time (any time from 30 weeks onwards- when head is down in pelvis)
- Peri Prep time (from 35 weeks onwards – every third day until birth)
Tummy Time: Firstly, I will focus and explain what tummy time is: Tummy time is about getting a woman to lean forward for twenty minutes a day two to three times a day if possible. This can be done incidentally while carrying out other tasks or on purpose in a desired place and position.
I find women can easily perform this task while:
- Talking on the phone—leaning over the kitchen table or bench top
- Watching TV—leaning over a fitball, bean bag or back of your arm chair or couch
- Swimming in the pool—in a prone (face-down) position with mask or snorkel (gravity is best though)
- Participating in a Yoga class—child pose, dog pose and cat pose
- Attending antenatal childbirth educational classes—sitting on a fitball, leaning over a fitball or beanbag (not sitting upright in an uncomfortable chair)
- Scrubbing and cleaning the floors—on your hands and knees (No, I am not kidding!)
- If on the computer, sit on a fitball or ergonomic chair that forces your body forward and back to be straight
- Playing on the floor on your hands and knees with your other children
- Pulling the weeds out of your garden or planting new plants in garden beds
- Chopping the firewood if you have a fire place-some people still do!
In order to rotate your baby to an anterior position or OA (Occipito Anterior) position as it is referred to, so that your baby may enter the pelvis with more ease, it is so important that from thirty weeks in your pregnancy, you avoid laying on your modular couch that has the ‘chase’, or reclining chair such as a La-Z-Boy, as this really does interfere with what optimal foetal positioning is about. I know this can be very difficult and tempting when you are pregnant and feeling tired and heavy, and nowadays we have such comfortable furniture that looks like a bed and beckons us to come and lay on it in the dreaded reclined position. Avoid doing so at all costs—I really can’t stress this enough! Ban yourself from lying down on this furniture for this very short time in your life.
I know personally that all you really want to do is lay on that couch at the end of a day and rest, however laying on your back can rotate your baby into a posterior position which is not really conducive to a straightforward and easy birth. Labour with a posterior baby position is hard work, make no mistake about that. Women can birth a baby in a posterior position however, it is harder on the woman due to the intense back ache that does not go away when the contraction is on and off, and often the labour can be very long and hard. Women who do labour with a posterior positioned baby need a medal for being so strong with incredible endurance.
Having a baby in a posterior position may cause the following:
- Labour pain in your back/constant intent back ache that does not go away
- Pain deep in the pelvis and hips on one or both sides
- The baby cannot enter the pelvis as easily in this position (it is often referred to as the ‘Military position’ where the baby is straight from head to bottom spine to spine with Mum- causing baby’s head to be rigid presenting widest part of head circumference)
- Continuous pain that does not go away when in between contractions
- A longer labour Irregular contractions More interventions (like induction to get labour started)
- The baby decides to turn in labour to the anterior position
- You go over your estimated date of birth
- The need for your baby to be rotated at the end of the labour with the head in the birth canal using forceps or vacuum or both
- The need for assistance to birth your baby using forceps or vacuum
Having an anterior position baby may mean:
- Labour being shorter Less pain associated with labour
- You will receive rest periods in-between contractions Baby may be born closer to estimated dates Less need for pain relief
- Less likely to need interventions at the end of labour due to your baby being in a better position
- In order to assist with optimal foetal positioning, try to avoid at all costs:
- Laying back in a semi-reclined position on furniture and in bed Long car trips with a bucket type seat
- Sitting with the legs crossed on any type of chair Squatting— should not be attempted unless your baby is head down or in an OA position
- If you are still working up until your estimated date of birth try not to slouch on your chair at your desk—try to use an ergonomic chair that tilts forward or sit on a fitball
Below are some practical ideas that I encourage women to do to get the baby down into the pelvis.
Ball time is about getting on a fitball every day once you know your baby is in an anterior position to encourage your baby to head down and into the pelvis rim. If you don’t have a fitball, go out and buy one as you can use it to labour on as well. Make sure when you sit on your ball that your knees are lower than your pelvis. Once your baby is in the anterior position, you have less chance of your baby deciding to rotate into an OP position or worse still, deciding to go breech! Ball time is about sitting on your fitball for twenty minutes or more a day, while swinging and rocking your pelvis forward and back, side to side, doing big round circles one way and back the other way. Then I often suggest you pretend to write your name on the floor with your vagina in cursive writing (this is always interesting and very entertaining in a class!) You can finish with your pelvic floor strengthening exercises (squeezing your pelvic floor muscles up to the 1st floor, 2nd floor and 3rd floor and holding for the count of six, and then letting it down slowly. This can be repeated eight times over, having a minute’s rest and repeating two more times. All up, you are doing three sets of eight exercises) If you are having bad problems with peeing when laughing, sneezing, chasing your toddlers around or jumping up and down when exercising then you will need to do three sets of eight three times per day to really get these muscles to engage and become strong once again. The more you do the exercises the stronger your muscles will become the less likely you are to leak urine and have a little accident. Remember if you go into labour with strong pelvic floor muscles your recovery after will be so much better and some women actually have great strength straight away post birth because of all the effort they put in prior to birth.
The thing to ask yourself is how strong are my pelvic floor muscles and how open is my pelvis?
Many women I work with have terrible pelvic floor muscles and very tight ligaments around the pelvis even though they have the wonderful ‘relaxin’ hormone in their body that should be assisting with ligament laxity in their pelvis. As for the pelvic floor muscles, women seem to think that the stronger the pelvic floor muscles, the harder it is to push a baby out. This is completely wrong and contrary to popular belief is in fact the opposite. The stronger the pelvic floor muscles, the easier and more dynamic the pushing can be, hence the pushing/birth phase of a labour can go very quickly Sitting on a fitball doing ‘ball time’ can open up your pelvis I love this following story as it highlights just how the pelvis can and does open regardless of the size of a baby and the size of the woman and the biased opinions that are out there that are taught to midwives, obstetric care providers and women who then project them onto other women making them doubtful of themselves and their body and it ability to fit a baby through the pelvis.
Pelvises I Have Known and Loved
by Gloria Lemay who has given me permission to share her story with you and I love it as it is a wonderful illustration of just what is possible.
What if there were no pelvis? What if it were as insignificant to how a child is born as how big the nose is on the mother’s face? After 20 years of watching birth, this is what I have come to. Pelvises open at three stretch points—the symphysis pubis and the two sacroiliac joints. These points are full of relaxin hormones—the pelvis literally begins falling apart at about 34 weeks of pregnancy. In addition to this mobile, loose, stretchy pelvis, nature has given human beings the added bonus of having a mouldable, pliable, shrinkable baby head. Like a steamer tray for a cooking pot has folding plates that adjust it to any size pot, so do these four overlapping plates that form the infant’s skull adjust to fit the mother’s body.
Every woman who is alive today is the result of millions of years of natural selection.
Today’s women are the end result of evolution. We are the ones with the bones that made it all the way here. With the exception of those born in the last thirty years, we almost all go back through our maternal lineage generation after generation having smooth, normal vaginal births. Prior to 30 years ago, major problems in large groups were always attributable to maternal malnutrition (starvation) or sepsis in hospitals. Twenty years ago, physicians were known to tell women that the reason they had a caesarean was that the child’s head was just too big for the size of the pelvis. The trouble began when these same women would stay at home for their next child’s birth and give birth to a bigger baby through that same pelvis. This became very embarrassing, and it curtailed this reason being put forward for doing Caesareans.
What replaced this reason was the post-Caesarean statement: “Well, it’s a good thing we did the Caesarean because the cord was twice around the baby’s neck.” This is what I’ve heard a lot of in the past ten years. Doctors must come up with a very good reason for every operation because the family will have such a dreadful time with the new baby and mother when they get home that, without a convincing reason, the fathers would be on the warpath. Just imagine if the doctor said honestly, “Well, Joe, this was one of those times when we jumped the gun—there was actually not a thing wrong with either your baby or your wife. I’m sorry she’ll have a six week recovery to go through for nothing.” We do know that at least 15 percent of Caesareans are unnecessary but the parents are never told. There is a conspiracy among hospital staff to keep this information from families for obvious reasons.
In a similar vein, I find it interesting that in 1999, doctors now advocate discontinuing the use of the electronic fetal monitor. This is something natural birth advocates have campaigned hard for and have not been able to accomplish in the past 20 years. The natural-types were concerned about possible harm to the baby from the Doppler ultrasound radiation as well as discomfort for the mother from the two tight belts around her belly.
Now in l999, the doctors have joined the campaign to rid maternity wards of these expensive pieces of technology. Why, you ask? Because it has just dawned on the doctors that the very strip of paper recording fetal heart tones that they thought proved how careful and conscientious they were, and which they thought was their protection, has actually been their worst enemy in a court of law. A good lawyer can take any piece of “evidence” and find an expert to interpret it to his own ends. After a baby dies or is damaged, the hindsight people come in and go over these strips, and the doctors are left with huge legal settlements to make. What the literature indicates now is that when a nurse with a stethoscope listens to the “real” heartbeat through a fetoscope (not the bounced back and recorded beat shown on a monitor read-out) the Caesarean rate goes down by 50 percent with no adverse effects on fetal mortality rates.
Of course, I am in favour of the abolition of electronic fetal monitoring but it would be far more uplifting if this was being done for some sort of health improvement and not just more ways to cover butt in court.
Now let’s get back to pelvises I have known and loved. When I was a keen beginner midwife, I took many workshops in which I measured pelvises of my classmates. Bi-spinous diameters, sacral promontories, narrow arches—all very important and serious. Gynecoid, android, anthropoid and the dreaded platypelloid all had to be measured, assessed and agonized over. I worried that babies would get “hung up” on spikes and bone spurs that could, according to the folklore, appear out of nowhere. Then one day I heard the head of obstetrics at our local hospital say, “The best pelvimeter is the baby’s head.” In other words, a head passing through the pelvis would tell you more about the size of it than all the callipers and X-rays in the world. He did not advocate taking pelvic measurements at all. Of course, doing pelvimetry in early pregnancy before the hormones have started relaxing the pelvis is ridiculous.
One of the midwife “tricks” that we were taught was to ask the mother’s shoe size. If the mother wore size five or more shoes, the theory went that her pelvis would be ample. Well, 98 percent of women take over size five shoes so this was a good theory that gave me confidence in women’s bodies for a number of years. Then I had a client who came to me at eight months pregnant seeking a home waterbirth. She had, up till that time, been under the care of a hospital nurse-midwifery practise. She was Greek and loved doing gymnastics. Her 18-year-old body glowed with good health, and I felt lucky to have her in my practice until I asked the shoe size question. She took size two shoes. She had to buy her shoes in Chinatown to get them small enough—oh dear. I thought briefly of refreshing my rusting pelvimetry skills, but then I reconsidered. I would not lay this small pelvis trip on her. I would be vigilant at her birth and act if the birth seemed obstructed in an unusual way, but I would not make it a self-fulfilling prophecy. She gave birth to a seven-pound girl and only pushed about 12 times. She gave birth in a water tub sitting on the lap of her young lover and the scene reminded me of “Blue Lagoon” with Brooke Shields—it was so sexy. So that pelvis ended the shoe size theory forever.
Another pelvis that came my way a few years ago stands out in my mind. This young woman had had a Caesarean for her first childbirth experience. She had been induced, and it sounded like the usual Cascade of Interventions. When she was being stitched up after the surgery her husband said to her, “Never mind, Carol, next baby you can have vaginally.” The surgeon made the comment back to him, “Not unless she has a two pound baby.” When I met her she was having mild, early birth sensations. Her doula had called me to consult on her birth. The mother really had a strangely shaped body. She was only about 5’1″, and most of that was legs. Her pregnant belly looked huge because it just went forward—she had very little space between the crest of her hip and her rib cage. Luckily her own mother was present in the house when I first arrived there. I took her into the kitchen and asked her about her own birth experiences. She had had her first baby vaginally. With her second, there had been a malpresentation and she had undergone a Caesarean. Since the grandmother had the same body-type as her daughter, I was heartened by the fact that at least she had had one baby vaginally. Again, this woman dilated in the water tub. It was a planned hospital birth, so at advanced dilation they moved to the hospital. She was pushing when she got there and proceeded to birth a seven-pound girl. She used a squatting bar and was thrilled with her completely spontaneous birth experience. I asked her to write to the surgeon who had made the remark that she couldn’t birth a baby over two pounds and let him know that this unscientific, unkind remark had caused her much unneeded worry.
Another group of pelvises that inspire me are those of the pygmy women of Africa. I have an article in my files by an anthropologist who reports that these women have a height of four feet, on average. The average weight of their infants is eight pounds! In relative terms, this is like a woman 5’6″ giving birth to a fourteen-pound baby. The custom in their villages is that the woman stays alone in her hut for birth until her membranes rupture. At that time, she strolls through the village and finds her midwives. The midwives and the woman hold hands and sing as they walk down to the river. At the edge of the river is a flat, well-worn rock on which all the babies are born. The two midwives squat at the mother’s side while she pushes her baby out. One midwife scoops up river water to splash on the newborn to stimulate the first breath. After the placenta is birthed the other midwife finds a narrow place in the cord and chews it to separate the infant. Then the three walk back to join the people. This article has been a teaching and inspiration for me.
That’s the bottom line on pelvises—they don’t exist in real midwifery. Any baby can slide through any pelvis with a powerful uterus pistoling down on him/her.
Gloria Lemay is a private birth attendant in Vancouver, B.C., Canada
Perineum preparation can begin at approximately thirty five weeks of pregnancy. This can be done either manually by yourself or your partner or by using an EPI-NO. An EPI-NO is relatively new on the market and is fast becoming very popular for women wanting to have a natural birth experience. The EPI-NO is like a thick rubber balloon which you insert into your vagina and you pump it up so that it opens this soft tissue gently stretching it. The idea is that you practice using it every couple of days working towards getting the balloon to ten centimetres in dilation. This of course represents the diameter of a baby’s head circumference.
I have attended many births where women have been using the EPI-NO and it really does work. I have seen the perineum open so wide and stretch without the need for an episiotomy or a natural tear at all. Even grazes are kept at bay.
As for manual stretching, this can be done by you or your partner every couple of days. I do recommend that you use my perineum preparation balm which I sell online through my website individually or as part of a labour kit, or a natural cold-pressed oil like apricot, olive or grapeseed. What you will need to do is rub the oil or balm into the perineum before the stretching begins, which will assist in the prevention of tearing and minimise damage by helping this skin tissue to stretch and remain soft and supple throughout the last weeks of pregnancy, leading up to the birth. If you are stretching the perineum yourself, the best position to be in is standing up. Put one foot up on a chair take your arm around behind your bottom and insert two to three fingers into the back of your vagina and pull back on this tissue towards your anus holding for the count of six to eight seconds. You should feel a small amount of discomfort in this area, if you do not it is not stretching the skin! Let go and have a little break, then try it again holding again for six to eight seconds. Perform this at least four to six times per session, pulling a little harder each time so that you can feel yourself stretching a little bit more each time. After a couple of weeks you should feel the difference. I recently met a Sexologist who told me how she suggests to women to use their sex toys to stretch this tissue which is basically the same idea as using the Epi-No but with the batteries included! If your partner is going to do your stretching for you, you will need to lie in a slightly reclined position on an armchair or on your bed. Keep your knees bent and your legs opened and relaxed. Your partner will need to place both thumbs into the vagina with oil or balm on them and proceed to push down towards your bottom, holding for about six to eight seconds and then moving his thumbs down and outwards for six to eight seconds as you practice your breathing. He will need to repeat this four to six times over, applying more pressure each and every time. Yes, it will be uncomfortable, and sting a little, so you will need to breathe and focus on letting go. It is great exercise to do in preparation for labour. Just note: If it feels nice and you are enjoying it – it is foreplay not peri prep time! There has to be some type of stretchy/intensity or you are not doing it correctly!
Dr Christiane Northrup, author of the book Women’s Bodies, Women’s Wisdom appeared on the Oprah show recently and spoke of masturbation, ‘getting in touch with one’s feminine energy’. I love how she referred to masturbation as ‘self-cultivation—keeping the energy alive’. She explained how it is so important for women to keep in touch with themselves and how masturbation should be spoken about as a natural, normal and healthy thing to do, which should be done on a regular basis as often as you like.
Masturbation is actually one of the things I suggest to pregnant women to get them into labour when they are over their estimated date of birth and being threatened by an obstetrician to be induced. It is amazing how so many women just look at me in disbelief when I suggest this as a viable option. I remember during my first pregnancy, that after lunch I would lay down to have a nap but before I nodded off I would ‘connect with myself’ and really get the ‘energy and juices going’ literally!
What I found happening to a great degree was that when I orgasmed, I could feel all my pelvic floor muscles bearing down into my vagina and I felt as though I was connecting and ‘tuning in’ to what it was going to feel like to give birth through my birth canal and vagina. What I also felt was that the more I masturbated with multiple orgasms, the stronger the sensation grew and I actually found I was quite addicted to this bearing down sensation as it brought on powerful Braxton Hicks as well as strong period type sensations—neither which worried or bothered me but actually had the reverse effect and reassured me that my body was functioning very well and I was preparing this area of my body to release my baby from within. It was comforting to know as well that I could still create that wonderful orgasmic energy and release it from my very pregnant body, as I did not feel very sexual in pregnancy at all. This was one way in which I could ‘let go’ and enjoy this time with myself.
The great payoff after my episodes was of course having a good satisfying orgasmic sleep. This was a luxury that I could indulge myself in at anytime, due to being pregnant for the very first time. The second and third pregnancies made my ‘self-cultivation’ a little harder to achieve, due to time constraints and not being able to have my own time to have afternoon naps. However, I just knew somehow it was equally as important to attend to on a regular basis if I could. I feel that my births may have been fast due to being so connected and in touch with myself ‘literally’ actually assisted me to experience my really fast labour, because I was so clear and ready to open my body to the world and allow myself to feel vulnerable. Being open physically, mentally and emotionally meant there was really nothing in my way that could present itself as an issue as I just didn’t have any. Maybe this readiness mentally and physically, having your baby in an optimal foetal position and ready to go is the key to a powerful, positive, quick birth?
Does straightforward uncomplicated birth occur because women are so prepared on all levels and are completely open?
I would like to suggest that this is definitely true of the many births I have attended over the last decade as a doula. Women can be their own worst enemy and be real drama queens if they want to be and make it all about them. This however serves no purpose other than to attention-seek and get everyone to fuss over them. This I feel is a real shame as women can gain so much from surrendering and going through the journey of labour, taking them from their selfish self-centred alter ego to that of selflessness, labouring literally to bring forth another human being into this world, ‘transitioning’ both herself, her body and her baby from one place to another. The ‘act of labouring’ is more powerful than we can ever imagine or comprehend and has a profound effect on women that carries them beyond birth and into the new realm of care provider and mother. An act that is totally ‘selfless’ and ‘unconditional’ in every sense of the word.
In summary what I feel women need to do to create a positive and straight forward labour is partake in doing the following:
Tummy time (30 to 40 plus weeks)
Ball time (from 30 weeks onwards – when head is down in pelvis)
Peri Prep time (35 weeks onwards every third day until labour)
Masturbation Time (self-cultivation on a regular basis)
Trust me when I say that by participating religiously in doing all of these activities you really can create your wonderful labour of love that you want and desire!
Estimated Due Date
Most gestational lengths are gauged by Naegele’s Rule, which assumes that every pregnancy lasts 280 days from the last menstrual period, and of course that the period comes in a 28-day cycle and a woman always ovulates on day 14! This ‘rule’ does not take into consideration that some women have just come off the pill or perhaps have not had a period, and not all women menstruate in a 28 day cycle or ovulate on day 14. It amazes me how the medical approach to pregnancy and birth casts one mould for all women and does not take into consideration individual differences.
The EDD is often the first step in creating a performance anxiety. It can put into a woman’s mind the idea that she really has to go into labour sometime within close proximity of this date, and if she doesn’t, something is wrong with her body.
The problem lies in how much pressure the woman is put under to have her baby within cooeee of that estimate. What I have found during my research is that a great deal of pressure is placed on a woman who is over her EDD, especially as she is then often referred to as ‘overdue’, when in fact her personal body/baby clock may not be ready for the birth. It is so important to remember that the EDD is only an estimate and it is very much a case of give or take two weeks. Women should probably only be described as ‘overdue’ when they are at forty two weeks or more, as some babies need the whole forty two weeks for gestation.
I know from experience that every day over the estimated due date can feel like an eternity. However, as long as a baby is happy inside and all is fine, why rush this natural process — the baby has a hormone trigger that it releases when it is ready to be born. I know from experience how heavy a woman can feel, how swollen her feet can get and how huge and tired she can become as she gets close to birthing. It is hard not to opt for some assistance in getting things going, or give in to obstetric pressure to have an induction. Having an induction however is like playing with fire literally and many women do end up getting burnt. The problem with having an induction is women often travel down a road they do not wish to go down and end up on the ‘Cascade of Intervention’. A road that many wish they had not taken in the first place as the final destination/outcome is not one that they wanted or desired.
My suggestion to women waiting for the imminent birth-day or night is to appreciate that everyday being pregnant is a blessing and to be patient. Turn off your phones and pull back from the world and stop listening to others comments and stories aimed at you. Go for long walks along the beach or in the bush, tune into ‘Mother Nature’ – absorb yourself in your own positive inner thoughts. Be still, meditate or listen to hypnosis scripts to empower yourself and gather your inner strength. Above all else keep trusting and believing in your body that it can and will go into labour when the time is right for you and your baby. Be at peace with yourself and all that surrounds you. Have a little faith and really TRUST that all is in divine order.