This is from a larger article from http://www.midwiferytoday.com/articles/dozen.asp The rest of the article is really quite interesting regarding obstetrics and how hospital professionals are being lied to when it comes to VBACs, thereby perpetuating the overuse of c/s & high failure rate of VBACs.
Heading In The Right Direction!From
A Butcher’s Dozen by Nancy Wainer
© 2001 Midwifery Today, Inc. All Rights Reserved.
[Editor’s note: This article first appeared in Midwifery Today Issue 57, Spring 2001.]
One of the reasons that so many of the women with whom I work have successful VBACs, even with very large babies, is that we pay strict attention to the position of their babies. Information about tuning in to the baby’s position during pregnancy, in early labor, and then paying careful attention to it throughout the labor, makes a tremendous difference in birth and in VBAC outcomes. I suggest that you pay very close attention to Valerie El Halta’s article “Posterior Labor: A Pain in the Back” [Midwifery Today Issue 36 and Wisdom of the Midwives] and the booklet Understanding and Teaching Optimal Foetal Positioning by Jean Sutton and Pauline Scott [available through Midwifery Today].
OK, so we know the baby’ s head is down. But that information alone is not enough. We need to know where the baby’s back is, what side the baby favors. It is appalling to me how many care providers are unable to ascertain this information without ultrasound. This is disturbing to me for a variety of reasons, not the least of which is that ultrasounds themselves may influence the position of the baby. In addition, and most women whose babies have been exposed will verify this: babies do not generally like to be ultrasounded. It seems to disturb them, causing them to become overly active: mothers will tell you it was “as if the baby was trying to get away from the ultrasound.” It is often easy enough to ascertain the position of the baby externally. But if there is a doubt, midwife Valerie El Halta asks: “What do you think suture lines and fontanels are for?” Answer: “They are God’s directional signals for midwives!” The anterior fontanel is diamond-shaped and the posterior fontanel is triangular. By feeling the fontanels and the suture lines, we can determine the baby’s head position.
[Note: I was most interested to receive Doris Haire’s note this week: “On Dec. 13th I posed the following question of David Feigal, MD, Director, FDA Center for Devices and Radiological Health: ‘Dr Feigal, it is my understanding that no one knows the delayed, long-term effects of diagnostic levels of ultrasound on human development. Is that still true?’ Dr. Feigal’s answer: ‘Yes, that is correct, no one knows the long-term effects of diagnostic levels of ultrasound on human development.'”]
When the baby’s back is on the mother’s left, or to her front (anterior), labor will most likely be short and productive. When the baby and head are “lined up” properly, the waves [contractions] are generally regular, with time in between, and the cervix dilates well. This is because the smallest part of the baby’s head is presenting, and it is the part of the head that molds most easily. In addition, this part of the baby’s head presents as a circle that applies direct, equal, and even pressure to the circle that is the opening cervix-voila!: 10 centimeters and pushing. However, if the baby’ s back is on the mother’s right, or the baby is facing front (that is, posterior), we must pay close attention. Unless this is rectified, either naturally or with assistance, several things most likely will occur: the mother will experience prodromal “on again-off again” labor, which is exhausting and discouraging; the waves will be on top of one another, occurring every two or three minutes, lasting only 20-30 seconds with sharp peaks and excruciating pain but very little accompanying dilation; mothers often complain tearfully how much their backs hurt; there is often pain even in between contractions. These are warning signs of a posterior or asynclitic (one of my midwife mentors, Clare, calls these “caddywumpus”) babies. In these situations the largest part of the baby’s head is presenting, and it is the part of the baby’s head that does not mold as easily or naturally. It is not a circle that is applying to the circle which is the cervix, but a large, convex, irregular oval that creates pressure only on random segments of the cervix. The result is that the cervix becomes irritable, contracting often but unevenly, and without much (or any) progress.
Without the presence of the correct part of the baby’s head, the woman’s cervix usually dilates only to three or four centimeters, with little further progress. She is in a situation that requires diagnosis, attention and correction. Techniques and measures such as visualization, relaxation, chiropractic, acupuncture, homeopathy, herbs, putting the mother in a hands and knees position, having the woman hold her own stomach and then redirecting the baby’s position externally, tennis balls, hot (or cold) compresses on her back have all helped certain labors, but more often there is little change, and the woman, discouraged and wracked with unremitting pain, anguished and defeated, begs for relief in the forms of drugs, anesthetics and cesareans.
If the woman is in the hospital, the obstetrician will most likely suggest Pitocin, which often causes other problems: maternal and/or fetal distress; stronger, but still ineffective contractions which are more difficult for the mother and so she needs-begs for-drugs or an epidural; and then we get into that whole CASCADE of interventions, and, most importantly/ominously, forcing the baby down in-and thus actually committing the baby to-the unfavorable position. Others suggest that the woman squat if she is not making progress-this may also encourage the baby to come down in the unfavorable position, causing a deep transverse arrest. Doctors often break the bag of waters, hoping to get things going-this is not generally recommended either, as this, too, often commits the baby to the unfavorable position.
Prevention of posterior babies is possible! We are all beginning to pay attention to this fact. We are telling pregnant women: Never recline during pregnancy-if you are going to sit and read or watch TV, for example, make certain that your back is absolutely straight. Put a wedge or a book or lots of pillows behind you. Follow this advice when you are in a car as well-make certain there is a pillow behind your back to straighten it. If you work at a desk with a chair that leans slightly backwards, find a straight-backed chair. Reclining can weaken back muscles and create a situation that encourages babies to hang out in unfavorable positions (and look at how all our little American babies are carried around in bucketed car seats for hours at a time, creating generations of girls who will later be predisposed to posterior babies as a result!) However, if a woman has entered active labor and is not making progress, it is important to begin to (literally!) turn things around, to intercede.
Midwife Valerie El Halta teaches the difference between intervention and intercession. An intervention is done without any regard for whether or not this action will assist the mother in having a natural birth. Interventions are not natural; for example, Pitocin and epidurals. They are often done for the convenience and comfort of the obstetrical staff, or to speed things along. They are often advocated in an atmosphere of mistrust of the natural process and in an environment of birth-related fear. An intercession, however, is something that is done with both safety and natural childbirth in mind. It is done with the unwavering belief in the woman’s ability to give birth. We intercede on behalf of the laboring mother to assist her in having a natural birth. Repositioning the mother and/or helping to rotate a posterior baby is an intercession, not an intervention.
The position that we find most always rotates posterior babies is called the Polar Bear Position. This term was coined from a magnificent picture in National Geographic magazine of a polar bear who is birthing her baby. Her front paws are down as low as they can go, as are her shoulders, and she has a big arch in her back with her knees apart and her butt way up in the air. (It has also been called the Playful Puppy Position, or Sleeping Baby). Women assume the position in early labor, when the contractions are established. If after 45 minutes or so the baby has not turned on its own, it is easy to go in (with the woman still in that position) and reposition the baby by gently but firmly pushing the baby back in. Many obstetricians tell women that the baby’s position cannot be adjusted until the woman is at least seven or eight centimeters or more, and unless the baby’s head is quite low in the pelvis. The problem, of course, is that many women never get to seven or eight with a posterior or asynclitic baby, and if they do, it has usually taken hours and hours. Adjusting the baby’s head position in early labor is imperative: it saves the mother from exhaustion, saves the baby from distress and eliminates the problem of a baby that is unable to turn. It is not unusual to have a mother who has been “stuck” at four or five centimeters for a while to automatically progress very quickly, because the head is now well applied to a cervix which has very much wanted to cooperate but has been unable to do so due to unequal (or non-existent) pressure.
Helping to rotate a posterior baby is safe. It is most likely as enormous a relief to the baby as it is to the mother. In thousands of tweakings/adjustments, there have been no incidents of fetal distress or stress or cord entanglement. In fact, it is far better for babies to have their heads positioned correctly, well applied to the cervix and dilating it symmetrically, so they can be born, rather than being “jammed” asynclitically or posteriorly without progress. Many babies who don’t get turned end up with meconium and other signs of stress—and off to the OR they go.
Nancy Wainer is a midwife, childbirth educator and an internationally known childbirth writer and speaker. She coined the term VBAC—vaginal birth after cesarean. She is the co-author of Silent Knife: Cesarean Prevention and Vaginal Birth After Cesarean and the author of Open Season: A Survival Guide for Natural Childbirth and VBAC. She is currently working on her third book, Birthquake: A Childbirth Book for Strong Women and Women Who Want to Be Strong.