Posterior Questions and Answers

Editor’s note: This article first appeared in Midwifery Today, Issue 114, Summer 2015.
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Let’s start by asking some questions:

What is posterior?
Why can it be a problem?
Why this position?
How can we tell if baby is posterior?
What can we do about it?
Posterior birth—is it possible?

What Is Posterior?

Posterior babies are simply those who are facing mom’s tummy instead of mom’s back.

Why Can It Be a Problem?

It can be considered a problem to labor with a posterior baby, but it isn’t always! I have had moms without complaint give birth to a posterior baby and be surprised when baby came out looking up at them! However, mom may complain of more back pain, and labor may take a bit or a lot longer (but how do we really know?). Baby’s face may be a bit swollen or even bruised. The baby’s face is coming past the bony pelvis and is not as effective in pushing through as well as a flexed head with crown (occiput). I have only transported to the hospital one posterior-lying baby in 33 years. This primip mama requested to go because she was in second stage for a few hours and was exhausted. I went with her and the doctor/midwife team was very professional and kind. The obstetrician applied, at the mother’s request, a suction device only to turn the baby’s head to an anterior position, and then requested the mother to push her baby out. He treated the mother with dignity, telling her she would birth her baby and he would merely help reposition the baby for her to do that more effectively. This petite first-time mama had an 11 lb 2 oz baby! The physician did make me guess the weight and kindly reprimanded me for allowing the baby to get so big! The mother came to my defense and informed the OB that at every visit, we discussed the size of her growing baby and we discussed reducing sugars and carbohydrates.

Why This Position?

Babies try to find the most comfortable position in the womb. If mother is often reclined in a chair or propped up in bed to read or watch TV, this makes her sacrum curve so that baby’s back falls nicely into it—a hammock of sorts. Mother may also have a pelvis that is shaped in such a way that baby feels more comfortable in a sunny-side-up position.

How Can We Tell If Baby Is Posterior?

Carefully assess the baby’s position at prenatal visits. Study Gail Tully’s book, The Belly Mapping Workbook, if you are unsure how to tell position. Chances are if the mom or the midwife is seeing or feeling limbs out in front, baby is posterior.

What Can We Do about It?

Gently talk to baby and massage baby to a better position. Using a rebozo or a long piece of cloth, rock baby gently into an anterior position while mother is in the hands-and-knees position. Encourage a mother to sit at the edge of her chair with her sit bones (as opposed to lying on the sacrum) so that her posture is better, with less tension on her lower back, to encourage optimal positioning for the baby. When she lies down, we recommend a side-lie position. We encourage mom to do her household cleaning on hands and knees. Crawling from place to place is a good idea. Weeding and planting on her hands and knees, as well as play time with young siblings on the floor, is beneficial (and the kids will think this is a lot of fun!). Knee/chest exercise is also helpful: Have mom create a hammock out of her belly, thereby encouraging the baby to rotate with its back in the hammock. With enough pillows, mom can even comfortably take a nap in the knee/chest position! We can also have mom get into this position in labor if the need arises. However, it is ideal to have baby assume an LOT or LOA position by around 34 weeks. We teach a mom how to pay attention to where her baby’s movements are felt and therefore determine her baby’s position. This empowers her and connects her with her baby.

In labor, if the baby is still posterior, with mom in hands-and-knees position, I will show dad how to place pressure over her sacrum, giving a squeeze with the heel of his hand on one side of the sacrum and the pads of his fingers on the other side. This relieves pressure for mom and often encourages baby to roll over.

When the midwife is examining a mother in labor, she can often determine by the fontanels how the baby is lying. If the midwife is feeling a fontanel up top under the pubic bone, she should be highly suspicious of a posterior lie. If all external attempts to rotate baby have failed, the midwife can assist baby to turn with mother in hands-and-knees by placing a finger on either side of the baby’s suture line and rotating the baby in the appropriate direction.

Posterior Birth—Is It Possible?

I have helped many women who are having VBACs because their first baby was persistently posterior. The questions I ask are: What positions was mom helped to get in for pushing? Was she allowed to labor in water (which takes off much pressure)? Was she on a time clock (because a posterior baby may just take a bit longer to birth)? I recommend hands-and-knees and/or waterbirth for a persistently posterior baby. Home, where the clock is not ticking and staff are not following strict time guidelines, usually provides a more relaxed environment to give birth. And remember it is possible to give birth to a posterior baby!

About Author: Diane Goslin

Diane Goslin, CPM, has been practicing since 1980. To date she has been the midwife for the births of over 7000 babies. She is the mother of 5 and grandmother of 14. She has primarily served in rural communities with a large portion of her practice among the Amish. Diane resides in Lancaster County, Pennsylvania, where she currently practices.

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