Posteriority

October 17, 2013 at 4:04 pm

Eight years ago today my second baby came into this world upside down, or “sunny side up” as some people say. And she has indeed been a ray of sunshine in my life.

133 Amber pics 153_edited-1

She was posterior (facing my front side) rather than the normal anterior position (facing my back). Her posteriority (I think I just invented a word!) brought with it some surprises. I had fully expected my second birth to happen very quickly. My sister’s labors were each roughly half as long as the previous. My first daughter’s birth lasted less than six hours, so I was expecting my second to come in less than three! I suspected she might be posterior, however, when that supposed-to-be-fast labor turned into an on-again-off-again roughly 28-hour labor.

Fortunately, for me and my baby, the planets aligned to make our birth experience smooth and uncomplicated. My labor started and stopped every few hours, eventually kicking into full gear after about 26 hours. I arrived at the hospital nearly 6 centimeters dilated and delivered my baby about two hours later. There was no need for forceps or vacuum to get her out, I pushed for less than 20 minutes (it wasn’t until then that my midwife said the p-word and confirmed my suspicions about my baby’s position), and I suffered only a minor tear. My recovery was terrific compared to my previous birth. My first baby was not born posterior, but I suffered extensive tearing followed by a very painful recovery. Ultimately, I succeeded in having a very satisfying unmedicated labor and delivery despite having a posterior baby.

I feel fortunate, because, for some women, having a persistently posterior baby can mean a much more interventive birth experience. A 2005 article in OB/GYN News explains: “Previous epidemiologic studies have estimated the prevalence of the occipitoposterior position to be about 5%. Among such pregnancies, there is a high incidence of cesarean section, instrumental delivery, third- and fourth-degree perineal tear, postpartum hemorrhage, and puerperal infection” (source).

I shudder to think what my experience could have been like. If I had gone to the hospital earlier when my labor was periodically stalling, it is likely I would have been given Pitocin. It’s also likely I would have been pressured to have my membranes ruptured to speed up labor. The contractions produced by the Pitocin would likely have been too painful for me to handle without medication, so I would have likely asked for an epidural. Epidurals can make the pushing stage more challenging for some mothers, and with a posterior baby pushing is already challenging enough. “Epidural is associated with a lower rate of spontaneous vaginal delivery, a higher rate of instrumental vaginal delivery and longer labors” (Source). In fact, epidurals (if placed when the baby is still high in the pelvis) can make it more likely your baby will remain posterior at the time of delivery (see this study).  If I had gone to the hospital too early, it’s highly likely I would have ended up with an instrumental or cesarean delivery. I feel so fortunate to have evaded those outcomes!

I don’t, however, want to villainize epidurals. A friend of mine pushed (unmedicated) for many, many hours with a posterior baby after trying everything imaginable to encourage him to turn. In the end, it was a brief rest with an epidural and a bit of Pitocin that enabled her baby to turn and slide right out. There is a time and place for those interventions, and they can help prevent instrumental and cesarean deliveries in some circumstances. Do what feels right to you!

We often hear that doing baby spinning techniques can help with posterior presentations. I myself have believed that to be true for all of my years as a birth advocate. So I was surprised to learn from Henci Goer’s analysis of the evidence that baby spinning techniques don’t have much evidence to support them. Here are her take home points after examining the research on baby spinning techniques before and during labor:

During pregnancy, before the start of labor: “Prenatal positioning and exercises aimed at preventing OP in labor don’t work. Women should not be advised to do them because they may wrongly blame themselves for not practicing or not practicing enough should they end up with a difficult labor or an operative delivery due to persistent OP.”

After labor begins: “It looks like rupturing membranes may predispose to persistent OP and should be avoided for that reason. The jury is still out on whether a posture that suspends the belly is effective, but it is worth trying in any labor that is progressing slowly because it may help and doesn’t hurt.”

(Source)

I spent most of my posterior labor upright, moving, walking, rocking my pelvis, getting on my hands and knees until I arrived at the hospital and got in the tub. Despite these efforts, my baby remained posterior. Fortunately, most babies find their way into the ideal position on their own either before or during labor. And even if “baby spinning” techniques don’t actually help babies to turn, they are still excellent ways to help labor to progress and ease discomfort for the mother (especially since “back labor” is common with posterior presentations), so they’re still worth using (in my opinion).

Having a posterior baby doesn’t have to mean a horrible birth experience. Henci Goer explains: “We do have one ray of sunshine in the midst of this gloom. Three studies of manual rotation (near or after full dilation, the midwife or doctor uses fingers or a hand to turn the fetus to anterior) report high success rates and concomitant major reductions in cesarean rates” (Source). But even without manual rotation, posterior babies can be born vaginally. I’m grateful my posterior birth went so well.

Have you experienced a posterior presentation during labor and delivery? What was your experience like?