The U.S. current rate of cesaran section is around 31%.
Labor & Delivery Nurse Ann Marie Gilligan’s Gilligan’s Guide teaches the importance of having an infant in the optimal position for birth, how to determine the position of the infant in utero, and how to get the infant into a more optimal fetal position during labor and beforehand.
Fetal Position & Rotation
Fetal lie is which way the baby is laying in the uterus. Fetal presentation is what part enters the pelvis first. Fetal position is a chosen point in relation to which side of the maternal body, left or right.
Studies show that the safest, most efficient way for a baby to deliver is a left occiput (the back of baby’s head) anterior position. The goal of maternal positioning is to get that baby into the left occiput anterior position. Risks associated with baby being in an occiput posterior position include: longer labors, increased rates of 3rd and 4th degree lacerations, increased postpartum hemorrhage, rises in infection, increases instrumental and surgical births. For the infant, we see an increase in meconium, birth trauma, admissions to NICU, lower Apgar, increased brachial plexus injuries, and acidemia (lower cord gas pH). We need to start talking about the position of the baby because of the relevance to these comorbidities and the correlation between the c-section rate and the posterior babies.
As the baby comes through the pelvis, it rotates clockwise. When you have a baby that’s malpositioned, it doesn’t allow for that internal turn to happen -you don’t have that baby come out looking at the earth, or an occiput anterior position.
When you measure the circumference of the occiput (back of the head) vs.from the forehead to the back, you’ve got a 2-3 cm. difference. The perfect scenario is when the baby enters the pelvis with its chin tucked-down to the chest and rotates from an occiput transverse position to an occiput anterior position – the easiest and safest way for the baby to come through.
The goal of the labor team should be to do what we can to get that baby in what we know as the optimal position for delivery – the occiput anterior position. The bony pelvis has the ability to change shape. The pubic symphysis, the back, the sacrum, the Relaxin hormone, the soft tissue, the uterosacral ligament, the broad ligament, the round ligament, the psoas muscles, the gluteal muscles, the pelvic diaphragm, the respiratory diaphragm; they’ve all done their job maintaining the pregnancy. During labor and delivery, it’s time for them to relax, balance and stretch to create space.
Signs of Malposition
There are several cues that baby might be malpositioned. One is in a vaginal exam, when a space is felt because the head is not centralized on the cervix, rather than the whole cervix being filled by baby’s occiput in order to dilate it beautifully all the way around.
Other signs are those stop and start labors. Example: patient sent home in the morning at 3 cm, comes back in the evening, and her cervix is still the same. But she was also having severe back pain with each contraction. Get her get off the bed, the worst place for her to be. Do the 20-minute monitoring with her standing up or leaning over with her elbows on a pillow and kind of rocking her hips back and forth. This position often eliminates that back labor. The baby is hanging down in a hammock-like form, her pelvic inlet is open, she’s created that 120 degrees, she’s provided movement with that rocking of her hips. Literally, 5, 7 minutes, two contractions, the pain in her back lessens, possibly goes away.
Another sign of a malpositioned baby is an early pushy feeling. Feeling pushy at about 7-8 cm means that occiput is pressing on the rectum, making it really hard to not push. Repositioning babies gets moms more comfortable so they don’t feel pushy prior to 10 cm and potentially swell the cervix.
The biggest thing is the contraction pattern. When a uterus has a malpositioned baby, that smooth muscle has a hard time efficiently contracting around that baby from the top, pushing that baby down, and if the axis of the body is off to the side, you’re going to see an irregular pattern of contractions. Possibly, boom, boom, boom, space, or nice big contraction followed with a little one. That is a sign to do some positioning because the main reason for a coupling pattern or an irregular pattern of contractions is malposition.
What You & Your Team Can Do
Around 34 weeks is the perfect time to start talking about anatomy, physiology, and things you can do to optimize that position of your baby. Babies are smart, they want to get in the right position, but sometimes it’s made harder with a woman sitting in a 90 degree chair for 8-10 hours, then going from that chair to a sofa and watching TV for the rest of the night. The weight of the baby, that heaviness of the back, is going to be towards the maternal spine and therefore, the baby looking up.
Simply by opening up the degree, the angle from the maternal spine to maternal femur in a sitting position will have a positive effect. Think about always having your knees lower than your hips, which actually opens that angle to 120 degrees, you’re going to be tilting the pelvis and allowing that baby more space to rotate. Many car seats are bucket seats, where your hip is lower than your knees. Slouched back, poor posture. If you can, get out of the car and lean over it, especially if you are uncomfortable.
Nurses need to be taught to assess patients by putting hands or fingertips on the belly and doing something called Leopold’s or modified Leopold’s Maneuver. Tapping fingers on the top of the baby and then down along the side of the baby tells you so much more about your patient than just doing a cervical exam.
There is way to optimize the use of epidurals. Studies all indicate that if you get an epidural when the baby is still high, you run a higher risk of having an occiput posterior baby. It’s because of the relaxation of the uterine musculature in the pelvic floor. You don’t have that tone for the baby to hit against to cause that internal rotation. When you have a baby that is on the right side to begin with and has not come into the engagement or the pelvis yet, you’re going to have a rotation that goes the opposite direction, to the posterior position. When people say, “get her an epidural. Everything will relax, baby will rotate.” Well if the baby’s not on the left side, the baby will rotate from the right side to looking up, which we know has the risks associated with occiput posterior baby. But if you get an epidural at the right time, when the baby’s on the left side, that rotation just needs to happen a little bit clockwise to fit into that pelvis in an occiput anterior position. The rotation is typically in the mid-pelvis and then it’ll come out looking at the earth.
When we look at the percentage of epidural use in this country, around 75-80% of women are in bed for the duration of their labor. Maternal positioning can be done with epiduralized patients, but it’s optimally done with women standing.
The nurse has to get her ready for an epidural and give her an IV of lactated Ringer’s (due to potential blood pressure drop). This takes approximately 30-45 minutes, so there’s time for some maternal positioning. If the baby is put in the right position for birth, then mother has the epidural, the baby will rotate from that left side to occiput anterior and you have a shortened labor and a much safer delivery than giving an epidural when a baby on the right side or is occiput posterior.
We have a current maternal and infant crisis in the United States and if we start talking about position of baby and including that in our initial assessment, I truly believe we will improve our current situation of maternal and infant mortality and morbidities in this country.
From Evidence-Based Birth podcast Feb 2021