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Posterior labor - a pain in the back! It's prevention and cure.

I have become increasingly frustrated and angered that posterior presentation [back of baby's head toward mother's back] and its ensuring complications in labor and delivery have accounted for an inordinate increase in cesarean sections. Many of the women who come to us at the Garden of Life Birth Center desiring VBACs have suffered a previous cesarean for a persistent posterior with its attendant "lack of progress." I feel that with appropriate early intervention, the condition could have been resolved and a favorable outcome obtained. Many times the position is not diagnosed until labor is advanced and progress arrested. Why?

Labor and delivery nurses are often untrained in diagnosing posterior, and a woman usually doesn't see her doctor until very near the end of labor. And the often nothing is done except to offer medications or a change of position for the pain. Many midwives also miss a posterior, 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 of the babies so presenting 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 on backwards!" just before the rest of her head came out, with baby looking straight up at us.

There are, however, many cesarean sections done for persistent posterior labors when failure to progress occurs or when maternal exhaustion or a high 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 (back labors can be excruciating) and possible necessary operative intervention by early diagnosis of the position.

We see our clients weekly during the last month of pregnancy. And along with watching for such things as signs of pre-eclampsia, careful evaluation of fetal growth and well-being, we are careful to assess the baby's presentation and position. If it is felt that the baby is in a posterior position, we give the mother exercises to try to help the baby assume an anterior position before the onset of labor. We encourage a mother with a posterior or ROA baby (ROA is the most frequent position leading to a posterior presentation) or for whom a previous labor has been posterior to come into the birth center at the first sign of labor to determine the position of the baby. It is relatively simple to assist the rotation of the baby when the mother is in early labor, and very difficult in advanced labor.

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 who has a narrow inlet is more prone to have this as well as other abnormal positions. I have found, as well, that a first-time mother who has a large pelvis allowing her baby to become engaged early may be at risk. Also, a woman who has had several children and this baby is a bit smaller, tends towards posterior delivery, but it is not usually a problem.

Diagnosis of Position Prenatally:

1. During the prenatal exam the mother often exlaims that the baby has too many hands and feet, and the moving limbs may be easily felt and seen.

2. The mother often complains of frequency of urination due to the baby's brow pressing against her bladder. Sometimes she will also be incontinent, not being able to feel an urgency to urinate as the baby's head presses out urine.

3. It may be difficult to ascultate fetal heart tones, or the tones may be indistinct. When it is suspected that the baby is posterior, have the mother roll to the side and the heart tones will be more easily heard.

4. While the breech is easily palpated in the fundus, it may be difficult or impossible to feel the outline of the baby's back, and the head will appear to be engaged.

Assisting in Anterior Rotation


1. Have the mother do the "pelvic rock" exercise at least three times daily.

2. Have the mother lie on a slant board (as with a breech position) several times a day for fifteen to thirty minutes at a time, as tolerated.

3. Have the mother take warm baths and gently massage and encourage her baby to "roll over." We have found ie very effective for the mother to visualize her baby in the correct position and to talk to her baby, telling i to move as well. One time we had a particularly stubborn baby, who liked the way he was lying just fine. The mother had had a previous posterior labor and was very anxious that this not be a repeat performance. She had tried in vain to get this kid to cooperate, so I called the dad in and said, "Show this baby who's the boss!" Dad said, "Turn around, Baby!" and he did.

Diagnosis of Posterior in Labor:

1. The mother usually complains of a persistent backache, which even in early labor may be severe enough that the pain of contractions are secondary. As a backache may be present even in a normal anterior presentation, it is important that the vaginal examination be done to correctly assess the baby's position by the fontanels.

2. Palpation of the baby's position abdominally is not sufficient, as it is possible that the deeply engaged head may remain posterior even though the baby's body appears to be aligned as in ROA or LOA.

3. The location of the fetal heart tones is not a reliable method of assessing fetal position as they may be heard through the baby's chest as well as through the back.

4. Early labor may be marked by a long period of irregular uterine contractions with little or no dilation. Contractions may be more frequent yet of shorter duration than desirable or expected in early labor, e.g., every three minutes but lasting only 30 seconds. This is due to inadequate application of the presenting part.

5. In the ROP position, the sagittal suture line will be felt obliquely (from 1 o'clock to 7 c'clock), and it will be possible to feel the bregma (larger front fontanel) at the top and to the side of the pubic bone (by 1 o'clock). It may be possible to feel the top of the baby's ear as well.

Assisting Anterior Rotation During


1. When it is verified that the baby is in a posterior position, the first thing that I do is to have the mother assume and maintain a knee-chest position for approximately 45 minutes. Although this position is not the most comfortable one for the mother, it is very effective as it allows the baby more room in which to rotate. I find that the mother tolerates this position very well if she is not in advanced labor. We make sure that she is well supported by lots of pillows and give her lots of encouragement and emotional support. Often, while in the knee-chest position, the contradictions become more regular and more effective, which also assists the baby's rotation.

2. If the mother cannot tolerate the knee-chest position for as long as necessary to turn the baby, we alternate by placing her in an exaggerated Simm's position (lying on left side, two pillows under right knee, which is jack-knifed, left leg straight out and toward the back.

3. Every effort should be made to avoid rupturing the membranes, as the "pillow" offered by the forewaters gives a cushion on which the baby's head may spin more easily. Furthermore, if the waters break before the baby has rotated to the anterior, it is possible that sudden descent of the fetal skull will result in a deep transverse arrest!

4. If labor is more advanced when the posterior is identified, say 4-5 centimeters, it may be helpful while the mother is in the knee-chest position for the attendant to place her hand in the mother's vagina and gently lift the head, somewhat disengaging the head and allowing it to turn face down.

I have addressed this article to the prevention of complications which may result when early diagnosis has not been made of the posterior position, and to offer some suggestions for assisting anterior rotation. 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 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 for half an hour.

Valerie El Halta is co-director of the Garden of Life Birth Center in Deaarborn, She has attended close to 2000 births over the past 18 years and shares her experience in the Advanced Midwifery Skills Workshops offered throughout the country.
COPYRIGHT 1991 Association of Labor Assistants & Childbirth Educators
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1991, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Author:El Halta, Valerie
Publication:Special Delivery
Date:Sep 22, 1991
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