Your Body is Not a Lemon
Your Body is Not a Lemon
I see something new with every single birth that I attend. Recent births have led me to reflect on the ‘back to back’ position. It is widely considered to be a problem, but here it is presented more as a variation of normal. That’s not to say that it doesn’t sometimes come with challenges!
Most commonly, at the point that the baby’s head is born they are what a midwife would call ‘anterior’ - the back of their head is at the front of the woman’s pelvis and they are facing their mother’s bum. This is generally the easiest way through, as the diameters of the baby’s head are smallest this way. The baby enters the top of the pelvis looking towards one of the mother’s hips and corkscrews to face backwards during the process of birth. Due to the shape of the uterus, the baby having their back on the left, and facing the right hip in late pregnancy is considered optimal. This is all well and good but recent experience has given me pause for thought…
‘Back to back’ may also be known as posterior, occiput posterior/OP, or ‘star gazing’.
From 34ish weeks, if you are seeing and feeling limb movements (sharp/pointy/knobbly) on both sides at the front of your abdomen, rather than tucked up towards the ribs on one side, the baby is likely back to back. This may be combined with a tickly sensation low down, at the front (hands). There may also be a dip around your belly button, when lying on your back.
With one recent client, first baby, the baby was on the right the entire pregnancy, despite my attempts to ‘fix’ it. Labour started at 41+5 weeks, in the evening. I went out to her in the middle of the night and found things well underway. We went into the birth centre together and the baby had arrived very smoothly by mid morning. Another client, first baby, was on the left the whole pregnancy. Great! In this case however the baby became back to back in labour and indeed was born that way. Two more births - 2nd babies this time - in both I observed a slightly longer period of pushing that one would expect for a 2nd birth, along with more pushing effort by the mother. In both cases the babies coped well with the process and were born, one facing the side and the other directly ‘back to back’.
These experiences lead me to the following conclusions:
Babies can start on the left and go posterior in labour, they will either stay that way or rotate to anterior.
Babies can start on the right and easily rotate to anterior.
Babies do not often do what we want, or expect them to do! There is wisdom in the process of birth, and with patience and with good physiologically informed labour care (more on this below) will generally find their way through the pelvis.
Attempting to ‘fix’ the baby’s position in pregnancy has the potential to cause anxiety and further entrench the belief that birth, bodies and babies work like machines, in a linear and predictable 1, 2, 3 step process (they don’t!).
There has been an upsurge of interest in ‘biomechanics’ in recent years. With many hospitals providing training for midwives to use and teach exercises and postures to optimise the baby’s position, and fix problems stemming from malpositioning in labour. Malpositioning is up there as a cause for instrumental and caesarean, especially for women having their first babies, so on the face of it this effort makes sense. I used to be proactive in universally teaching these positions to women, especially those having their first baby. But this needs to be tempered alongside creating trust in the innate wisdom of the body and baby to manage the process themselves!
I wonder (as many have before me) if ‘malpositioning’, leading to caesarean, actually reflects a wider systemic problem within the maternity system, rather than the woman’s body? Certainly continuous fetal heart monitoring (restricting movement), epidural and the application of universal time limits applied to each stage of labour, do not create an optimal environment for a ‘malpositioned’ baby to find their way out.
So what can we do to help?
Aim for an active pregnancy with lots of varied movement. Walking, swimming, yoga, pilates are all great. When a client tells me they are a dog walker or a yoga teacher I am pleased!
The early stages of ‘pre labour’ can be prolonged with a ‘back to back’ baby. Prioritise rest, food and hydration. A TENs machine, hot water bottle or bath may also help.
There seems to be an association with waters breaking before labour. Ensure you have fully explored the risks (ask for numbers) and benefits of induction vs. waiting if labour doesn't start within 24 hours.
In labour there is often an ‘early’ urge to push and/or poo. As a student midwife I observed that the usual suggestion for this was an epidural, however this rarely helps. It may be helpful to try a variation on the all fours position with your chest to the floor and bum in the air. This may help the baby reverse out of the pelvis and reposition. It is possible that this early pushing helps the baby to rotate.
If the baby stays back to back, the pushing phase is generally longer and harder. Some women report the sense that the baby isn’t fitting well somehow. If you and the baby are coping well with labour (the baby moving and their heart rate is normal), and an intervention is being offered, you may wish to ask for more time to try a different position or even rest for a while.
Keep well fed and watered, as in all births, keep moving, and regularly visit the toilet to empty your bladder. Feel free to stay sitting on the toilet for as long as feels tolerable.
Some midwives and doctors have the skill to use their fingers or hands to help the baby turn. This is something you could ask about to try, especially if an intervention such as forceps is being offered.
There may or may not be back pain associated. Back pain in labour does not necessarily mean the baby is ‘back to back’ and vice versa.
And finally, know that babies being in different positions in late pregnancy and labour is common and usually a variation of normal. Environments like birth centres and home are likely to be more supportive, and the midwives more experienced in supporting births like this, without recourse to interventions such as epidural.
I’ll end by sharing the wise words of midwifery legend, Ina May Gaskin…
“Remember this, for it is as true as it gets. Your body is not a lemon.”
To read
Spinning Babies
https://www.spinningbabies.com/pregnancy-birth/baby-position/posterior/
Rachel Reed - In Celebration of the OP baby
https://midwifethinking.com/2016/06/08/in-celebration-of-the-op-baby/