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Labor and delivery nurses are often untrained in diagnosing posterior, and the woman usually doesn't see her physician until near the end of labor. Even if the physician were present and an early diagnosis made, generally he/she would do nothing to correct the position. When progress in labor is slow, often the first action taken is to break the amniotic sac, followed by pitocin augmentation. This is the worst thing that can be done in a posterior labor since when the waters are broken and contractions are enhanced, the baby's head will descend, only worsening the situation. In order to become anterior, it is necessary for the head to go through a long rotation of up to 180 degrees. (Normal rotation requires a 90 degree turn or less). If the head descends too deeply before rotation is accomplished, the risk of a deep transverse arrest increases, greatly reducing the chances for successful vaginal delivery. If the position is not adequately diagnosed until late in labor, the only recourse may be to offer a para-cervical block or an epidural anesthesia as it is almost impossible for the mother to relax enough to allow the deep muscles of the pelvic floor to relax sufficiently to allow the baby to turn.
Nothing can prepare a mother for the severe unremitting pain that accompanies labor when the baby is in a posterior position. Often, labor begins with short, painful yet irregular contractions which are often shrugged off by care givers as "false labor". It may not be productive as the ill fitting posterior head is not properly applied to the cervix, but the mother IS experiencing discomfort! She is often sent home to wait for "real labor" to begin but is unable to sleep and often unable to eat, sometimes for several days. So, adding to the stress of a painful back labor, we begin with a mother who is already tired out! I have heard women describe the pain as "it felt as though someone were sawing my back in half" or, "I couldn't even tell when I was having contractions because my back hurt so much!". All attempts to ease the pain have little effect and the labor is a long, hard exercise in determination.
Many midwives attending out-of-hospital births have not been taught to help correct a posterior presentation, and despite their best efforts are forced to transport the woman to the hospital when confronted with a mother begging for pain relief or after several hours of pushing have resulted in little progress or a large caput has formed. Then there is the mother who finally delivers her baby after a 36 hour labor and is so exhausted by the ordeal that she has difficulty bonding with the baby, postpartum involution is delayed and she may suffer from urinary tract infections due to the pressure upon and swelling of the anterior vaginal wall. Did I fail to mention those nifty lacerations up top? I would love to see this picture changed. As a midwife it is my goal to do everything that I can to help the mother to achieve an optimum birth outcome, to use my skills to alleviate unnecessary pain and suffering and to help a new family begin in safety, peace and joy. Hence the purpose of this article.
The incidence of a posterior presentation occurring at the onset of labor is 15 to 30 percent, and many such babies rotate spontaneously to an anterior position. When the pelvis is adequate, a posterior baby may be born face up with little or no difficulty, as if saying, "Surprise! It's my little face!" On one such occasion, as a woman was delivering precipitously here in our center, my daughter who was assisting at the mother's side, said "Mom, the baby's ear is upside down!" just before the rest of her head came out, with the baby looking straight up at her mother. There are, however, many Cesarean sections done for persistent posterior labors when failure to progress occurs, or when maternal exhaustion or a transverse arrest makes vaginal delivery either very traumatic or impossible. As we are unable to guess at the onset of labor what the possible outcome will be, I feel it imperative that every effort be made to avoid both a long and difficult labor and possible necessary operative intervention by early diagnosis and correction of the position.
We see our clients weekly during the last month of pregnancy. One of the things we are careful to assess is the baby's presentation and position. An ROA position is watched expectantly, as statistically ROA is much more likely to become posterior than LOA. [Ed.: Oxorn-Foote, 5th ed., pg 161: "Right occiput positions (ROP) is five times as common as left occiput posterior (LOP)". This is probably because the left descending colon is taking up the left side of the mom's pelvis and preventing the baby from turning posterior.] If the baby is posterior, we give the mother exercises to try to help the baby turn. Having the mother do pelvic rocking three times daily in sets of twenty often assists the baby to assume a more favorable position. It may also be helpful to have the mother assume a knee-chest position for twenty minutes, three times a day, or to utilize a slant board as with a breech baby to help disengage the baby, allowing gravity to assist in the rotation. At the onset of labor, the position is re-evaluated and if the exercises have not helped to change the presentation, we encourage her to come into the birth center in early labor. It is relatively simple to assist the rotation of the baby when the mother is in early labor, and very difficult once labor becomes advanced.
There are some women who seem to be more at risk for a posterior position. The woman who has an android or an anthropoid pelvis, or a woman who has a narrow inlet is more prone to have this as well as other abnormal positions. Certainly, the woman who has had a previous posterior labor is much more likely to suffer a repeat. Remember to keep a watchful eye on an ROA.
It is my hope that through early diagnosis and appropriate intervention, many women might be liberated not only from long and difficult labors but from complications of such labors leading to inevitable cesarean sections. I have used these techniques with very favorable results for many years. To date I have had to transfer only one woman (in 1977) for a transverse arrest due to my inexperience at that time in diagnosing her posterior baby. Even a woman birthing in the hospital could help herself if she is having excruciating back pain or if she is told her baby is posterior by assuming a knee-chest position until she feels relief from the back pain or for at least half an hour.
For those of us assisting VBAC moms who have had a posterior labor leading
to cesarean, or moms who previously have had vaginal deliveries after long
posterior labors, a word of caution: In my experience, when a subsequent
baby is not in a posterior position the women are often advanced in labor
before they realize that they ARE in labor. This has led to many interesting
and amusing situations!
Addendum: The currently advised obstetrical management of posterior in arrested second stage. From a Detroit newspaper:
An obstetrician here has developed a modified technique for manual rotation of the fetal head in cases of prolonged second-stage labor. In his experience with about 50 patients, he has found the technique less traumatic to mother and fetus than the use of forceps.
"Prolonged second-stage labor is often caused by persistent occiput posterior or transverse arrest of the fetal head", notes the physician. "While the majority of these will undergo spontaneous rotation, some will not."
The Dr.'s procedure is to rotate the head from either a posterior or lateral transverse position to the anterior position. The diameter that must enter the pelvis is thereby decreased by as much as a centimeter and the head descends more rapidly.
"The idea is to bring the posterior fontanel forward from the 3,6, or 9 o'clock position to the 12 o'clock position. Then the baby is more deliverable. In the right sided position you rotate it clockwise. In the left-sided position you should rotate it counterclockwise."
The obstetrician stresses that the physician should put his fingernail on the lambdoidal suture. "The head is smooth and covered with vernix, so you just can't turn it with your finger alone. You must be sure to anchor your fingernail in the crease between the bones. And do it during contraction; otherwise the head won't turn easily," the obstetrician explains.
The modified manual rotation technique is not meant to be a replacement for forceps. But with it the doctor has had to use Kielland's forceps in only about 10% of the patients.
"When left entirely to natural forces, resolution of prolonged second stage labor may require several hours, increasing maternal exhaustion, maternal and fetal morbidity, and the possibility of fetal mortality," he observes.
"Good obstetric practice recommends timely, judicious intervention.
The technique I use is simple and can be used by midwives, medical students,
and interns as well as residents."
I again assert that to refrain from acting in the interest of the mother
by not correcting a posterior in early labor when it is both non-interventive
and safe, is to inflict needless pain and suffering upon the mother and
her baby, and may lead to a much higher level of intervention, ie: drugs,
episiotomy, forceps, cesarean section and not the least, digging one's
finger into the baby's fontanel!
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