Turning Posterior Babies
Occiput Posterior/Occiput Transverse (OP/OT): notes from Obstetrical
Training Day, October 31, 1997, Rochester General Hospital (New York)
Speaker: Henci Goer
[Ed. Note: These are excerpts; in no way do they represent Henci’s
entire presentation. Notes courtesy of E-News reader Amy Haas. Thank
you, Amy!]
-Half of the cesarean rate results from OP/OT babies. With an epidural
this rate increases to three-quarters. 15 -30% of all labors start
with an OP/OT baby.
How to Diagnose:
1. Self-diagnosis: Belly shape; feels lots of hands and feet; frequent
urination; irregular labor pattern; ruptured membranes, back pain;
hard to pick up fetal heart tones, long painful labor
2. Caregiver’s diagnosis: external palpation (harder to do in labor);
vaginal exam (look for suture lines when mom is dilated enough)
Predisposition:
1. Pelvic shape: convergent sidewalls, narrow pubic arch, sacrum
intrudes, prominent ischial spines
2. Size of baby: either very large or very small (not guided by pelvic
floor, can’t get into position)
3. Right occiput anterior in pregnancy as opposed to left
4. Exaggerated spinal curvature (lordosis) and a relatively inflexible
spine
Correcting OP/OT in pregnancy:
1. Pelvic rocks: 10+ pelvic rocks on hands and knees per day
2. Dancing: rotate hips
3. Yoga: One midwife noted that her clients who do yoga have a smaller
incidence of OP/OT.
4. Crawling on hands & knees in a kiddie swimming pool
Strategies to Promote Rotation:
1. General tips:
-DON’T RUPTURE MEMBRANES
-Usually what the mother finds most comfortable is also most
effective. Let her move instinctively. Epidurals prevent instinctive
movement.
-Help the baby rotate by using positioning that opens the pelvis,
activities or manipulations that shift the baby, and gravity to bring
the baby down.
2. Birth ball: lean on it, or sit on it and lean on bed. Rotate hips.
3. Positions:
-Hands and knees during pregnancy. One study showed a 3/4 rotation in
10 min.
-Side-lying, SIMS position. Lie on the same side as the baby is
facing, then switch.
-Lunge: opens one side of pelvis, feels good; let mom choose side
-Squat-Kneel: opens pelvis
-Squat
-Dangle: almost a hanging sit, mom’s back to sofa, don’t go into a
full squat
-Standing leaning forward
-Kneeling, facing back of hospital bed
-Knee-chest position (rear end in the air), 30-35 min. in early labor
will almost always turn baby.
-Semireclining, heels together (don’t use with epidural)
-Pelvic rocks
-Change position
4. Activity or Manipulation
-Lots of position changes
-Pelvic rocks
-Stroke the mother’s belly in between contractions in the direction
you want the baby’s back to go.
-Double hip squeeze: Sit facing mother, place both hands on back of
each hip and squeeze.
-Write the baby’s name with pelvis
-Stair climb
-Crawl back and forth
-Acupressure: fingernail pressure on outer edge of little toenail
(could also turn breech)
-Delay epidural until at least 5 cm dilation. Doing one earlier may
lock the baby in the OP/OT position. Stay off back, even
semireclining. Hands and knees may be possible. Supported squat (w/
epidural): Set up bed like a birth chair, use stirrups as hand holds
and to support forearms.
-Manual internal rotation by care provider (Valerie El Halta – see
Midwifery Today Issue 36). Do early. May invoke negative memories for
women with a history of sexual abuse.
-Don’t rupture membranes – could wedge baby permanently into the OP/OT
position, preventing rotation.
-Cup mothers kneecaps and push back to relieve pain.
Coping with a Long Difficult Labor:
1. Extra support: Secondary labor support person (doula); use talking
for relaxation and positive reinforcing attitude (e.g., “My body knows
just what to do” chant).
2. Food and drink: calories, especially at home
3. Stay home in early labor, which is often prolonged.
4. Reframing the problem:
-It’s normal for an OP/OT labor to be longer and hard.
-Going from 50% effaced to 70% effaced is a major change.
-Stuff is happening.
-Cervix going from anterior to posterior is progress.
-Use short-term goals, bargain for milestones.
-Stay in the present; focus on the now.
5. Develop a ritual: women will often do this automatically if allowed
to.
6. Groan “open” on the exhale.
7. Use shower or bath. (One hospital reduced its epidural rate by 80%
by requiring women to take a bath before getting their epidural.)
8. Show the mom on pelvis model what she is feeling looks like
9. Hot pack with rice and herbs heated in microwave
10. Avoid vaginal exams
11. Don’t push too soon; delay until head on perineum – reduces use of
forceps.
12. Per American College of Obstetricians and Gynecologists: The
duration of second stage is not related to fetal outcome as long as
fetal heart tones are good.
Coping with Back Pain:
1. Temperature: A laboring woman’s skin is sensitive to temperature.
Hot items should be cool enough to hold, frozen items should have
intervening layer(s).
-Heat: Local blood flow and temp. increase, muscle spasms decrease –
contributes to relaxation
-Cold: Local blood flow and temp. decrease – works best for decreasing
pain because it slows transmission of painful sensations (Ice chips in
an exam glove, frozen peas)
2. Touch
-Counterpressure
-Acupressure – low on sacrum (inch out on either side), sciatic point
(dimples in rear end), palm (center, high five and hang on)
3. Sterile water injection: intradermally, 20 sec; sharp local pain: 1
-2 hr. relief. Do not use saline. (see Midwifery Today Issue 44)
4. TENS (transcutaneous electronic nerve stimulation): effectiveness
questionable
5. Pain medication: Delay epidural until 5 cm. dilation, delay pushing
until head is on perineum (reduces the use of forceps).
Factors that Hinder Rotation in Labor:
1. Reclining: Gravity works against you; reclining fixes sacrum so it
can’t open.
2. Early epidural: Relaxes pelvic musculature too much; Pitocin use
and C-section rates increase.
3. Early amniotomy: Head surges down and there is a deep transverse
arrest. May actually slow labor down.
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.
The Birthing Way 