Wednesday, May 25, 2016

Maternal Positioning isn't the only thing

Gravity first?

The idea of using gravity to swing baby's back around to a pregnant mother's abdomen is a popular hope with a misunderstanding of the cause of challenging fetal positions. It seems that people, even in birth work, think that the baby is floating randomly and settles into position only by virtue of gravity pulling the baby downward. This idea is popular because we look at one variable. Gravity.

I think gravity is only one important variable of maternal position. Others include the state of the mother's anatomy. Are there muscles and ligaments that are too tighten, too twisted, or too loose to do their job?

Specific types of pregnancy body work seem to address these soft tissue structures to the uterus and pelvis quite well. Not just massage but therapeutic pregnancy massage, and skilled myofasical releases, cransiosacral and osteopathic/chiropractic structural care combine for improved fetal position.

Myofascial therapy is a term I use broadly and can be Maya Abdominal Massage, a mother's own activities, often with a helper, Rebozo abdominal sifting, and foam roller work. Homeopathy, Acupuncture and other methods add benefit.

Balance First!
 Once "balance" is restored, then the maternal positions aligning with gravity maintains the space. A baby follows the space to get ready for birth and to move through the pelvis. Developing habits of balance may promote a good fetal position - that's one that in which the baby fits the pelvis.

Then we cycle back to maternal positioning!
In labor when baby needs help to enter the pelvis, pelvic brim opening positions are better than pelvic closing positions!

Posterior Pelvic Tilt
Abdominal Lift and Tuck
External rotation of the femurs
Back extension such as a supported bridge pose or Walcher's

When baby needs to rotate in the mid pelvis,
we start with Sidelying Release and then add
Lunges

When baby needs room to get past
the tuberosities (sits bones) at the bottom of the pelvis
(the nurse gets the first glimpse of the baby's head with her flashlight!)
then we choose positions such as

Anterior Pelvic Tilt
Internal rotation of the femur
Deep squat or low birth stool










The flexed thigh positions explored by Guittier this year in a published article, "Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial." BJOG: An International Journal of Obstetrics & Gynecology.



I commend Guittier's attempt, but was sad that all 6 of the kneeling and forward resting positions chosen had the mother flexing her thighs. This is a comforting pose for labor for sure. But while some muscles are relaxed and gravity helps pull baby off the mother's back, they also constrict the front of the pelvis where the posterior baby needs room to change position. They open the lower pelvis but the baby's rotation is best achieved at the brim. Once the baby is low enough for this position to work, the pushing efforts are either not strong enough for the average posterior baby in this position, or we still need an upright or extended back which this position doesn't allow. Therefore these are really best at comfort positions for the well progressing labor. 

Whoops! 





So maternal positioning can only be the leading action for improving a fetal position when we make useful room in the pelvis. In pregnancy and labor this is by "balancing" muscles, really restoring the balance that the body would have if not for sudden stops during a twist in earth's gravity. In other words, a fender-bender, a fall, a bad posture habit or work or play that twists us a bit while we lift, carry or stop suddenly.

The simple vertical positions of standing and walking help most babies become head down. The key time is second trimester. Expect baby to settle head down in the womb by 28-32 weeks.


Babies fit the space available
For those with less room in the womb, for instance, a septum or single "horned" uterus, having the baby head down as early as 14-20 weeks may be important to avoid a breech presentation.

More common, however, are twists or tensions in the supporting ligaments and muscles to the pelvis and uterus. These can press or pull on the womb and actually reduce the space in the lower uterine segment where baby's head needs the space to settle downwards.



A flash from the past

In labor, many women prefer being upright, and though we can, after giving birth in an upright position imagine that women have preferred this since the beginning of time, it was in
Birth Journal in 1979 that Roberto Caldeyro-Barcia M.D. reported the following:
Birth

Birth

Volume 6,  Issue 1pages 7–15March 1979

 Labor was 36% shorter in primiparous women and 25% shorter in all women who were upright during labor. Maternal position had no effect on fetal head molding or Type I and Type II heart rate patterns. The upright position was preferred by 95% of women.


Birth Journal also reported that squatting shortened the pushing stage in
Golay, J., Vedam, S. and Sorger, L. (1993), The Squatting Position for the Second Stage of labor: Effects on labor and on Maternal and Fetal Well-Being. Birth, 20: 73–78. doi: 10.1111/j.1523-536X.1993.tb00420.x


Why is it that so few women can really move freely in labor? IV poles, monitoring and beds indicate a passive position in bed, but poles can be pushed and monitors have portable options now. Beds are great for kneeling on and hanging off of... .read more about Forward Leaning Inversion to get that joke.  Why are women still lying down to push babies out?

Safety? The provider is trained to do delivery maneuvers with the mother on her back. Not to mention that all the training for rescue maneuvers (suction, shoulder dystocia maneuvers, unwinding a cord (not often tight so its uncommon that the cord needs unwinding), etc.

But just as we had to learn driving skills in many situations, providers can learn skills for all these situations in a variety of maternal positions. Even epidural medications can be adjusted so that women can "walk" meaning, be on their feet or at least somewhat mobile with a constant companion helping to prevent a fall.

Maternal positioning and solutions for a long or stalled labor are best explained in the Spinning Babies; Parent Class and once you have seen that or a Spinning Babies Workshop, then the Quick Reference download will be a constant companion to the provider of birth care.




Changing the Earth by supporting Birth

Mothers bring forth life; medical corporations do not. Birth can be simple, powerful and loving. Fetal positioning, natural birthing and practical help for normal birth.