It's Not Always Easy

I recently had a couple from my childbirth classes go through two full straight days of back labor. Because I have spent so much time studying optimal fetal positioning, and apply it extensively in my doula work, it can be very difficult for me to stand back and not try to jump in and "help".

The mom and dad both remained in touch with me throughout the labor via phone calls and text messages. They kept me updated with what was going on, and asked for input every now and then. I offered to come over and help them periodically, but I was not hired as their doula. They wanted to do this on their own.

And I thought over and over, if only they'd invite me over! I could help them out so much! At a difficult moment for the mom, dad asked me to come over and lend an extra set of hands. This was on their second night of intense back pain. I did a ton of rotational techniques, getting mom in all sorts of various positions. But I could only encourage mom to do what felt right to her. I could not take control over her body or her labor. As much as I'd like to have, this was her labor, and she needed to make the choices.

I went home after an hour of being with them. Left them relaxing in their bed, hoping that something I did had helped, but not knowing whether it had.
A few days later I received an email from the mom, and it really struck my heart what she said;

I feel like our labor experience really created and set the foundation for our family. I've had so many reflections on the beauty of it all. So many times we try to run from suffering at all costs and miss out on the amazing, redemptive power of it all. That was the hardest thing we have ever experienced, but it brought us closer together than we could imagine and because of that the pain was the best gift. Michael was an excellent coach and I admire him so much more now that we have been through that, and he has seen my strength by what we were able to do together.

If I had insisted on going over there earlier on in their labor, when I knew that I could make things easier for them, what would that have accomplished? It probably would have made for a faster, easier labor, yes. But did you hear how that labor has shaped these parents? A quick, easy labor was not what these parents needed. A long, difficult labor is what they were given, and they excelled with it. They learned from it. And they are wiser and stronger because of it.

As childbirth educators and doulas, we give our clients all the information and tools ahead of time, but then it is up to the couple as to how they will use it.
We are not to be their guides on the journey. Even if we know for certain a better way, an easier way, how a different decision will create a better outcome. We are not to guide them along the pathway to parenthood. The parents are the guides, learning some of the most important things they'll need to know as parents - how to make decisions on their own.

We are not the guides, we are the observers of this journey. A presence along the way to witness the strength and the transformation of these parents, emerging from self into selfless.

Why Natural Birth Isn't Beneficial...

Say, what??!! Isn't this blog titled, "Natural Birth In Kitsap"? Aren't you a propenent of natural birth?
Why, yes. Yes, I am.
What I want to share with you is something that has been spreading in the breastfeeding world for some time now, and I think needs to also spread to the birth world.
Natural birth does not hold benefits. It holds normalities.
As mammals, this is the normal way we were intended to birth babies. Moving, private, peaceful, freedom. As humans, this is the normal way we were intended to birth babies. Supported, loved, nurtured, unmedicated.
Natural birth doesn't add anything to the birth experience. It is the way the birth experience was intended to be. It doesn't benefit the baby. It doesn't benefit the mother. It doesn't bring short-term, nor long-term benefits. It is where we set our human standard. Anything other than this is deviating from the way we were inteded to be. Not birthing naturally brings risks.

Just as with breastfeeding, our bodies have a specific way to work. We have a specific birthing function, a specific feeding function. It is a correlation between the mother and the baby.
Any time we alter from that course, we increase risks of things going wrong, and causing harm.
Often times we are told that our bodies are not good enough. That, even though we are mammals, whose very defination is one who "gives birth" and "nurses their young", our bodies cannot do. We need help from man-made products. "Supplements".
We supplement with membrane sweeps, cervical ripenings, artificial oxytocin. Supplements lead to less of us, more of them, until we find ourselves unable to produce at all. Unable to produce milk, unable to produce contractions.
We are told our nipples are the wrong shape, our uteri are the wrong shape, our pelvises are the wrong shape. Our bodies will harm our babies. They tell us this, and they are wrong.
We are told that natural birth is dangerous, that it is impossible, that it is unrealistic, and that we are just trying to martyr ourselves. When did normal become such a big deal? When did we get so detached from ourselves that we can't fathom our bodies functioning in normal ways?
We have set the standard at medicated birth, just as our society has set the standard at artificially-fed infants. We have tests and procedures that are necessary for medical births, that have become routine and "normal". We have nurses trained to help medicated mothers but unaware of what to do for a naturally birthing one. We have doctors who have been trained to interfere and do so with such regularity, that we have to specifically state over and over that for *this* birth, we want to be left alone.
Shouldn't it all be the other way around?
Shouldn't we be wondering at the dangers of medicated birth? Of interfering with the natural bodily functions? Shouldn't we base our studies, not on how natural birth might lower risks, but how interference may increase risks? Shouldn't the burden of proof be placed on deviating from normal, rather than deviating from medicalized?
Why are we looking for studies and statistics which prove the worth of natural birth? Do we look for studies and statistics which prove the worth of natural breathing, natural urination, natural eating? Why don't we hear studies talking about the benefits of NOT catheterizing everyone? Or NOT putting everyone on a ventilator. Or NOT giving everyone a feeding tube? Wouldn't that be a ridiculous world to live in where everyone was made to believe that they could not eat, breathe or urinate without medical intervention?
And yet, with birth, we find a huge discrepency. A normal bodily function that is overseen by doctors, nurses, medications and machines. We are told that we can't do it naturally. And medicalized birth becomes the norm.
We need to stop setting the birth standard at medicalized birth. Any deviation from the normal way the body functions should be backed by a true medical reason. We should not be laughed at, rolled eyes at, scoffed at, annoyed at, or ridiculed for wanting to do what is normal. Normal should be supported and accepted. It should not be rare. It should not be so hard to attain. It should not be something we have to battle for!
The health benefits, bonding benefits, breastfeeding benefits, etc. associated with natural birth are not benefits at all. They are what every mother and baby were intended to have. They are the standard. And, yet, how many know this? How many are choosing risk because they believe that risk is normal?

Natural birth is not beneficial. Natural birth is normal.

A World of Safety Nets

“Differing definitions of safety also play a part. Doctors often feel unconcerned about side effects – even life-threatening side effects – provided they know what they will do to treat them and that the life-threatening ones occur reasonably rarely. So, two doctors writing for their colleagues can say reassuringly: “These [epidural] complications should not cause fatalities if trained personnel and adequate resuscitation facilities are available.” Loose translation: If a laboring woman develops a life-threatening complication from an epidural, she or her baby won’t die of it provided hospital staff are on the ball.”
From, The Thinking Woman’s Guide to a Better Birth by Henci Goer, page 127

“What has happened in the rich world is that, while removing the ideal food and feeding method, there has been progress in the elimination of other immediate risks. It is important to remember that it is still only a minority of the world’s population that can be artificially fed from birth without getting ill or dying.”
From, The Politics of Breastfeeding by Gabrielle Palmer

While these two quotes talk about two different things – medicated birth and artificial feeding – they are essentially saying the same thing about the world we currently live in. That those of us in first world countries live in societies filled with safety nets. And while that’s great for us, the rest of the world cannot manage to live the same way and afford the same healthy outcomes.

The switch from births happening at homes to hospitals and the rise of artificial milk for babies has followed a similar trend. They were at first disastrous. Dangerous. Doctors in hospitals and artificial baby food makers did not really know what they were doing. It was all trial and error, and many mothers and babies died as a result. With the awareness of germ theory, sanitation, and clean water sources, births in hospitals and artificial feedings improved. As the western world improved in wealth, it also began to take risks with its health. As long as they had a way of fixing the mistakes, it was okay to risk making them.

But living in a world of safety nets is a precarious world to live in. Walking a tightrope is risky, especially if there is not a safety net below. But even with the safety net, you will need to deal with the consequences of walking in a way that our bodies were not intended to walk. The feet of tightrope walkers tend to have many broken bones. Bodies react when we force them to do something outside of what they were intended to do.


When we interfere with the natural processes of labor, there will be reactions. Most doctors see these reactions as perfectly acceptable, since they tend to have plenty of safety nets set up in place – epidurals, pitocin, cesarean sections, drugs to bring blood pressure back up, resuscitation devices, and epinephrine. We believe that taking risks with our bodies while in labor is safe because we have become so accustomed to the safety nets. We have begun to forget what normal is meant to look like, and only what it’s like in a life of safety nets.



The same goes with artificial baby foods. A mother’s body is meant to breastfeed her baby, and a baby’s body is meant to breastfeed from it’s mother. When we alter this normal process, there are reactions. We have come to believe that ear infections, upper respiratory infections, and digestive problems are normal for infants because they happen so often. But these are reactions to altering the normal state of being. And this is only acceptable in our society because we have so many safety nets set in place. We have clean water to mix with formula. We have unbelievably easy access to fuel with which to heat the milk. We have easy access to transportation if our child becomes ill, and many hospitals, clinics and health care providers to offer care for our sick children. All of these are safety nets. Without such easy access to these things, feeding our babies with anything other than breastmilk would be dangerous.


But this alternate form of normal is acceptable in our society because a world of safety nets has become the new normal. And while I do not wish for these safety nets to stop existing – I am very thankful for them, actually! – I do wish that we would understand that safety nets are meant to protect us in case of emergency, not as a daily way of life. Normal labors should not routinely need to be induced or augmented. One third or our women should not need to have their babies removed from their bodies for them. Breasts should not be seen as so easily unable to provide nourishment. Ear infections and upper respiratory infections should not be common childhood ailments.

It does not take moving to a third world country to begin to understand the effects of a life based on alternatives without safety nets. What would we do in our comfy, wealthy society if these safety nets were suddenly sparse? It sounds unlikely, but all you need to do is consider Florida after the 2004 Hurricane Charley. Or the Gulf Coast after 2005’s Hurricane Katrina. We are not a country immune to natural disasters. And these disasters could easily wipe out all of our safety nets from beneath our feet.


In order for a medicalized birth to be above dangerous, there are many safety nets that need to be in place. Electricity, clean water, access to medications, availability of trained physicians, anesthesiologists, and surgeons. This may seem standard to many, but when hurricanes barrel through, earthquakes topple down, tsunamis wash away, or volcanos erupt around and upset all of this, we find that those must-have inductions and must-have cesareans become less urgent. We find that women can labor without being numbed, and that babies can come out without all the gadgets and gizmos set up in a hospital. And many see it as a tragedy that, because of a natural disaster, these women had to birth in a normal way!

In order for artificial feeding to be above dangerous, there are also many safety nets that need to be in place. How long does it take to boil water in order for it to be sterile? How many times must a mother do this in a 24 hour period for a formula-fed infant? How many gallons of water must she carry to her home? How much wood or other fuel source does it take to heat up the water for formula or for cleaning the bottles and nipples? How far is it to the nearest health care clinic, and how long would it take her to walk there with a sick child? How available is a health care provider in an emergency situation? During Hurricane Katrina, this is what formula feeding parents had to consider. In most of the world, this is what all parents have to consider.

I hear over and over again that formula feeding is perfectly safe ), and that breastfeeding really is not much better than formula feeding. What arrogance we have in our society! To take away the immunities and healthy digestive system our babies were intended to have, and replace it with a safety net of doctor’s trips, antibiotics, special hypoallergenic formulas, inhalers, insulin, etc. just because that is what is now normal, does not mean that it is safe. We can only claim it’s safety because we have all of the safety nets in place to catch our children when they fall. Those safety nets would not be as necessary if we followed the natural order our bodies and our babies’ bodies were intended to follow.

In our country, we have the ability to choose whether we want to have a natural or medicalized birth. We have the ability to choose whether we want to breastfeed or formula feed. But just because these choices are available, it doesn’t mean that they hold the same level of safety. At any moment we could be in a situation where our safety nets fail.

Reflection

The other day while waiting for my daughter's ballet class to finish up, I began chatting with a woman who was also waiting. During our chat, it came up that I am a doula. "A do-what?" this middle-aged Ukranian woman asked me.
Though the term doula is becoming more and more well-known, this is a question that I hear often. And I've noticed that older women tend to not understand the necessity of my role as do the younger women. And not knowing much about birth in the Ukraine, I was not really sure what this woman would think about the work I do.
"Are you more for the emotional support, then?" this woman asked me when I tried to describe my role at a birth.
"Yes! Exactly!" I responded.
This opened the door for this women to share her own experience, as often is the case when talk of my profession comes up.
I love that women feel that they can trust me to be a sounding board for them as they describe in great detail a part of their lives that is so intimate, and so personal. I love to listen and gain more insight into the beauty and pain of womanhood.
This woman told me of her first birth, thirty years ago at a Soviet hospital in what is now the Ukraine. She told me how she had no idea what was happening to her, that no one had explained how the baby would come out of her, and that no one bothered to inform her at the hospital. She told me how she was left alone to experience pain after pain, not knowing if she was dying. She asked me if I tell women what to expect before they go into labor. I assured her that this was a large part of my role as a doula, and that I teach entire class series on what to expect through my childbirth classes. "This is good," she told me. "Women need to know. And they need someone with them to help them through it. What you are doing, it is a very good thing."
I think that it is important for us, as birth workers, to hear not only the good stories of birth, but be reminded of the bad stories, and how our efforts must continue - that history must continue to change so that all women can experience birth in a safe and satisfying way.

OFP, part 4 - Putting Optimal Fetal Positioning into Practice

WHAT IS “OPTIMAL”?

What is Optimal Fetal Positioning? Optimal fetal positioning is the act of manipulating a mother’s body through movement in order to alter the fetus’s position into one that is favorable to moving through the mother’s pelvis.
In the previous blog post, I explained why the left occipital anterior (LOA) position is the most favorable for a baby to start in during labor. While this is true for the majority of labors, I’d like to refer back to the first blog post on the various pelvis shapes among women, and explore how this may not be true in all cases.
Because the gynecoid pelvis is the most common shape – one that 50% of women possess – this is the pelvis that is mainly referred to in OFP discussions. But, what if you have one of the other three types of pelvises? Optimal fetal positioning may then look different for you. While the general thought is that OFP is trying to get the baby into the LOA position, variations in the pelvic shape will change what is the optimal position for the baby.
I will reiterate here: the optimal position for the baby is whichever position the baby most easily fits through the pelvis. So, in the case of the anthropoid or android pelvis, the shape of these pelvises makes it much more likely for a baby to be in the posterior position. While a labor where the occipital bone of the baby is pressing against the mother’s sacrum may not sound ideal to the mother, if it’s the place that baby best fits through, it’s the best position in which the baby should be.

OPTIMAL FETAL POSITIONING DURING PREGNANCY

*POSTURE In the last blog post, I brought up one of the best things a pregnant woman can do to encourage OFP, and that deals with her posture.
I would say that the majority of “failure to progress” babies are due to malpositioning, and that the majority of the malpositioning is due to our modern lifestyles. Instead of walking for travel, we slouch in our cars. We do not sit cross-legged on the floor, nor do we squat, we lounge on sofas and in easy chairs. The majority of our work is done while seated, and the majority of us sit poorly.
So, watch your posture! Get a birth ball to sit on during the day. Tailor sit at home. Take breaks from sitting and do pelvic rocks. Spend a good 10 minutes when you get home from work just leaning over your kitchen countertop and moving your hipsThese positions will move the uterus forward, and help the baby to rotate into an anterior position. These postures will encourage flexibility in the pelvic joints which will enable them to open up to make more room for the baby.

*BODY WORK Some of us may need more help than just normal posturing to get our babies to move into more favorable positions.
Perhaps you had a bad fall when you were a kid. Maybe you were in a car accident. Or you played soccer and made the same one-sided twisting motion over and over again. All of these things can affect the pelvis alignment and uterine ligaments.
When the pelvis is bumped out of alignment, or the uterine ligaments are tighter on one side of the uterus, there’s going to be a twist in the uterus. While a slight twist or misalignment may seem like a minimal problem from the outside, everything is magnified on the inside. A slight twist outside turns into a large twist on the inside, making rotation more difficult for the baby.
Chiropractic care is wonderful for dealing with these bone and ligament issues. Mayan Abdominal Massage is another form of body work that helps get the uterus into better alignment.

*MOVEMENT What happens when you sit the same way, walk the same way, move the same way over and over again? Your body becomes rigid and tight, only allowing certain movements to take place. In pregnancy and birth, we want the body to be able to open up, the pelvis to open and move, the ligaments stretch. So, to help a baby be able to move, you need to move! Certain movements are more helpful during pregnancy and for optimal fetal positioning than others.

- squatting – opens up the pelvis, stretches your leg muscles, gets baby into alignment.

- tailor sitting – this stretches out the legs, opens the pelvis, moves the uterus forward and aligns your body.

- pelvic rocking – this helps get the baby out of the pelvis to allow it to move into a more optimal position, loosens the joints and ligaments of the pelvis and uterus and tones the abdominal and back muscles..









- forward lean – this helps to counter all the leaning back we do during the day. Lean against a table, a counter and while you lean move your bottom around to loosen up the hips!
















- hip shimmy – this is where, as mom leans forward (over a birth ball or a table or a bed) her partner comes up behind her, grabs each side of her hips and shimmies them back and forth. This helps to loosen up the pelvis and the uterus, gets baby moving around and feels good to mom








- dancing – dancing is one of the most fun ways of helping to get a baby positioned correctly! Last year when I attended a Zumba class with a friend, one of the dance instructors leading the class was 8 months pregnant. While her movements may have not been as mobile or precise as the other instructors, I couldn’t take my eyes off of her! The whole time I watched her I was thinking how great these movements were for her pelvis and uterus, and what a wonderful gift she was giving her baby through movement and flexibility!

* SIFTING Sifting is a technique that has been used by Mexican midwives for centuries. It involves wrapping a rebozo (“shawl”) under the bottom or belly of a pregnant mother, and shifting the shawl back and forth while raising the mother’s body slightly off the floor. This takes some arm strength, so have someone strong apply this technique! If you do not have a traditional shawl, a towel or sheet, or any longer piece of material, will work. This technique is similar to the hip shimmy in that it helps to loosen up the pelvis and uterus. It loosens ligaments and muscles, gets the baby moving, and can really help to rotate a baby. Whether or not sifting should be done on the woman’s belly or bottom depends on the position of her baby.




It is a wonderful technique to use on most pregnant women, as it often helps to ease any lower back discomfort that is common in pregnancy.

* DUMPING Dumping is a technique that was brought to my attention by my friend and chiropractic care provider, Dr. Joella Pettigrew. When a pregnant mama comes into her practice and she determines that baby is lodged into a bad position, before she performs an adjustment on the mother, she will have her get up on her table, and bend down – feet on the raised platform, bottom in the air, and hands on the floor. This is something that should not be done by oneself, but with supporters on both sides. What happens with this position is that it allows gravity to work on getting the baby out of the mom’s pelvis, in order to then get the baby to rotate into a better position through the chiropractic adjustments. Dumping prior to the other movement techniques helps to increase the likelihood of getting a posterior baby into a more optimal position.

GETTING BABY TO FLEX ITS HEAD

Referring back to the second part of the OFP posts, whether or not a baby’s head is flexed can make a huge difference on the ease with which the baby will fit through the mother’s pelvis. How to get a baby to flex its head may be a question that arose while reading through that post. While it’s not as simple as the rotational techniques, there are still some things that can help get a baby to have a well flexed head.
First off, before a baby has engaged deep into the mother’s pelvis, a skilled midwife can feel, through palpation, whether or not the baby’s head is flexed. And, if the baby’s head seems to be extended, she can help the baby to flex its head all from the outside of the mother.
Another way to encourage a baby to have good flexion, is to have toned abdominal muscles. Women with multiple pregnancies, which tend to stretch out both the uterus and the abdominal muscles, seem to present more babies with extended, or asynclitic heads. Keeping the abdominal muscles toned in between pregnancies, and through pregnancy with pelvic rocks, will greatly help with getting the baby to flex his head.
Along with well-toned abdominal muscles, sifting can be very helpful in getting a baby to flex his head. The shifting movement of the mother’s body can help to shimmy the baby down in the most accommodating place of the pelvis and encourage the baby to tuck his chin.

OPTIMAL FETAL POSITIONING DURING LABOR

Many of the techniques for optimal fetal positioning during pregnancy can also be applied during labor. While it’s best to have baby in an optimal position prior to labor starting, sometimes it cannot be helped!

*MOVEMENT Key to any labor, but especially one in which the mother is trying to get a baby to change position, movement allows gravity and momentum to work together to get a baby to rotate. Walking is simple to do and a wonderful way to encourage rotation! The back and forth shifting of the pelvis as the mother takes her steps helps to get baby moving too.
Rotating the hips while sitting on a birth ball is another movement which encourages baby to move and find the best fit through mom’s pelvis. Dancing with a partner, or just moving side to side, swaying your hips, these primal, unconscious movements that many mothers make during labor are all ways that the body works to get a baby to move around and down.

*UPRIGHT Unless you are trying to get the baby out of the pelvis, or to move more specifically, upright positions will allow the most opportunity for babies to rotate and find their good fit. It also tends to be most comfortable for moms, allowing them to freely move.

*TURNING A BABY FROM RIGHT TO LEFT If the baby is starting with its occipital bone facing the mother’s right side, it is important to remember that babies tend to move dextrorotationally. Meaning that they move clockwise and will therefore have to move into a posterior position before swinging around to the left. How will you know if the baby is in a right position? One way is belly mapping, which can be discovered at the spinning babies website. Another way you can see a baby’s position is by looking at the mother’s hips from behind her. If a baby’s occipital bone is pressing down into the pelvis, you will most likely see that side of the mother’s pelvis bulge out. This is only visible if the baby is in a more posterior position. If the baby is starting in an ROA position, you will probably not see any difference in the hips.
If baby is starting out in an RO position, the best way to get it moving in the right direction is to purposely rotate the baby first into a posterior position. That may not sound pleasant, but if a baby is turning clockwise, it will need to move around the back before coming back over to the left! Depending on which position baby starts in – ROA , ROT or ROP, you may need to start with right side-lying to get baby to move farther back.
If the baby is engaged into the pelvis, and especially if the bag of waters has broken already, it might be necessary to first get the baby out of the pelvis. Dumping was one option already mentioned, though it might be scary to do during labor. Another technique for lifting babies out of the pelvis is called the belly lift and tuck (described below). I discovered this technique on the spinning babies website and have used it very successfully! Once baby is brought back up out of the pelvis, sifting while mom is on her back is what I’ve found to be best.
This shimmies the baby to rotate into a posterior position. Sift only between contractions. Babies rotate between contractions, move down during.
Once baby is established in the posterior position, moving mom onto her left side will help get the baby rotated into an LO position. Just side-lying can do the trick. A little hip shaking while mom is side lying isn’t bad, either.
When you feel certain that baby has moved to the left side (again, look for the hip bulge), have mom get up and walk around to get baby to engage in this position. Hopefully, once this is done, progress will be seen soon after!


*SIFTING This was brought up as part of the rotational process above, but it can be helpful no matter what position you either think, or know, the baby is in. Sifting is also the best technique to use if a mother has one of the “other” types of pelvises in which the baby best descends in a posterior position, or with an asynclitic attitude. Sifting is like jiggling a key in a lock to make it fit. It will help to get the baby into the pelvis because it is moving the baby around until it finds the best fit!

*BELLY LIFT AND TUCK This is a technique I learned from the spinning babies website and have used successfully in getting stalled labors going again. What I discovered with labors that progress with contractions but not with dilation, is that it often has to do with either the attitude of the baby’s head, or the position of the baby. If a baby cannot fit down into a pelvis, it will not be putting pressure on the cervix to dilate it. In Bradley® classes, we talk about the NAP – the Natural Alignment Plateau – that occurs in over one-third of all births. While there are many reasons for an NAP (emotions, hormone production, head molding), one of the most common is what the name infers. Alignment.
When you help the baby get into a better alignment, the labor will progress with dilation and descent.


What the belly lift and tuck does is lift the baby out of the pelvis where it is assumed he has tried to descend, either with a wonky head, or in a suboptimal position. Once he got there, he couldn’t go any further. So, when the mother lifts her belly up during a contraction, it helps to lift the baby out of the pelvis. While mom lifts her belly, she also tucks her pelvis under as she would do during a pelvic rock. This helps the baby find a better entry point into the mother’s pelvis. If the stall in the labor is due to the baby’s need to flex or straighten his head, this may be all that is needed to finish labor rapidly. If baby still needs to rotate, this technique in combination with some of the others will be best in getting labor to progress further.


*HIP SHAKING Like dancing, moving, and sifting, the hip shake technique described in the pregnancy portion can help to rotate a baby into a better position. This is a useful technique if a mother does not want to lie down to be sifted, or does not want her belly touched with sifting. The partner can stand behind her, ask her to lean over the bed, counter, chair, etc., grab her hips firmly and move them in the same fashion as the sifting would.

Optimal fetal positioning is a wonderful skill to know, whether you are the pregnant mother, a doula, a nurse, midwife or doctor! Knowing how to utilize these techniques may mean the difference in a vaginal or a cesarean birth. It may mean the difference in a 12 hour labor and a 48 hour labor. It may mean the difference in an extremely intense back labor, or a labor that is more manageable. Knowing how to make the difference is an invaluable skill to have!

While all of these techniques can help get a baby rotated and into an optimal fetal position, it is important to remember that pelvises and babies’ heads are still amazing at adapting. Babies can still be born in posterior positions, with brow and face presentations, and in other “non-optimal” positions. It may take a little more time, and a lot more effort, but the human body is amazing at making birth work.

WHERE I LEARNED THIS STUFF (a.k.a References and Resources)
* Childbirth International Physiology in Birth Course Manual
* Childbirth International Birth Doula Skills Course Manual
* Understanding and Teaching Optimal Foetal Positioning by Jean Sutton and Pauline Scott
* The International Chiropractic Pediatric Association
* Joella Pettigrew, D.C.
* Spinning Babies

* The Belly Mapping Workbook
* Personal Experience

Optimal Fetal Positioning, Part 3 - Putting the Pieces Together

In my first blog post on Optimal Fetal Positioning I focused on the dimensions of the human pelvis. With my second post, I explored the shape and angles of the fetal head. This next post on OFP will be bringing these two parts together, showing how well they can fit when things are done right.

CARDINAL MOVEMENTS

The way a baby moves through the mother’s pelvis on its exit from the womb is described as the “cardinal movements.” The cardinal movements always begin with the fetal head in the LOA position, though sometimes babies do not go that route. The reason why LOA is the most described starting position is as follows.
As the baby enters the inlet of the pelvis, the widest diameter is transverse – from side to side. The baby’s head, when flexed well (or even when not), will be wider front to back. So, the best way for the baby’s head to enter the pelvis is in a sideways, or OT position.

INTERNAL ROTATION

As the baby is pushed further into the pelvis by the power of the contractions, and enters the pelvic cavity, the dimensions change. The cavity is more equally rounded, and since body movements tend to move in a clockwise direction (I’ll explain this more below), the baby is rotated from LOT to LOA.



EXTENSION

The pelvic cavity is where head flexion really has a big impact. With an equal diameter of 12 cm, a well-flexed head will have a much more successful journey past the ischial spines than an extended head with an 11-13.5 cm diameter. As the baby moves through the cavity, it will continue its rotation from LOA to OA.



EMERGING

Once the baby has moved through the pelvic cavity, the front part of the pelvis basically disappears with the pubic arch. But the sacrum and coccyx at the back are still creating a posterior resistance. The pelvic outlet is absolutely wider from front to back than to side to side. But, if mom is in a position that allows free movement of the sacrum and coccyx (side-lying, hands and knees, upright/squat), the front to back opening will be even greater as the baby pushes the sacrum and coccyx back. This anteroposterior opening creates a space that favors an OA position for the baby’s head.




CROWNING

As the baby’s head moves through the pelvic cavity, and under the pubic arch, on the outside of mom’s body we see the baby start to crown. Through the pelvis the baby has rotated from LOT to OA, and when the baby’s head is born, the baby is usually looking toward mom’s back

EXTERNAL ROTATION/RESTITUTION

The baby’s head has already gone on its internal rotational journey. As the head emerges, the shoulders follow with their own rotations. The shoulders enter the pelvis side to side, because they are widest that way, which puts the baby’s head in the OA position. As the shoulders move through the tight pelvic cavity, the body spins clockwise, and on the outside you’ll see the baby’s head turn toward its mother’s right leg.

As the shoulders move through the pelvic cavity, the rotation continues until the shoulders are front to back, this being the widest diameter of the pelvic outlet. Because of the pubic arch, the anterior shoulder will emerge first, followed by the posterior shoulder. The baby usually continues rotating until its facing up as the rest of the body is born.













BACKING UP

What I’ve just described is the best way that a baby fits through the twists and turns of the maternal pelvis. The two were designed to work together in this manner and allow the baby and the mother to remain intact. Getting a baby to this starting point is what optimal fetal positioning is all about.

DEXTROROTATION

Why does it matter if the baby starts in a left position or a right position? Inside the body, there’s a certain phenomenon that takes place called dextrorotation. This describes the body’s tendency to have its processes move in a clockwise direction. Our uteri move the same way. As the uterus contracts and releases, babies are turned in a clockwise manner. If a baby were to start out in an ROA position, this would mean that the baby would need to rotate all the way from ROA to ROT to ROP to OP to LOP to LOT to LOA. That’s quite a long journey and includes a nice length of time moving through the posterior position, which can be extra painful for many mothers. Starting out in the LOA position means that the uterus can focus on pulling open the cervix and moving the baby down, instead of also working on getting a baby into a good position.












GETTING A GREAT START

One of the best ways you can help start labor off right is by paying attention to your body movements in pregnancy.
Consider the way your spine curves. Most of us are lazy when we sit, especially if we like to sit in comfy seats such as couches and overstuffed chairs. In these places, we tend to tilt our pelvis back and curve out our lower spine, rolling our shoulders forward. Because the back of the baby’s head is heavier than the front of its head, sitting in slouched or reclined positions allows gravity to turn your baby to a posterior position, and the baby’s back is curved nicely along your curved back. If you were to sit with the pelvis tilted forward instead, your lower spine would have a nice curve inward, and your body would be more upright. This would allow the uterus to move forward, the baby to fit itself along the curvature of your spine, and the heaviest part of the baby’s head would then be toward your front.

Optimal Fetal Positioning, Part 2 - The Fetal Head

In the first blog entry on Optimal Fetal Positioning, I discussed the shape and variations of the first participating body part of OFP – the maternal pelvis. Before we discuss how Optimal Fetal Positioning really works, I need to explain the next participating body part – the fetal head.

As with the maternal pelvis, the fetal head is made up of various mobile bones that form a variety of shapes and sizes. Because babies’ heads move in different directions, both on their bodies, and in relation to the mother’s pelvis, I’m going to break down the different ways we describe the fetal head.

“Attitude”

The first part of the baby’s head position to consider deals with “attitude”. This describes the amount of flexion or extension of the baby’s head, or how tucked the baby’s chin is. Why is flexion important? The amount of flexion going on will alter the diameter of the baby’s head as it moves through the pelvis, the cervix, and through the vagina. A cervix opens only as far as it needs to fit around the baby’s head. If the diameter is small, it will only need to dilate that amount. If the diameter is larger, then more dilation will need to occur. . A well-flexed head is a baby whose chin is tucked well into its chest, with the occipital (or back of the head) bone as the presenting part. From here there are varying degrees of flexion and extension.

Complete Flexion: this is the optimal position for a baby’s head to be in. The angle of the head and neck are less than 90 degrees, baby’s chin is tucked well into it’s chest, and the very back of the head presents first. The diameter of a completely flexed head, the suboccipitobregmatic diameter, is measured from just below where the occiput starts out to the center of the front fontanel. This diameter is about 9.5 cm







Moderate Flexion, or Military Attitude: with the military attitude, the baby’s head and neck are at a 90 degree angle, as if the baby is looking straight forward. The diameter of a military attitude, the suboccipitofrontal diameter, is measured from just below where the occiput starts to about the center of the forehead. This diameter is about 10 cm






Extended or Brow Presentation: this attitude has the baby’s head tilted back a bit, the angle of the head to the neck greater than 90 degrees. The diameter of brow presentation, the occipitofrontal diameter, is measured from the occiput start at the back of the head to about the eyes or the brow. The diameter is about 11.5 cm.
















Hyperextended, or Face/Chin Presentation: this attitude has the baby’s head tilted way back and can be referred to as “star gazing”. The diameter of a hyperextended attitude, the mentovertical diameter, is measured from the tip of the chin to the highest point on the back of the head on the vertex. The diameter is about 13.5 cm.







As you can see, the variation in diameter of the fetal head is great in relation to how well flexed is the baby’s head.

Fetal Head Bones/Molding

So, can an unflexed head still fit through the pelvis and birth canal? Though it often takes more time and effort, yes, an unflexed head can still fit through!
Many pregnant women cringe when they think about pushing out a newborn baby’s head through their vaginas. How could something so large come out of something usually so small, they may wonder. While the majority of that topic can be turned into a blog post all on it’s own, for the sake of this blog post on OFP, we will discuss how the baby’s head can change size in order to fit through the mother’s pelvis.
We’ve already talked about how the attitude of the baby’s head alters the diameter of the presenting part. But, what if the baby comes down in one of those suboptimal positions, or what if the baby really does have a large head? The wonderful thing is, we were designed to deal with this as well. Just as the maternal pelvis can expand to allow more room, the fetal head can contract to take up less room.













The fetal skull is formed from five main bones – two frontal bones, which make up the forehead area; two parietal bones, which make up the majority o fthe skull; and the occipital bones, which makes up the very back of the skull, protecting the spinal cord.

The adult human skull has a static shape – it is not going to change unless the bones are broken. But from fetus up until eight years of age, the sutures between these bones have not yet fused. These unfused bones and the fontanels, or small gaps, between the bones, create a skull with the ability to shift, bones overlapping bones, reducing the diameter of the skull. This ability can even allow a malpositioned baby to fit through his mother’s pelvis. I’ve seen some pretty amazing coneheads in my practice! The ones that are always so amazing to me are those that cone at an angle, or off to the side of the baby’s head. It amazes me that we are able to adapt so well; that vaginal birth really is very accommodating!

Fetal Head Position

Fetal head position is different than the attitude of the head. The attitude deals with moving the head up and down from the neck. Position deals with the direction in which the head (and the body that follows) is facing.

When discussing fetal head position, the occipital bone – the one at the very back of the head – is always what is used as the point of reference. We describe the fetal head position as which direction of the mother is the fetal occipital bone pointed toward.

The front portion of the mother is called the anterior. The sides are called transverse. And the back portion of the mother is called the posterior. So, if the back of the baby’s head is pointed toward the front of the mother, the baby would be in an occiput anterior position
















The various fetal head positions are as follows:

ROA (Right Occiput Anterior)
ROT (Right Occiput Transverse)
ROP (Right Occipital Posterior)
OP (Occiput Posterior)
LOP (Left Occiput Posterior)
LOT (Left Occiput Transverse)
LOA (Left Occiput Anterior)
OA (Occiput Anterior)