Baby Malpositions: Implications for Birth
DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider.
- Definition of Malpresentation
- Definition of Malposition (All Head-Down)
- Common Complications Seen With Baby Malpositions
- Research on Malpositions
- Why Malpositions Happen
- Strategies To Correct Malpositions
- Post Script: Kmom’s Story—3 Malpositions (2 Cesareans and a VBAC)
There are two terms that are used to refer to how the baby is located in the mother’s body, presentation and position. Although some resources use these terms inconsistently, presentation properly refers to which part of the baby ‘presents’ first at the vagina; in other words, whether the baby is head-up (breech), head-down (vertex), or shoulder-first/sideways (transverse). Position usually refers to how the back of the baby’s head is lying in reference to the mother’s spine (towards her spine or away from it, etc.).
Traditionally, the obstetric community has placed great importance on a baby’s presentation (breech, transverse, or vertex). Subtle problems in baby position and how they impact labor have been largely ignored, however. In other words, if the baby is head-down it is assumed to be ready for vaginal delivery and any deviation from a ‘normal’ labor curve viewed as a failure of the mother’s ability to labor and birth, therefore ‘needing’ drugs and/or surgical intervention.
However, when subtle variations of the head-down position occur, a longer and more difficult delivery may result, often even necessitating forceps or a c-section. Research shows that persistent malpositions often end up with a high degree of intervention and operative delivery, yet the obstetric community still does not recognize the role positioning plays.
Many c-sections are performed unnecessarily because of subtle baby malposition problems, yet few doctors or even midwives pay close enough attention to the influence of baby’s position on the progress of labor. Many c-sections (or long, hard labors) could probably be avoided with more careful attention to preventing baby malposition, a quicker diagnosis of malposition during labor, and by employing corrective measures during labor if malposition is a possibility. Since few doctors and only some midwives are being trained in this, parents, doulas, and childbirth educators must step into the gap and educate and advocate for themselves.
Kmom’s Story In Brief: I have had two cesareans and one vaginal birth. All three births probably had some degree of fetal malposition involved, so this is a subject near and dear to my heart! In fact, I believe that I was able to have a Vaginal Birth After Cesarean (VBAC) with my 3rd child largely because we paid strict attention to the issue of baby position, and although the third baby did probably have a malposition, it was a relatively minor one that was able to resolve more easily.
My own personal experience has led me to believe that baby position is of VITAL importance, and the many cesarean stories I have collected for the Birth Stories FAQ convinces me that many other women have also experienced unnecessary cesareans for unresolved baby malpositions. Yet most often they believe it was because the baby was ‘too big’, their pelvis ‘too small’, or that they simply ‘don’t dilate well’. In reality, there may be alternate explanations. This FAQ is an attempt to present this largely understudied area of knowledge in hopes that other women may help prevent or resolve baby malposition before a cesarean becomes necessary.
- For those who have had a c/s or difficult birth caused by baby malposition, it often IS possible to have a VBAC by preventing a malposition from recurring
- For those who are having their first babies, pay close attention to position and posture issues; try to prevent any problems before they occur in labor. You may save yourself a lot of pain and perhaps even some surgery!
- For those who are childbirth educators, doulas, or doctors/midwives, please learn more about this important issue so you can help the women you serve. Many midwives have found that after employing this knowledge and these techniques, their cesarean or transfer rates significantly declined. May it have a similar effect on your practice!.
You can read other stories of malpositions on this website in the FAQ, BBW Birth Stories: Malpositions. Some of these malpositions ended up resolving and ending in vaginal birth; most ended up in cesareans. Read them and see first-hand how malpositions affected labor and birth. Other websites that discuss the issue of malposition include www.cefcares.org/fetal/position.htm, www.gentlebirth.org/archives/position.html, www.homebirth.org.uk/ofp.htm, and www.aims.org/uk/posterior/htm.
Definition of Malpresentation
Not all resources use the terms correctly, but basically malpresentations are those in which the baby’s head does not present at the cervix first. Malpositions, in contrast, all present with the head down BUT may not be situated in the way that is most optimal for birth. The head may be tilted to one side, the baby may face towards the mother’s tummy instead of towards her back, the baby’s chin may not be tucked under, or the baby may have a hand/arm up by its head. All of these are head-down, but the subtle variations may cause labor to be harder, more drawn out, more painful, or even cause the baby to get ‘stuck’. All can usually be fixed (or may resolve on their own) so that the baby can be born vaginally, but there is a high rate of problems if the position is not resolved.
The basic presentations are breech (bottom- or feet-first), vertex (head-down), or transverse (sideways). In most current obstetric practices, only vertex presentations are considered for vaginal delivery, although some providers trained in the old ways will consider vaginal delivery for some breeches or will try everything possible to turn a baby to vertex before resorting to a c-section. However, most OBs these days simply schedule a c/s if the baby is thought to be breech or transverse, often without even trying to turn the baby. The most common presentations are:
Vertex: Baby is head-down, a requirement for vaginal delivery in most practices. Most OBs generally don’t distinguish between the subtle variations in positions among head-down babies; they just care that the baby’s head is presenting first.
Transverse: Baby presenting with its shoulder or side first; there is a high chance of cord prolapse. Baby must turn (or be turned) for birth, or come by c-section. If baby does not turn and a c/s is needed, the incision may need to be low vertical or perhaps ‘classical’ (up-down) because of the baby’s difficult position. Transverse can sometimes be prevented/fixed through maternal position changes or ‘external version’, but few doctors try.
Breech: Baby’s head is up by mother’s ribs; the baby’s bottom or legs present first instead of its head. This presentation results in more risk to the baby, whether born by c/s or vaginally. Most OBs today have not been trained in the art of vaginal breech birth and so routinely deliver by c/s (despite questionable evidence that it improves outcomes); some midwives and OBs still know how (and are willing) to attend breech births. Among breech babies, there are a number of variations as to exactly how the baby presents. Some of these are more favorable for safe vaginal delivery than others.
- Frank Breech: Baby presents butt-first; this position is the most favorable for vaginal birth
- Footling Breech: Baby presents feet-first; this position is a difficult one for vaginal birth and very few providers attempt it, but a few do know how to best assist this presentation. A single footling breech presents with one foot only; a double footling breech presents with two feet.
- Other Breech Presentations: There are other subtle variations on the breech position, but books label them inconsistently (complete breech, incomplete breech, etc.). These variations include how the legs are positioned (folded, straight out, kneeling), etc.
Again, the main difference between malpresentation and malposition is that malpresenting babies have a part other than their head near the cervix and ready to come out first. Malpositioned babies are all head-down but may not be in the most optimal head-down position for birth.
Definition of Malposition (All Head-Down)
“Position” assumes the baby is head-down; the terminology refers to how the BACK of baby’s head (occiput) relates to the mother’s body. Occiput anterior (OA) means the back of baby’s head is toward the mother’s front and occiput posterior (OP) means the back of baby’s head is towards the mother’s spine. However, most people find it easier to think in terms of where the baby’s eyes are facing, and this is the referencing used here.
- Anterior: baby is head-down and ‘looking’ at the spine. The ideal/easiest position for birth is generally LOA (Left Occiput Anterior), with baby facing the mother’s back, chin tucked under, head looking slightly towards the mother’s right side and the baby’s spine along the left side of the mother’s belly. A baby that is ROA (Right Occiput Anterior, or back along the right side of the mother’s belly) can also be delivered fairly easily, but has a distinct tendency to flip into a posterior position before or during labor.
- Posterior: baby is head-down and ‘looking’ at the mother’s tummy; its spine is against the mother’s spine. The diameter of the head that must fit through first is larger, and many posterior babies have their heads de-flexed (chins not tucked under, or ‘military position’), which creates an even larger diameter. This often makes for a much more difficult, slow, and painful birth. Although some posterior babies can be born vaginally if they are smaller and/or have their chins well-tucked under, a large percentage of posterior babies result in c-section due to a “Cephalo-Pelvic Disproportion” diagnosis (CPD, or baby ‘too big’ for mother’s pelvis in that position) or a “Failure to Progress” diagnosis (labor stalls out partway through dilation because of unequal or inadequate pressure on the cervix from baby’s position). A posterior position can often be turned to anterior through the use of special exercises/positions before or during labor, some turn on their own, and a few providers also know how to go in and turn the baby manually during labor. Once they turn, these babies usually are born very quickly.
- Transverse Occiput Arrest: baby is head-down but the head is turned completely sideways towards the mother’s hipbone, causing baby to ‘arrest’ (get stuck) because it doesn’t fit well. The same exercises used for a ‘posterior’ baby can often help disengage and rotate the transverse baby to facilitate normal birth. [Note: ‘Transverse‘ can refer to both a baby that is in a transverse presentation (that is, sideways, or presenting shoulder or belly first) or a baby that is in a transverse position (baby is head-down but the head is turned completely sideways in a way that doesn’t fit).]
- Asynclitic: baby is head-down and probably anterior but the head is slightly tilted to one side or ‘off’ in some way so that the head does not move down into the pelvis smoothly. Usually the side of the head or ‘parietal’ bones present first instead of the crown of the head, making the diameter much larger. There are also exercises that can help resolve this position.
- Compound: baby’s hand presents alongside its head (sometimes called a ‘nuchal hand’), making a larger size that has to go through the pelvis; many of the same symptoms as other malpositions. One other variation of this is when the baby’s arm or elbow is across its face (‘nuchal arm’), which can cause intense pain. A baby can be born with a nuchal hand alongside its head, although the process is usually slow. Often however, something happens to make the baby move its hand or arm back, and then the baby is born very quickly thereafter. Very painful position, but resolves more easily than some of the others.
- Brow or Face: baby is head-down with the head de-flexed and the chin tilted so that either the forehead (brow) or face is towards the mother’s vagina. This is very difficult for vaginal birth (although a few are on record); most often results in a c-section if the position cannot be fixed.
- Oblique: baby is head-down but its whole body is at an angle to the pelvis and cannot enter. If the position cannot be resolved, usually results in a c-section. [Note: Compound, Brow, Face, and Oblique are listed as either malpositions or malpresentations, depending on the source.]
For the spatially challenged among us, there are illustrations of some of these positions on the internet at www.cefcares.org/fetal/position.htm. As noted, other articles discussing various positions and what to do about them can be found at www.gentlebirth.org/archives/position.html, www.homebirth.org.uk/ofp.htm, and www.aims.org/uk/posterior/htm.
Common Complications Seen With Baby Malpositions
There are a host of problems often associated with subtle baby malpositions, most of which get attributed to other causes by most OBs. Women who have been told that their pelvis is “too small”, their babies “too big”, or that their cervix “just doesn’t dilate well” may well have had a problem with baby malposition instead. The popular mentality most doctors have been trained into is that labor problems must lie with the mother, rather than a problem that has gone unrecognized by the provider. So they often reinforce the myth of the ‘too small’ pelvis or the ‘huge’ baby that can’t fit through. Only rarely is this true, however.
A good analogy is a key (the baby) and a lock (the mother’s pelvis). If the key is aligned properly, it slides right into the lock, turns easily, the door opens, and the person moves through. However, if the key is upside down (posterior), sideways (occiput transverse), or even slightly angled to the side (asynclitic), the key has a hard time getting into the lock, let alone getting the person through the door. The solution is either to pull back the key and then turn it to align it with the lock, or to jiggle the key until it works its way into place. Similarly, with babies, the solution is either to ease the baby out of the pelvis so it can turn more easily, or to ‘jiggle’ the baby through maternal shifts in position so that it can work its way into place.
When a baby is LOA (anterior and perfectly positioned), the pressure placed on the cervix is even and smooth, labor advances smoothly and usually fairly quickly, and the baby is usually able to proceed through the soft pelvic bones without problems or delays. The mother’s pelvis stretches and expands at the ligaments to let the baby through, and the baby’s soft head bones fold like a vegetable steamer at the fontanelles (called molding) to also facilitate easy passage. The labor curve generally follows the accepted ‘averages’, and the birth usually proceeds without any real difficulties.
When a baby is malpositioned, the pressure on the cervix is placed inconsistently, and it often dilates slowly, erratically, or stalls out altogether, even though the mother experiences sufficiently strong contractions and significant pain. The diameter of the baby’s head that presents is usually bigger, which means that more molding of the baby’s head must take place. If the baby is at the wrong angle, he may be forced against the pelvis uncomfortably (especially if pitocin is added to augment contractions), which may cause fetal distress.
Often the baby gets ‘hung up’ or stuck before getting past “0” station (entry to the pelvis proper). This also often causes the labor to be slow and inefficient (‘uterine inertia’ or ‘uterine dystocia’), stop altogether (‘failure to progress’/FTP), or keeps the baby from moving through the pelvis despite good contractions or even full dilation and pushing (‘cephalo-pelvic disproportion’/CPD, or ‘baby too big for mother’s pelvis’).
For example, although there is more than one possible cause for the following problems, the occurrence of one or a cluster should raise a high suspicion for baby malposition:
- Days of tiring pre-labor or ‘false’ labor before ‘true’ labor; mother may begin labor exhausted
- A tendency towards post-mature (long) pregnancies and ‘overdue’ babies
- A baby that does not engage before or even well into labor
- Feeling lots of hands and feet in front by the mother’s belly
- PROM – Premature Rupture of Membranes, or the bag of waters breaking before labor starts
- Difficulty finding the baby’s heart tones where you usually would find them
- ‘Stalled labor’ – labor that stops between 4-7 cm and does not progress
- Prolonged labor, especially in the pushing stage
- ‘Back labor’ – painful contractions felt mostly in the back; common with posterior labors because the baby’s back is pressing against the sacrum (low back); also found with the arm across the baby’s face because the arm is pressing on the mother’s sacrum
- High need for pain medication, since the pains are abnormally difficult
- ‘Early transition’ – showing the signs of transition (nausea, chills, high pain levels, shakiness, etc.) between 4-7 cm instead of between 7-10 cm
- ‘Fetal distress’ – baby’s heart rate has problems because baby is stuck and gets stressed; this may also increase incidence of fetal meconium in labor
- ‘Early pushing’ – feeling the urge to push before being fully dilated
- ‘Anterior lip’ – dilating to about 9.5 cm but a small ‘lip’ of the cervix is stubbornly left
- ‘Stuck baby’ – a baby that gets stuck before passing the ischial spines (0 station) and does not descend even after hours of pushing
- Great pain with pushing, especially on one side or another
Not all malposition situations follow the same scenario. A lot depends on how the baby begins labor and what happens thereafter. For example, some babies start labor malpositioned but rotate during labor. These moms and babies usually have hard labors but things ease once the baby resolves its position. Most of these babies end up being born vaginally and all is well.
Some babies start labor well-positioned but rotate or shift to a less-optimal position during labor. This may be because of the mother’s position (often on her back) or the lax musculature caused by an epidural. These babies often are born vaginally, if not easily (and some end up being born by c/s as well). However, most of these babies tend to do pretty well.
The most difficult cases involve babies that start labor malpositioned and stay that way all through labor ( ‘persistent posterior’). Studies show that between 60-90% of these babies are born via ‘operative delivery’ (i.e. forceps, vacuum, or cesarean). These tend to be very difficult, hard labors, and often the doctor breaks the waters or utilizes pitocin along the way; fetal distress, meconium, or even bruising is not unusual in these cases. Many persistent malpositions result in cesareans after long hard labors.
In summary, studies have found particularly increased rates of problems with persistent posterior and other malpositions, and this reflects the anecdotal observations of many midwives. Many women in Vaginal Birth After Cesarean (VBAC) groups also have found (or strongly suspect) that their cesareans were actually done for malpositioned babies. The scope of this problem is probably wider than most providers suspect.
Why Malpositions Happen
No one knows for sure why malpositions happen. As noted above, malpositions may occur because of our modern tendency towards poor posture and unphysiologic positioning. These malpositions tend to be very responsive to maternal repositioning, and often resolve if the mother has sufficient mobility in labor. However, the way most women are forced to labor (on their backs in bed, with limited mobility due to constant fetal monitoring) can make it difficult for babies to turn.
Some midwives have noted a tendency towards posterior positions when the placenta is anterior (front-lying), since babies reportedly tend to face the placenta. A 1994 study by Gardberg and Tuppurainen confirms that anterior placentas predispose to a posterior position. Anterior placentas are particularly common with women who have had prior cesareans or other uterine surgery, but can be found in other women as well.
Malpositions may also occur with large and significant fibroids. These may tend to crowd the baby in-utero and force the baby to assume an unnatural position. Sizer and Nirmal (2000) noted that malpositions were more common with big babies; they theorized that it may be more difficult for larger babies to rotate when labor progresses, so perhaps this is why these were the ones that tended to have persistent malpositions that did not resolve on their own.
Some authorities note that women who are very short-waisted, sway-backed, have bad backs, or have had a previous back injury tend to have a lot of malpositioned babies and back labor. Women who have experienced a pelvic injury may also have a higher rate of malpositioned babies.
In addition, women with Symphysis Pubis Dysfunction (i.e., pain turning over in bed, discomfort lifting one leg to put on clothes, sciatica, a ‘clicking’ feeling in the hips/pelvis, difficulty moving apart their legs to get in and out of the car, etc.) probably have a misaligned pelvis, especially in the front where the pelvic bones almost meet. This area is called the ‘pubic symphysis’, and if these bones are out of alignment, they pull on the soft cartilage in between the bones (pubic symphysis), causing a great deal of pain both in front and in the back, and may predispose the woman to a baby malposition.
A misaligned pelvis can cause the soft tissues to pull, twist, or spasm the uterus out of its optimal shape, thus forcing the baby into a less-than-optimal position and making it difficult for the baby to descend properly. When the pelvis and sacro-iliac area are put into better alignment and the soft tissues released, the baby can resume its most optimal position and usually turns. However, if the pubic bone misalignment continues, the woman is at risk not only for baby malposition, but also significant and debilitating pubic symphysis damage during birth from common obstetric interventions and positions.
Therefore, some providers believe that women may benefit from regular chiropractic care in pregnancy, especially women with bad backs, pubic symphysis pain, a history of malpositioned babies, or prior c/s for Cephalo-Pelvic-Disproportion. In particular, the woman may need not only her back/sacroiliac area realigned, but also the pelvis and the pubic symphysis areas in particular. (For more information about Symphysis Pubis Dysfunction (SPD), see the FAQ on this site on Pubic Pain.)
Another very popular theory among some midwives and OBs is that malposition may have to do with the pelvic shape of the woman (i.e., the relative size of each part of the pelvis, thus creating the pelvic ‘shape’–see www.fpnotebook.com/OB31.htm for further explanations about pelvic shapes). Although most women have the most ‘desirable’ type of pelvic shape (gynecoid), some women have a pelvic shape (anthropoid, android or very rarely, platypelloid) that may allow less room in certain parts of the pelvis. This may make the baby more comfortable in a different position such as posterior, or it may make it harder for the baby to move under the pubic bone during birth. Thus pelvic shape might conceivably influence baby position.
How relevant if pelvic shape to birth? Authorities disagree. OBs tend to treat it very fearfully. Many use pelvic shape and pelvimetry (measuring the relative dimensions of parts of the pelvis through x-rays or manually) to tell women their pelvises are ‘too small’ and they will ‘need’ a c-section without any trial of labor. This is unreasonable because pregnancy hormones loosen the pelvis and ligaments significantly by the end of pregnancy, and the baby’s head has bones that overlap or ‘mold’, and between the two, there is usually MUCH more flexibility for the baby to be born than pelvimetry in pregnancy would indicate.
Some doctors insist on pelvimetry (measuring the pelvis manually or by x-ray) after a CPD cesarean in hopes of being able to predict whether a VBAC is likely or not, but studies show this does not reliably predict vaginal birth. A significant number of women predicted (via pelvimetry) to have ‘inadequate pelvises’ and to need future CPD cesareans go on to have VBACs anyhow (Goer, Obstetric Myths vs. Research Realities). For example, Thubisi (1993) found that 55% of women in the Trial of Labor group judged to have an ‘inadequate’ pelvis by postpartum x-ray pelvimetry had a vaginal delivery anyhow. If more than half the women predicted to have inadequate pelvises birthed vaginally, pelvimetry is not useful and may be harmful. The authors called x-ray pelvimetry ‘not necessary’ for a trial of labor, and noted that “it increases the caesarean section rate and is a poor predictor of the outcome of labor.”
Other OBs have tried to determine other ways of determining true CPD, including strict interpretations of stalled labor parameters. O’Herlihy (1998) found that only 84 women out of 42,793 actually met these strict criteria for ‘true’ CPD when carefully reviewed. 40 of these women with ‘strictly defined’ CPD had a trial of labor after prior cesarean, and 68% birthed vaginally, 7 with larger babies. 15 of these 40 women had had a cesarean at full dilation (10 cm) previously, yet 73% went on to birth vaginally with no serious maternal or neonatal problems. The authors concluded that even strict definitions of CPD should not be used as an automatic ‘recurrent’ indication for elective repeat cesareans
So unless there is significant malnutrition or grievous previous injury, pelvic shape or pelvimetry should not be used for choosing an elective c-section. No one can tell the degree of molding, flexibility in the pelvis, or loosening that may occur during labor, so an adequate trial of labor is the only way to tell for sure ‘if the baby will fit’. Many women with pelvises initially judged to be ‘too small’ or the ‘wrong shape’ do end up delivering vaginally, and about 2/3 of women who have had previous cesareans for “CPD” and try for a VBAC do end up having subsequent vaginal births, often with babies even bigger than their cesarean “CPD” babies. This casts the diagnosis of “CPD” under considerable suspicion.
Midwives tend to be of two schools of thought about pelvic shape/pelvimetry. Some midwives think it is modestly relevant, especially if other factors like prior back problems or pubic symphysis pain are present. However, midwives differ from OBs in that they use pelvic shape to help women find the most effective position to help the baby move through the pelvis. Sometimes lying down at a certain stage, arching the back markedly, or using the McRoberts position—knees to ears—may help babies get under the pubic bone that might otherwise have difficulty descending. Unlike OBs, these midwives do not use pelvimetry to scare women into elective c-sections that are probably unnecessary, but they may use it to help women find the most efficient way to birth.
On the other hand, other midwives dismiss the importance of pelvic shape altogether. They feel that it is a ridiculous limitation, that evolution has assured that nearly all women will have functional pelvic shapes, and that pelvimetry has proved wrong too often to trust. Midwife Gloria Lemay writes about this in her article, “Pelvises I Have Known and Loved,” which can be found online at www.birthlove.com/pages/pelvises.html.
In summary, all malpresentations and malpositions probably do not occur because of one factor only, but may occur because of a combination of factors such as:
- Anterior placenta
- Poor posture
- Perhaps baby size in some cases
- Back problems, short-waistedness, sacro-iliac problems, prior back injury
- Prior pelvic injury
- Misaligned pubic symphysis area (SPD)
- Perhaps pelvic shape in some cases, especially in combination with other factors above
Malpositions do not have to be an immutable sentence to a difficult labor, lots of intervention, or a c-section. There are things that can be done to turn babies into the most optimal position for birth.
- Avoid sitting with the hips lower than the knees
- Avoid lying back with the feet up
- Avoid slouching back in a chair
- Avoid bucket seats in cars
- Avoid sitting with the legs crossed
- Swimming (belly down)
- Pelvic rocks on all fours (several sets a day)
- Sitting on a birthing ball
- Kneeling and leaning forward on a bean bag chair while watching TV
- ‘Tailor sitting’ (sit with back upright and soles of feet together)
- Sleeping or lying predominantly on your left side
- Scrubbing the floor, crawling, or doing other tasks that require being on all-fours a lot in the week or two prior to labor (not just for a few minutes, for 20-30 minutes at a time at least)
It is critical that Artificial Rupture of Membranes (AROM, or breaking the waters artificially) does not occur if a malposition is a possibility. Amniotic fluid often cushions the baby, protecting it from distress due to a poor fit in its malposition. If this cushion is taken away, the baby may experience significant distress as the contractions force it down against the pelvis despite its poor fit. This distress may cause the baby to pass stool prematurely (meconium), which can sometimes cause problems for the baby.
AROM also may inhibit the baby from turning into the more favorable anterior position. The waters keep baby from engaging so deeply it gets stuck and cannot turn; after AROM, it is much more difficult for the baby to rotate. AROM is also often accompanied by pitocin, which artificially strengthens contractions and can force the baby deep into the mother’s pelvis in its poor position, causing ‘labor dystocia’, ‘deep transverse arrest’ or ‘arrest of descent’ (i.e., getting stuck) and making rotation into the anterior position almost impossible. Although it may still be possible to realign the baby by using the open knee-chest position to help the baby move out of the pelvis enough to turn, even this position may not be able to ‘unstick’ the baby in deep transverse arrest.
altering the level of the mother’s hips (swaying or dancing, circling the hips, belly dancing)
rocking from side to side
kneeling on one knee, raising one foot
an exaggerated ‘marching’ step
marching up and down stairs (with exaggerated lifting of the knees)
going up and down the stairs sideways
stepping on and off a stool
asymmetric labor positions (lunged to the side, or with one leg bent and up, etc.)
side lunges, done over and over again
‘double hip squeeze’ (a helper squeezes together the upper part of the woman’s pelvis from behind)
Janie McCoy King also discusses a technique commonly known as ‘abdominal lifting’ to help correct malpositions. In this, the mother interlocks the fingers of both hands under her abdomen and lifts upward and inward while bending her knees to tilt the pelvis (bending the knees and doing a pelvic tilt while lifting the abdomen is very important). This changes the angle of the baby relative to the mother’s pelvis and often enables baby to slip down into the pelvis or lifts baby out of the pelvis so it can improve its position. Penny Simkin, author of The Labor Progress Handbook, notes that many Mexican midwives do a version of this using the Rebozo (a type of shawl) tied around the mother’s abdomen, then lifted up and out from behind during a contraction while the mother does a pelvic tilt.
The refusal of many providers to consider these alternatives has led to many unnecessarily painful and difficult labors, many unnecessary cesareans, and many women feeling their pelvises are ‘inadequate’ or ‘too small’. The abundance of data showing that the majority of women with a previous cesarean for “CPD” who labor do end up birthing vaginally (often with a bigger baby) implies that many of the original cesareans may have been due to baby malpositions instead. Although there are relatively few scientific studies of the highest quality that examine resolving baby malposition, some data does exist and supports the efficacy of these techniques. In addition, anecdotal evidence from hundreds of midwives, doulas, and birthing women shows how important these can be for easing many ‘difficult’ labors and in preventing cesareans.
My birth stories are good examples of the troubles a baby malposition can cause. I share them here in hopes that others may find them instructive. Other birth stories involving malpositions can be found in the FAQ, BBW Birth Stories: Malpositions.
My first birth was highly interventive, highly medicalized from early on. I was induced right at 40 weeks because of a borderline case of gestational diabetes, and nearly every intervention in the book was involved. Long story shorter, the doctor broke the bag of waters early in labor before the baby was even engaged; although we cannot be sure, it seems quite likely that she was in some less-than-optimal position and became fixed in this position once pitocin was added and the waters were broken. Labor was long and very difficult. Eventually I did dilate fully and we pushed for two hours, but it was extremely painful and the baby never descended past a -2 station (high up in the pelvis). I also had terrible back labor, like a welding torch being held to my back and side. We eventually chose a cesarean, though that turned out to be an even worse nightmare. It was a very difficult birth, to put it mildly. The cause of the cesarean was put down to “Cephalo-Pelvic Disproportion”, or baby too big for mother’s pelvis.
My second birth was much better in many ways, although it too turned into an unexpected cesarean. I paid very close attention to nutrition and exercise and was able to avoid a recurrence of gd, which meant I could transfer to the care of a nurse-midwife. My OB wanted to induce labor early to get a smaller baby, but I did NOT want to go through another induction, so I went with a nurse-midwife who would not insist on early induction. Unfortunately, I knew little about the importance of posture near term, and spent a lot of time leaning back with my knees higher than my hips. This was the position I was in when my water broke at 39+ weeks. We didn’t know it then, but his position was posterior (facing my tummy instead of my back) and he became fixed into that position when the waters broke before labor. I went into labor naturally, had a wonderful labor (much easier than an induction!), dilated fairly quickly although I experienced transition-like symptoms early on, and got to 9.5 cm before getting stuck with a cervical ‘lip’. Eventually we got to pushing, and we pushed for nearly 5 hours before choosing a repeat cesarean. At first pushing felt good, but as we got him down to the pelvis (0 station), the back labor and ‘welding torch’ effect to my side started up again. The last several hours of pushing were very hard. Fortunately, the c/s went well this time, and as they pulled him out, the surgeons said, “Well, no wonder! He was posterior!” However, nowhere was this written on our charts, as if it was irrelevant. If we hadn’t heard them say it, we wouldn’t have known it. The official ’cause’ of the c/s was again “CPD”.
My third birth was a VBAC (Vaginal Birth After Cesarean). I had read up on baby malpositions and was convinced that this was what had probably caused my cesareans, and was sure that if we could avoid a malposition, I could almost certainly birth vaginally. I chose a direct-entry midwife for my care, one who specialized in correcting malpositions. I also found a chiropractor who knew how to do the “Webster Technique” and helped resolve some significant sacro-iliac back pain issues, although I only found her late in pregnancy and only had a couple of treatments with her. We encouraged labor to come at 38 weeks. I was expecting a fairly easy dilation stage, since I had dilated twice before to 10, and the natural labor had not been that difficult to handle. However, this labor got stuck at around 5 cm for several hours despite strong contractions and significant pain. We chose to break the waters at that point in hopes that it would help bring more pressure on the cervix to dilate. (Big mistake–I won’t do that again!) Labor quickly became unbearable. We labored for several more hours despite extreme pain levels and little dilation, at which point I elected to go in for an epidural (against the midwife’s wishes) in hopes of preserving a chance for a VBAC. However, getting ready for the epidural got me more mobile, and the hospital bed was uneven, which caused my hips to shift a lot as we got into position for the epidural. The baby apparently had had his arm across his face, which tends to cause extremely painful labors, lots of back pain, and can hold up dilation. Shifting on the uneven bed apparently made his arm move away from his face, and suddenly we were pushing! No epidural for me. We took care of a stubborn cervical lip, I arched my back strongly, and then he was born within 15 minutes or so of starting to push! (Lots better than 2-5 hours of pushing, let me tell you!) I unfortunately did not avoid a malposition completely, but at least this time it was a malposition that resolves fairly easily with the right moves, and once resolved, the baby was born quickly. Baby position can make a LOT of difference.
I really feel that my births are an interesting representation of the difficulties that baby malposition can cause. You can bet that next time I will again pay VERY close attention to posture during pregnancy, and get regular chiropractic care (I later found that adjusting the pubic bone itself helped resolve SO much of my back discomfort; I wish we’d done this in pregnancy in addition to the back adjustments!). I will also choose NOT to break the waters artificially, and to be even more mobile in labor (I may take up belly-dancing!). Hopefully, others can learn from my experiences and not have to endure some of the difficulties I did.
Best wishes for a wonderful and optimally-positioned birth! 🙂 ——Kmom