April 2, 1999
Volume 1, Issue 14
Midwifery Today E-News
“Posterior Labor”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Let's Talk!
5) Question of the Week
6) Assisting Anterior Rotation During Labor
7) Why Posterior?
8) My Story: Painless OP
9) Switchboard
10 How I Became a Midwife
11) Letters
12) Coming E-News Themes

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1) Quote of the Week:

"The wise (wo)man does at once what the fool does finally."

- Gracian

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2) The Art of Midwifery

For a firm hotpack that holds heat for a considerable period of time, dampen a folded bath towel, fold it up in a Chux (waterproof bed pad) and heat in a microwave for approximately two minutes, turning after one minute. Wrap again in a soft dry towel or receiving blanket. This can be rolled or folded as needed and is especially useful for back labor.

- Arlene Settle in Midwifery Today's Tricks of the Trade Volume One, 1996

To ease back labor: The laboring woman positions herself on hands and knees or in any forward leaning position she finds comfortable. The midwife stands next to her at her waist, facing away from the woman's head. She puts pressure with the heel of her hand on the posterior aspect of the sacrum (behind) and applies downward pressure to the sacrum in the direction that is away from the woman's head. From a chiropractic and neurological view, this technique is more beneficial than applying pressure to the sacrum in an upward or directly inward direction while positioned behind the woman.

- Douglas Carlstrom D.C. in Midwifery Today's Tricks of the Trade Volume One, 1996

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3) News Flashes

Patience Please

Women have commonly been denied trials of labor if their first cesarean section was performed for failure to progress or for cephalopelvic disproportion, the most common indications for primary cesarean. In a 1987 study published in the American Journal of Public Health, the largest percentage of women attempting vaginal birth after cesarean (VBAC) had cephalopelvic disproportion or failure to progress cited as the primary indication for their initial cesarean. Of these women, 65 percent, or almost two-thirds went on to have normal births; many of the babies were much larger than the baby for which the original cesarean section had been performed.

- ICAN Clarion, September 1997

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4) Let's Talk!

Sixteen hundred of you are now receiving this weekly transmission and almost one hundred new subscribers join us each week. (Remember to forward E-News to your friends.) I call that a rich global community of maverick people!

I love the Internet and the many ways we can use it. One of its major benefits is how quickly information can be communicated. We at Midwifery Today E-News are trying to find ways to get all the wonderful experience and ideas you have accumulated over the months and years out where we can all learn from it.

We would like to pose a question in each week's issue. Let's talk!

Those of you who have a little time to look into your experience or to pass on your research, please share it with E-News readers by responding to the question. We are looking for the kind of information you feel would help other practitioners in their work or in their lives. Moms are invited to share their knowledge and experience too, though the general emphasis will be on practitioner oriented information and questions.

For starters, we are repeating a question that appeared in Issue 12 on meconium. Give it some thought, then please get in touch!

- Jan Tritten, editor

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5) Question of the Week: At what rate in your practice do babies pass meconium before birth, not counting breeches? Are your statistics from a homebirth practice or hospital practice? Also tell us how you handle the problem of meconium. Send your response to: mtensubmit@midwiferytoday.com

See Switchboard below for Ina May Gaskin's statistics from her community, The Farm.

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6) Assisting Anterior Rotation During Labor

1. When it is verified that the baby is in a posterior position, the first thing I do is have the mother assume and maintain a knee-chest position for approximately 45 minutes. Although this position is not the most comfortable one for the mother, it is very effective as it allows the baby more room in which to rotate. I find the mother tolerates this position well if she is not in advanced labor. We make sure that she is well supported by lots of pillows and give her lots of encouragement and emotional support. Often, contractions become more regular and more effective while in the knee-chest position, which also assists the baby's rotation.

2. If the mother cannot tolerate the knee-chest position for as long as necessary to turn the baby, we alternate by placing her in an exaggerated Sim's position (lying on left side, two pillows under right knee, which is jack-knifed, left leg straight out and toward the back).

3. Every effort should be made to avoid rupturing the membranes, as the "pillow" offered by the forewaters gives a cushion on which the baby's head may spin more easily. Furthermore, if the waters break before the baby has rotated to the anterior, it is possible that sudden descent of the fetal skull will result in a deep transverse arrest.

4. If labor is more advanced when the posterior is identified, say to four to five centimeters, it may be helpful while the mother is in the knee-chest position for the attendant to place her hand in the mother's vagina, gently lifting and somewhat disengaging the head, thus allowing it to turn to anterior.

If the posterior has not been discovered until complete dilation, or if the other methods have not been applied in early labor, the baby's head can still be turned to make delivery more likely. With the mother in a knee-chest position, knees slightly apart, the midwife inserts her hand into the woman's vagina. She should attempt to lift the head by grasping it firmly, waiting for a contraction, then turning the baby into an anterior position. As soon as the head is correctly positioned, hold on tightly. When the uterus contracts again, urge the mother to push very hard. If the amniotic sac has not ruptured, do so now. This will assure that the position remains fixed and the baby will usually be born very rapidly. This procedure is both safe and sane, yet it must be acknowledged that it will take some physical strength to turn this recalcitrant little head against the force of a good contraction.

- Valerie El Halta, excerpted from "Posterior Labor: A Pain in the Back," Midwifery Today Issue No. 36, Winter 1995

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Read Valerie El Halta's entire article "Posterior Labor: A Pain in the Back" in Midwifery Today Issue No. 36. Get this back issue for only $6.00 plus shipping (regular price: $7.00). Call 800-743-0974 to order today! Mention code 940 and save $1. Expires April 16, 1999.

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7) Why Posterior?

One of the most important lifestyle changes has been the advent of television. This has meant a change from straight-backed armchairs and sofas to furniture which is designed to relax in while watching TV. When a pregnant woman sits down in a modern design armchair or sofa, her pelvis tips backward and so does her "passenger." To balance her body in this position, the woman has to cross her legs--which further decreases the amount of space in the front, or anterior part of her pelvis. Her "passenger" has no alternative but to lie toward the back or posterior part of her pelvis. If the woman spends a lot of her time resting in modern furniture during the latter part of her pregnancy, it is probable that her baby will remain occipito-posterior and enter the pelvic brim in this position. The same sequence of events can happen if the woman travels in a car seat, especially if it is a "bucket" type seat, for long periods at a time.

Another important factor in relation to lifestyle changes is the way women work now and how they did in the past. In times gone by pregnant women worked physically hard in the home scrubbing floors on their hands and knees and doing other menial tasks around the house or farm, which usually meant leaning forward. In that era also, the importance of correct posture and good deportment was encouraged. Young women learned to sit upright with their knees together and to walk with their shoulders straight. All these postures are ideal for correct alignment of the fetus into the maternal pelvis.

If a woman (primigravida) regularly uses upright and forward leaning postures, particularly during the last six weeks of her pregnancy (the last 2-3 weeks for a multigravida), her baby is given an excellent chance of positioning itself into the occipito anterior position. This is because when the pelvis tilts forward, it allows more space for the broad biparietal diameter of the fetal head to enter the pelvic brim. Most of these postures, especially those that are forward leaning, are positions where a woman's knees are lower than her hips. Many postures can be incorporated into the woman's daily life; for instance, TV watching can be accomplished by sitting on a dining room chair or kneeling on the floor, leaning over a bean bag or a couple of floor cushions. Another way is to sit on the sofa or armchair but to make sure a firm cushion is placed under the woman's bottom and lower back so that she is sitting more upright. When resting or sleeping the woman should make sure she is lying on her side with pillows behind her back and her top leg resting forward so that the knee touches the mattress. This ensures that her abdomen is forward, creating a "hammock" for her baby. An extra cushion may be needed between the woman's thighs.

- Jean Sutton & Pauline Scott, excerpted from "Understanding and Teaching Optimal Foetal Positioning" Birth Concepts, 1996

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"Understanding and Teaching Optimal Foetal Positioning" should be required reading for all birth practitioners. This little booklet is available from Midwifery Today for $12, $4.00 shipping & handling. To obtain a copy, call 1-800-743-0974. Please mention code 940.

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8) My Story: Painless OP

My first child was a persistent occipitoposterior (OP). Of course I didn't know it at the time. I had a high stress job and was on my feet constantly. Near the end of the pregnancy I was having to take frequent feet-up breaks to calm an irritable uterus. My water started leaking when I was 34-35 weeks. It took a couple of hours for contractions to start. My caregiver didn't seem concerned; he just told me to call again when contractions were five minutes apart.

My contractions didn't seem to be very difficult and were very irregular. My husband finally went to bed, tired of waiting for that "magic" five minutes apart. Contractions would happen every ten minutes followed by seven minutes followed by five minutes followed by thirteen minutes! I didn't hurt, just needed to focus and relax and use effleurage. Finally I got too tired to stay up and went to bed. I instinctively propped myself up with pillows and often found myself with my fists in the small of my back. But it still didn't hurt.

About 2 a.m. I got up to use the bathroom and had a whopper contraction. I tried to lie down on my side afterward, but the next contraction was a classic double peak and hurt! As soon as I sat up, the pain went away. The contractions were still not "regular," but after that big one I decided to awaken my husband. We got going to the hospital at about 3 a.m. I was catching my breath at the peak of contractions. We went up to the labor and delivery floor only to be told that I could not use the birthing room because I was too early, and why hadn't I called them to let them know I was in labor? I coped just fine around the irritating nurses. I found a bedside table to hang over and was gently pushing. They didn't like that! They made me lie down for a vaginal exam, and when they found me fully dilated they began to panic!

My doctor came in just as the nurses were trying to get me to climb up on a delivery table. They were coming at me with leather restraints and trying to take my glasses away! I was about to start screaming and fighting when he calmed everything down, made them take away the straps and gave me back my glasses. I don't remember any contractions during that time. Finally I was given the "official" OK to push. I got poor hubby to lift me up during each contraction since they "couldn't find" a wedge. I pushed for three hours. Doctor never mentioned OP, thought I had a "tight" perineum and gave me a pudendal block to relax it. He was conferring with an OB in the back of the room who was clanging forceps together when my daughter finally rotated and shot out! She never fully rotated, but restituted three quarters of the way around. The doctor cut a massive episiotomy and she was finally born at 7:05 am. The clanging of the forceps must have scared her out! She weighed six pounds, two ounces and measured nineteen and a half inches long. She had bruises under her eyes like a prize fighter for weeks. I never felt pain except for the one transitional contraction on my side. I never felt the terrible backache so characteristic of OP. But I had/have a strong feeling that if "they" had left me alone and let me continue to push upright as I was doing instinctively, she would have been born hours earlier. Total labor was only twelve and a half hours, with a four hour second stage. We concluded later that she must have been OP judging by the rest of the characteristics of the labor.
I find it interesting that because I didn't experience severe back pain (or much of any pain at all) people have doubted me. Yet this child, now a young lady of 16, definitely was persistent OP!

- Pamela Golliet, LPN

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9) Switchboard

My son was born eight years ago. He was in the posterior position and we didn't know it until his head was being born. I had absolutely no back labor at all. After the birth the attending midwife (a student midwife assisted me with the actual delivery) said that if she had been doing the delivery she would have "cut" me when she saw that the baby was posterior. I'm still confused by this revelation. Why would she have elected to violate my birth plan and give me a much unwanted episiotomy simply because the baby was in a posterior position? Is there a protocol for CNMs on this?

This was my first baby and it was estimated just before birth that he would weigh between five and six pounds. He in fact weighed seven pounds, seven ounces. I only had two minor external tears that required two and three stitches respectively. I did perineal massage with sesame oil each night near the end of the third trimester. I feel very fortunate that I had the student midwife who decided to take a chance and honor my wishes to keep my perineum intact.

I'd appreciate any feedback on this. I continue to look forward to each issue of E-News and I'm learning so much that will help me have an even better birth experience the second time around.

- MJ

I am very interested in the "new discussion" over vaginal delivery after several cesareans. Do you encourage mothers to try vaginal deliveries after several sections?
BJC

In response to the question asked in E-News Issue 12--at what rate do you see meconium in homebirth or birth center situations? Do you think it differs from the rate it is seen in hospital births? Why or why not?--Ina May Gaskin reports variations seen at The Farm in Tennessee. Of the first nine hundred births from which statistics were kept and which were among Farm residents--relaxed, strong birthers accompanied by their friends--thirty-seven had evidence of meconium to any degree, from tea colored amniotic fluid to actual stools, for a rate of 4.1 percent. During the period when The Farm assisted at the births of people coming in from the outside for birth and were not residents of the community, meconium was noted in 156 out of 1,175 births or a 13 percent rate. Stress, or at least uncertainty and unfamiliarity, must have been a contributing factor.

Obstetrics and the Newborn: An Illustrated Textbook 3rd edition, 1997 states that meconium is passed in 20 to 25 percent of births. Undoubtedly this statistic is based on hospital births.

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10) How I Became a Midwife

In the mid 1970s I lived in Australia. I was visiting at a girlfriend's house (I was about sixteen then) when some friends also came to visit. The woman had recently given birth and the baby was only two days old. I had never seen a baby so new because my mother always stayed in the hospital a week when she had her babies (children under sixteen weren't allowed to visit back then).

I became absolutely fascinated as the woman proceeded to tell us about her birthing experience. Her birth at home with a midwife was so natural and normal. It was completely different from any childbirth story I had ever heard in the United States. At the end of her story she turned and looked directly into my eyes and said "If you ever want to do anything to help women, be a midwife." That's all it took--I was hooked. From that moment on, I read anything I could get my hands on about childbirth and midwifery.

After moving back to the United States, I eventually got married, gave birth to five children, and finally pursued my dream. Now I help women as a homebirth midwife.

- Alison B.

How did you become a midwife? Share your experience with E-News readers around the world. Let's get to know each other! Send your story to: mtensubmit@midwiferytoday.com.

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Thinking about becoming a midwife? PATHS TO BECOMING A MIDWIFE: GETTING AN EDUCATION is the book for you!

Learn about the different ways to become a midwife, then choose your school or program from the listings at the end. The new edition has many new articles, and all new schools listings.

Regular price is $29.95 plus shipping for over 300 pages of vital information for any aspiring midwife. But order by April 15, 1999 and pay just $25 plus shipping. Be sure to mention code 940.

To order or for more information, email inquiries@midwiferytoday.com, or call: 541-344-7438,1-800-743-0974 (USA only) FAX 541-344-1422

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11) Letters

Thank you all for bridging the gap. You have been faithful and true for years. I have greatly appreciated this commitment and love. Blessings to you all.

- Carole

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12) Coming E-News Themes

Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- infections (April 9)
- education (April 16)
- tear prevention (April 23)
- International Midwives' Day (April 30)
- CIMS (May 7)
- episiotomy
- epidurals
- breastfeeding
- waterbirth
- breech birth
- homebirth
- premature rupture of membranes
- nutrition

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.


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