By Rosie Denmark
I first heard about the posterior presentation of babies early in my pregnancy from Margie Polden's article 'Getting into position' . The description of the shape of the abdomen in a posterior pregnancy came back to me as the months went by, as I noticed that my bump, quite small and compact and prominent to the right, and with palpable hand and feet kicks at the front, did not appear to be developing the forward round shape of the other pregnant women I knew. Indeed, people were always remarking on how small and neat my bump looked, usually with admiration for retaining a slim figure.
I would almost say that I had an instinct that something was wrong-above and beyond the usual and fairly constant pregnancy worries. Around week 26 onwards I had thought that I could feel that my baby was in a breech position-normal at this stage of pregnancy-as I could feel her kicks very low down in my abdomen. This was so uncomfortable that I slept for a few nights with my hips raised on a large cushion. I felt her turning during one night; and the next day my bladder no longer felt as if I had a foot pushed through it. A few weeks later, I became more and more suspicious that my baby was presenting in a posterior position.
At 32 weeks, I tried to confirm this suspicion with my midwife. However, she neither seemed confident to diagnose her position ('So does the baby feel as if she's posterior?' 'Well, her head's down, so that's good' 'Yes, but is she posterior?' 'Well lots of babies face outwards at this stage') nor happy to discuss exercises to change her position if she was posterior. Her opinion was that babies stay in the position most comfortable to them, and there's nothing you can do to change that. She told me that she would tell me my baby's position at 38/39 weeks.
I do not know whether this midwife was unsure of the position of my baby, or whether she simply would not tell me. Despite the fact that the presentation of the baby is a key factor defining the progress of labour, with posterior labours well-recognised as longer, more painful, and often necessitating more medical intervention , is it the case that many midwives only routinely diagnose the cephalic/breech presentations?
Indeed, a recent title of an article in a mainstream pregnancy magazine stated 'Why the position of your baby matters-breech or cephalic'. Is it really the case that these are the only presentations routinely recognised? And is it coincidence that breech presentations are the ones that doctors (sometimes) "fix" - but not (generally) something that mothers and midwives can do anything about?
As this was my first baby and I was booked for a home birth, I was alert for any problems which might indicate a need to transfer into hospital-a scenario repeatedly raised by my midwife. As I knew that posterior labours had a high rate of medical intervention, I decided to find out more. I was also deeply worried at the idea of diagnosing my baby's position at the very end of pregnancy, when it would be too late anyway. Having spent 10 years successfully using natural family planning, and being therefore quite used to knowing and respecting what was happening in my body, this deliberate ignorance seemed mindless to me.
At this point I tried the exercises outlined in the literature for turning posterior babies1, but succeeded only in making myself very uncomfortable and bringing a lot of fear and negativity that I wouldn't be able to change my baby's position and therefore would have to have a hospital birth. I vacillated between wondering if I was making a 'fuss over nothing' (which the approach of my midwife seemed to imply); and panic that I was rapidly heading towards a hospitalised, managed labour. I found it far too hard to keep up all these exercises without support and was in a vacuum of self doubt, with my body telling me one thing-that something was wrong-and the midwife another.
So how did my body tell me something was wrong? I did not feel 'settled', and I felt as if my baby was uncomfortable. I used to feel an 'edginess'-physically, as her head began to engage, as if two bones were grinding together. I would wake up feeling uncomfortable with the strangest urges-one night wanting to sleep kneeling on the floor with one leg cocked up like a dog! I had a dream of lying sideways on the top of stairs and falling forwards, with the forward rolling sensation being very peaceful and comfortable. I felt as if my body was 'urging me on'-but to what, I didn't know. I noticed that when I was relaxed the baby would do deep churning movements as if she was turning right round. In summary, I had a strong urge to do something physical, but I was not sure what!
In my first two weeks of doing the exercises alone, I simply increased my feeling of pain and agitation. The forward leaning exercises (described below) caused the baby to move more, and the deep uncomfortable churning movements increased, often waking me up for long periods at nights. Along with my own lack of confidence in what I was trying to do, I simply found it too hard alone.
Around this time, I received my copy of Jean Sutton's book Optimal Foetal Positioning . The morning I read it, I cannot describe the fear and panic it instilled in me. Far from my home birth, it raised a likely spectre of a managed labour, even a caesarean. It frightened me sufficiently to change midwives: it was clear to me that I needed to have my baby's position properly diagnosed and have some help if possible in trying to change it; and so I eventually changed my booking to independent midwives.
Following their first visit, my suspicions were confirmed that my baby was in fact posterior, and I was very relieved to get a proper diagnosis. My midwives were very understanding of my fears, but managed to convey a calm and confident attitude that it was perfectly possible for posterior babies to change. They gave me exercises to do, and I wrote out a list that I left in each room of the house of postures to aim for and avoid.
Three times a day, I would spend 20-30 minutes per day on hands and knees, or lying on my front. In the mornings this tended to be reading on my front propped up by cushions in bed, and at night on hands and knees in a warm bath. I did a lot of house painting on my hands and knees. This was, admittedly, difficult to maintain as it made my heartburn very much worse, and I would sometimes feel quite sick afterwards.
I was very strict about never using backwards leaning postures, always sleeping on my side, never sitting back on the sofa (the hardest!), only sitting on a special back chair that allows you to lean forward with your knees lower than your hips, or sitting forward leaning on a bean bag. I also had a large 'birth ball' (available through the Active Birth Centre catalogue), which I would sit forward and rock my pelvis on. I am convinced that it is the birth ball that made the real difference for me: after 5 or 10 minutes of rocking on this, I would feel the baby start churning movements, and if I then went into the kneeling forward positions I could almost feel her fall forwards.
The feeling of agitation that had previously been my instinct that something was wrong now became more definite: the baby was trying to move and I could help her to do so. It is worth making central to our understanding that babies themselves seem to want to move into the right position. Research has begun to recognise that it is babies who instigate the birth process, and it therefore seems highly likely that they are active in trying to find the right position in which to do so.
I was still occasionally woken up at night feeling uncomfortable; now I went and rocked on my birth ball, and did the exercise my midwife gave me of walking up the stairs sideways, two at a time. I had a difficult weekend of pre-labour pains when the agitation peaked, and I awoke constantly with a feeling of bones grinding in my pelvis. It was at this point, discouraged and worn out by pain, that I eventually resolved to really work at it, thinking clearly that my baby had to turn at some point: it would be much less painful to do this before labour than during, possibly with the help of forceps or ventouse. This was a passage through which I had no choice, so weary as I was, I might as well get on with it.
In the last weeks of my pregnancy, my midwife suggested that I go to the swimming pool every day, floating forwards in the water for 20 minutes or so. I'm sure the local swimmers thought I was mad; but the combination of relaxed muscle tone caused by being in a warm pool and the forward leaning posture seemed to do the trick as, at my last antenatal visit, direct anterior was diagnosed and I went into labour shortly afterwards.
The main reason I think the exercises worked on the second attempt is that skilled support enabled me to 'walk into' the discomfort (which I had anyway been experiencing but which the exercises made worse) and go beyond it. It became clear to me that this agitation was in fact the experience of the baby trying to move; fairly painful in itself, and therefore more painful as it is successful. On my second attempt at trying to turn her, my baby's head had already begun to engage.
As I continued with my exercises she disengaged, re-engaging as direct anterior. My 'forwards kneeling, never leaning back' regime was really hard work, and I was much encouraged by the support and positive attitude of my midwives. Having experienced both pre-labour pains whilst my baby was turning, and an anterior labour, it is clear to me that contractions with a posterior baby are of a very different nature to usual first stage contractions, and are recognised as being particularly painful : the pain is more agitating and exhausting and somehow more 'difficult to handle'. I do not think I could have coped with a posterior labour at home.
Your baby's position is fundamentally about the relationship between your body and yourself, and your baby and you. Your body gives you clues as to the positioning of your baby, some of which you can begin to learn to interpret yourself, although you may need an experienced and skilled midwife to help. It is the sensations that you feel that guide you through your progress in the exercises. And getting your baby into an optimal position for labour is one of the most important aspects of your relationship with your baby as you approach birth together.
At a time when medicalisation of labour can act all too often to reinforce our natural fear and apprehension as we approach labour, when a lack of confidence in our abilities to give birth is paramount, perhaps we should start by trying to get the basics right, starting with the position of our babies. And as with the rest of motherhood, it often takes a lot of hard work to get the fundamentals right.
1 Polden, M. 1995: Getting into position. Maternity and Mothercraft. April/May, 43-4.
2 Sutton, J. and Scott, P. 1996: Optimal Foetal Positioning. (2nd revised edn) New Zealand: Birth Concepts (available from NCT Maternity Sales).
3 El Halta, V. 1995 Posterior labour: a pain in the back. Midwifery Today. Childbirth Education. Winter (36) 19-21.
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