A new perspective on an old problem.

For as long as I have been involved in birth, the link between back pain in labor and a baby in an occiput posterior (OP) position has been assumed. We have talked with our students and clients about the challenges of laboring with a baby in this position: dysfunctional labor patterns, failure to progress beyond a certain point, and back pain that can occur with contractions or persist continuously until the baby rotates. However, the majority of us who attend women in labor have likely witnessed those labors that defy this logic. We've seen women exhibit signs that the baby is OP with no significant discomfort in their back. Perhaps the labor was very slow and irregular, or the contraction pattern had the tell-tale sign of coupling (a repeating pattern of two contractions close together, sometimes the first being stronger than the second, followed by a longer break), or the baby failing to descend beyond a certain station regardless of all of the mother's efforts. We have also seen women go through what seemed to be a completely normal labor with effectively progressing contractions and not a single sign of labor dysfunction, but the mother struggled with excruciating pain in her back for some or all of her labor experience.

I have seen both of those scenarios play out many times over the years. And I have been most struck by those occasions where my client's labor was progressing normally but with a lot of back pain, and a nurse (or doctor, or midwife) would enter the room, notice the back pain, and make a statement about the baby being OP even though there was no other evidence to suggest that that was the case. This got me thinking.... does every OP baby cause back pain and a more difficult labor, and does every labor where the mother experiences back pain have a baby in an OP position. That connection has been assumed for as long as I can recall, but time and experience have shown me that that connection cannot always be assumed.

In May of 2005, Dr. Ellice Lieberman, et al, published their study "Changes in Fetal Position During Labor and Their Association With Epidural Analgesia" in Obstetrics and Gynecology, the journal of the American College of Obstetrics and Gynecology (ACOG). While the intent of this study was to identify the relationship between fetal position and the use of epidural analgesia, contained within this study is interesting and thought-provoking information about the relationship between fetal position and labor outcome as well as the connection between fetal position and the woman's experience of labor.

The study included 1,562 women experiencing their first birth with either spontaneous or induced labor with a single fetus at term (37 to 42 weeks gestation). Each woman received an ultrasound exam to determine the position of the baby's head at enrollment (admission to the labor unit), at epidural administration, or at 4 hours after the initial ultrasound examination, and at late stage dilation (preferably at 8 cm). The study results showed that regardless of the baby's head position at enrollment, most babies were OA (occiput anterior) at birth. What is important to note in the results is that the baby's final head position was established close to birth. The ultrasound exams showed that changes in the fetal head position were common throughout labor, with 36% of babies in an OP presentation on at least one ultrasound. Of those babies who were OP late in labor, only 21% were still OP at birth.

Women who chose epidurals did not have more OP babies when they were admitted to the hospital and did not have more OP babies at the time of epidural placement or at the 4 hour exam. However, women with epidurals DID have more OP babies at birth (12.9% with epidural versus 3.3% without). What can we conclude from this data? Fetal position changes are common during labor, with many babies assuming an OP position at some or many points during the labor process. The final fetal position is established close to birth, not earlier in the process.

How does this study information tie into the discussion about back pain and back labor? Let's go back to the original assumption: back pain in labor is caused by the baby being in an OP position. Based on the study results, women with OP babies at birth did not report more painful labors at enrollment. Using a pain scale, pain scores were 4.9 on average for women with an OP baby at birth and 5.2 for women with a baby who was not OP at birth. During labor, women with an OP baby had a mean pain score of 5.3 while women with a baby in any other position had a mean pain score of 5. 1. Women with OP babies at enrollment were not more likely to report maximal pain in their back compared with women whose babies were in other positions.

As educators and doulas, many, if not most, of us have counseled our clients and students about the challenges of laboring with babies in an OP position and have encouraged exercises (positions and movement), done both prenatally and during labor, to ensure optimal fetal positioning. On many occasions I have asked myself, do babies who are OP either during pregnancy or during labor really need to be turned in order for labor to progress? This study shows us that fetal head position at enrollment was not an indicator of fetal head position at birth. Of those babies who were OT (occiput transverse) at enrollment, 78% were OA at birth. Of those who were OP at enrollment, 80% were OA at birth. Of those who were OA at enrollment, 83% were OA at birth. Fetal head position at birth is not determined until very close to birth. It is not determined prenatally and it is not determined early on in labor.

So what do we do with this information? How do we effectively teach and guide our clients towards a positive birth experience without instilling a sense of fear (fear of the dreaded OP baby) or a sense of fault ("I didn't sit the right way on my couch or in my office chair, and now my baby is OP")? An important clarification to make to our clients and to ourselves is that back pain does not always mean an OP baby, an OP baby does not always cause back pain, and babies move in labor. Labor is like a dance between the mother and baby where the baby can move in response to how the mother uses her body, and the mother may move in response to what she feels in labor. If this relationship is honored and the mother is able to feel, and therefore work with her body through the process, she will be much more likely to know what to do with her body to birth her baby.

Because babies in an OP position, as well as those who are OT or asynclitic (the head cocked off to one side, not coming down into the pelvis with the occiput centered at the cervix) can cause labor dysfunction, it is beneficial to recognize other signs that the baby may not be well positioned in relation to the woman's specific pelvic structure, and not to rely solely on the experience of back pain as the indicator of a malpositioned baby. Other signs might be:

* Long or multiple episodes of prodromal labor with or without back pain

* A slow or irregularly progressing labor

* A long and/or painful early labor

* An inconsistent contraction pattern

* Coupling of contractions

* A premature urge to push

* A non-reassuring fetal heart rate 

* Failure to progress in first or second stage labor

Back pain in labor can be caused by many things:

* A baby in an OP position (yes, this is certainly a possibility)

* A baby with a compound presentation (arm alongside the head)

* A baby who is OT or asynclitic

* A baby who is low in the pelvis and putting pressure on the bones, ligaments and nerves

* A previous back injury or chronic back weakness

* A normal aspect of a woman's experience of labor

The important message is that the strategies implemented to deal with or manage the back pain or to help enable a baby to move into a more optimal position, are the same regardless of the cause. One of the most valuable tools we can provide our students and clients is the knowledge of strategies and techniques to deal with these challenges in labor--empowering them to know that they can proactively work with their babies in labor towards a successful birth outcome without dwelling on the fear of certain fetal positions or of back pain.

If we are working as promoters of normal birth, our focus should be on emphasizing what is normal as opposed to promoting fear. If 25-36% of all babies are OP at some point during labor, can we say that this position is abnormal and a problem that needs to be solved? Many, if not all of us, talk with the women and couples in our care about the fear-tension-pain cycle and the impact of fear-related hormonal shifts on the labor experience and birth outcome. The fear of a malpositioned baby or of back pain can create the same kind of labor challenges as fear of anything else can. Fear increases tension which increases pain sensations. Fear also triggers the fight-or-flight response, releasing adrenaline-like hormones and corticosteroids that do many things to change the body's physiology, including inhibiting the release of oxytocin, which can have a negative effect on how labor progresses.

There are a number of strategies a woman and/or support person can implement to reduce back pain. Position changes are one of the most helpful strategies, and the ability to change positions is one of the primary reasons why avoiding or delaying an epidural for as long as possible can be so beneficial to a woman's labor. Options are:

1. Forward-leaning positions--these positions help drop the uterus out of the pelvis, relieving some of the pressure on the sacrum. It provides an opportunity for the baby to rotate or reposition if needed, and it makes the back-side available for physical support and comfort measures.

2. Squatting positions--these help to open the pelvis, making more room for the baby's head and alleviating some of the pressure on the bones of the pelvis. The extra space within the pelvis that is created by squatting may also help facilitate head rotation if that is needed in order for the baby to find a better fit.

3. Side-lying--this position does help to open the pelvis depending on how the position is assumed. A "runner's posture", with the top leg well in front of the bottom leg and the hips angled more towards the bed (almost as if the woman is trying to lay on her belly) is often most beneficial. It is also a good position for enabling full relaxation between contractions, makes the back available for support, and allows for fetal head rotation if needed.

Movement is a beneficial addition to the positions that women use in labor in that it helps to keep the pelvis and the muscles around the pelvis loose. Movement helps to open and flex the pelvis which can diminish pain, help with labor progress, and enable a better fit where the baby can move through the pelvis with less resistance. Options for movement are:

* Rocking and Swaying

* Lunging

* Pelvic Tilts

* Supported swaying

* Shaking the hips

Touch and massage have long been recognized as strategies for pain relief and muscle relaxation. Massage helps to increase circulation, bringing more oxygen (and, therefore, energy) to the part of the body being massaged, and can increase circulating endorphins, which help with pain reduction. Massage may also help with oxytocin release, enhancing overall progress in labor. Touch and massage can be done with the use of heat or cold, depending on what feels best to the mother. The physical contact from touch or massage can also help a woman to feel grounded, connected, and free from fear, all of which help her to have a more positive experience in labor. Specific techniques that can help with back pain are:

1. Counter pressure--this can be done with a hand or massage tool, with or without massage, and with the use of heat or cold as needed. Counter pressure helps to counter the pressure that the baby is putting on the bones from the inside, "pressing away" the pain.

2. Massage--either on the whole back or concentrated on the sacrum, can relax the muscles around the bones, release endorphins, and it feels good!

3. Double Hip Squeeze--by pressing the sides of the pelvis back in towards the sacral joints, some of the pain can be reduced or alleviated. Women also describe the feeling of "being held together", which may make it easier to relax the whole lower back and pelvic area, thus reducing pain.

4. Knee Press--in pressing the knees back towards the pelvis, the sacral joints can be closed, reducing pain. This can be done if the mother is sitting upright in a chair. If she is sitting on a birth ball, or if she is side-lying in bed, a support person can use one hand to provide counter pressure on the sacrum and the other hand to press one or the other knee back towards the pelvis.

5. Pressure points--while stimulating pressure points is not an effective pain relief strategy for every woman, it does work for some and may be worth trying.

Hydrotherapy, or the use of a shower or tub, is an excellent source of comfort, relaxation, and pain relief for many women during pregnancy and labor. Warm water on the skin is relaxing and helps with the release of endorphins. And circulating or spraying water on the breasts can stimulated the release of more oxytocin, enhancing the contraction pattern and labor progress. In the shower, the spray of water directly on the back can help to reduce back pain. In the tub or Jacuzzi, the buoyancy of the water can help relieve back pain and pressure, and the pulsating water from the jets on the back can also be beneficial.

Additional techniques worth exploring for the relief of back pain are the use of sterile water injections and the use of a TENS (transcutaneous electrical nerve stimulation) unit. Sterile water injections involve the administration of sterile water intradermally to create a bleb (or blister) of sterile water just under the skin at 4 different points in the sacrum; two just inside of the superior sacroiliac crest and two just inside of the inferior sacroiliac joint. The mechanism for how sterile water injections minimizes back pain is not fully understood, but it is thought that the irritation of the sterile water helps to block or overload the pain gates, making it difficult for pain sensations to be transmitted. Sterile water injections are more helpful when begun earlier in labor, when back pain is milder, and can provide up to 1.5 hours of relief. Once back pain has become acute, it is unlikely that this technique will work.

TENS units have been used by physical therapists to help their patients manage back pain for a long time. It is not common to see TENS units on the labor floors, but this is due more to a lack of awareness than a lack of effectiveness of the tool. Transcutaneous nerve stimulation also blocks or overwhelms the pain gates in the sacral area, diverting pain stimuli and preventing pain sensations from being transmitted. TENS can also help in the release of endorphins. There are not many studies looking at the use of TENS in labor, but in the general population, TENS has been shown to be effective in reducing back pain for as many as 90% of users.

The majority of this information is common sense. Women often know what they need to do, how they need to move, or what kind of support can help them to alleviate back pain either during pregnancy or during labor. The intent of this article is to remind you of what many of the options are so that you are able to share this with your students and clients. It is not a complete resource (other modalities, such as chiropractic, acupuncture, homeopathy, and Ayurveda, have not been mentioned here), but it does include the majority of options available to women during labor.

For many of you, separating back pain in labor and back labor will be a difficult transition. We have been so entrenched in the mind-set of back pain in labor being caused by an OP baby, that shifting that paradigm will take a lot of effort. Back pain in labor is a common complaint, as is labor progress that is challenged by a baby in a difficult position. These are real problems that require real solutions, and often the solutions are the same. But these situations cannot always be lumped together, and when we instill fear in our clients about the "dreaded OP" baby or the horrors of back labor, we do nothing more than compound the problem. We benefit our clients by empowering them with knowledge, tools and support to deal with the labor they have as they experience it at any given moment, and in this they can find their strength and ability to have a positive and a safe birth.

BACK LABOR: MORE THAN JUST A PAIN IN YOUR BACK!

Posterior (OP): The baby's back, or back of baby's head, is facing the mother's back.

Anterior (OA): The baby's back, or back of baby's head, is facing the mother's front.

Asynclitism: The baby's head is coming down into the pelvis at an awkward angle, sometimes caused by the baby having a hand or both hands up by its head or face.

This article was adapted from the presentation "A New Look at Back Labor", given by Randi Bigelow, CCE, CD. and Biddy Fein, CNM. at the Partners in Perinatal Health Conference. 2006, and the Lamaze International Conference, 2006.

References

Liberman, Ellice, et. al. 2006. "Changes in Fetal Position During Labor and Their Association With Epidural Analgesia." Obstetrics and Gynecology, Vol. 105, No. 5.

By Randi Bigelow, CCE, CD

ALACE Director of Childbirth Education