Episode 120 - Preparing for posterior labour
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey. Hello Rebels and welcome to this week's episode of the Great Birth Rebellion which is all about how to prepare for a posterior labour and birth but really.
[0:33] If you're preparing for a posterior labor and birth, you're preparing for any birth. So even if you're not anticipating that you're going to have a posterior labor, this episode is going to be helpful for you. And in order to keep this podcast free for you, our listeners, I want to take a moment to thank today's sponsor, Arielle from Bliss Birth. This is a great resource for anyone planning a physiological birth because Bliss Birth offers TENS machine hire, which are popular for providing a drug-free tool during labour.
[1:08] Ariel, the founder and mum of two, offers obstetric-grade TENS machines for hire across Australia. TENS, which is short for transcutaneous electrical nerve stimulation, TENS, uses gentle pulses delivered through pads that stick to your lower back. And these pulses may help ease discomfort by influencing your body's pain pathways while also encouraging the release of endorphins. And purchasing a TENS machine can be pricey, but you can rent one with everything you need for birth through Bliss Birth at a much lower cost. Plus, Arielle is offering a special discount for our listeners, so use code BIRTHREBEL at the checkout and just head over to blissbirth.com.au to reserve yours. All the details will be in the show notes. Let's get on to today's episode. Welcome everybody, let's talk about posterior labour and birth, where I'll be talking about how to prepare for a posterior labour. There's going to be some really practical tips for anyone to use during labor any kind of labor, but we'll also make sure you are prepared for a posterior labor because you never know if you are going to experience a posterior labor and so being prepared is the only way to feel capable of managing it if it happens to you.
[2:29] So essentially, if you are prepared for a posterior labor, then you are prepared for labor full stop. So today we are going to firstly discuss what is posterior labor, about the clinical and health consequences of posterior positioning. Discuss the type of labor you might expect if your baby is in a posterior position. And then give some practical strategies that you can employ to work with a posterior labor. Let's get into it. So firstly, what is posterior labour? So posterior labour is not really very descriptive in itself. So let me explain what I mean and what your care provider might mean when they're talking about a posterior labour. So a posterior labour, some people might call it back labour, or they say your baby is posterior. And they'll say that if what's happening is firstly, you're in labour. And secondly that the baby is in an occiput posterior position or OP position and an OP or occiput posterior position means that that bone on the back of the baby's head the occiput so if you run your hand up your neck vertebrae.
[3:45] And the first bone that you meet when you get to your skull if you clasp the bottom the back of your head that is considered the occipital area or the occipital bone on your baby and if the baby's head is flexed forward so it's chin it's on his chest and bent all the way forward and you run your hand up your neck once you get to the top that flat section you meet is the occipital occipital bone which becomes the back of the baby's head when it's flexed downwards.
[4:14] So occipital posterior means that the occiput of the baby is in a posterior position in relation to the woman's body and pelvis. So the front of the woman's body would be her anterior part, that's her belly. So if she's standing in front of you and you can see her beautiful round pregnant belly you're looking at the front or the anterior part of her and the posterior would be her back. So occipital posterior position explains that the occipital bone of the baby, the back of the baby's head, is facing the back of the woman's body or pelvis. So the baby's back is against the woman's back. And the baby is facing out to its mama's belly button or pubic hair. And in an occipital posterior position or an OP position, the baby is head down, not bum down. Which is why we use the occiput as the marker on the baby who is posterior. And not the sacrum or the romp. So that was a long way of explaining that a posterior labor is a labor where the baby's occiput is in a posterior position in relation to its mother. And if that was too confusing, just imagine the baby upside down, head down, with its back against its mother's back and it's looking forward to its mother's belly button. And sometimes you might hear women say that they had a back labor as a more sort of slang way of describing this. And they're probably explaining that their baby was in an OP position during labor.
[5:44] This explanation really can be better with some visual aids. And I've included some helpful YouTube videos and links and visual resources in the resource folder, which is completely free to anyone who's on the podcast mailing list. And you'll see a link in the show notes. If you want to join the mailing list, then you get a link to the resource folder and you'll be able to look into this more thoroughly. And so what are the clinical and health consequences of a baby in an OP position during labor? So what does it matter if a baby is in a posterior position instead of an anterior position? So firstly, episode 118 has some great information on the implications of OP labor, but I'm going to go over some things as well.
[6:33] And this episode took me so long to write because of the amount of information that I could have brought to this and the differing opinions and research based on what we do for women in labour. So I'm really cautious about where to start and there's so much to say and I'm torn about what to talk about because so much of the consequences of having an OP baby during labour are because so many of the issues that arise with posterior labors are quite possibly the result of your care provider and selected place of birth being unprepared or unaware of how to care for a woman whose baby is in a posterior position. And so the actions of your care provider and the policies and restrictions of the facility that you're giving birth in start to impact on the course and then also the outcomes of your labor and birth independent of what your body was going to do.
[7:35] So what we know is that statistically speaking, the outcomes for posterior labors are different to labors where the baby is in an anterior position. But is that because posterior labor itself presents some inherent complicating factors or is your care provider under experienced and frightened by posterior labor and unable to care for you in an individualized way in the place where they work? So we have to acknowledge that hospital policies put restrictions and limitations on what women can do or what they're allowed, in inverted commas, to do in labour when they're in hospital. And unfortunately, the care providers who work in hospitals become restricted in their practice as well because of the hospital policy and culture.
[8:29] So what I'm going to suggest actually is that the place in which you give birth to your posterior baby could have more of an impact on the outcomes of your labor than anything else. So I'm suggesting that posterior labor itself is not inherently a risk factor for things going wrong, although some posterior labors, just like anterior labors, will have complications. Let's just entertain the possibility that posterior labors are potentially different to anterior labors. And because of that, the hospital system is not prepared to deal with that. And therefore, you're exposed to more interventions and therefore more complications. Just going to leave that there, floating the idea. You can see why this was a really tricky episode to write. So to discuss what the implications are of a posterior baby, Let me start by explaining the rotation that the baby goes through as it makes its way out of your uterus into your pelvis and out your vagina in order to be born.
[9:34] And what we've come to understand as a normal or most usual rotation is that the baby spins around on its head like a break dancer with the aim of rotating its back towards the front of your belly. So its occiput, the back of its head and spine are pressed up against the mother's belly and its face is looking in the direction of its mother's spine. And this is called an anterior position.
[10:01] And one of the actions of contractions in labor is to motivate the baby to rotate into an anterior position because it's believed that in an anterior position the baby will experience the most efficient labor and birth with regards to time and the pattern of contractions that we've become accustomed to as maternity care providers now i myself am guilty of explaining the anterior position as a good position. So in inverted commas, good position in pregnancy. You know, when you feel a woman's belly and if they're getting close to their approximate due date, saying things like, oh, your baby's in a good position for labor.
[10:42] Because in the mind of a midwife and other care providers, we're thinking, oh, good. The baby's already done that rotation around to the front. And maybe the woman's body has less work to do during labor to position the baby ready to descend through the pelvis. And I'm telling you this because this is the line of thinking that might be in the mind of your care provider when they're assessing the position of the baby before or during labor. So in the mind of a midwife or obstetrician, it does have a relieving feeling to know that a baby is in an anterior position, but that is a product of our conditioning and training around fetal positions. So more on that later, but just so you know, it's really easy for care providers to fall into that trap of believing that an anterior position is better than a posterior position for various reasons, mostly our training and cultural understandings around the impact of a posterior labor. But as you'll see on the Great Birth Rebellion, we are rebelling against culture-based care and focusing on evidence-based care and what we know from birth from women.
[11:54] And from history. So what are the clinical and health consequences of a baby in an OP position during labor? And I just really want to highlight that it's entirely possible that there is nothing wrong with your baby or your body, and that your labor is actually not pathological when your baby is in a posterior position, but the outcomes could be a result of the actions and decisions of your care provider and lead to a cascade of interventions rather than an inherent risk associated with posteriorly positioned babies. Having said that, I'm a home birth midwife and I have seen my fair share of posterior labours and a number of them have not gone well and required transfer into hospital. And so I'm also not suggesting that posterior labour is so normal that we need ignore it. So this is the nuance in this conversation. And I know home birth midwives and hospital midwives would all have stories about times when posterior labours didn't go well. And I just want to acknowledge that there is a really broad range of ways that we.
[13:09] What might you expect if your baby is posterior? Firstly, it's thought that posterior labours take longer.
[13:18] So from the time you start labouring till the end, it's considered a longer journey and it's potentially because of that further rotation that the baby has to do. And so if the baby's got a 180 degree turn to do, it could take a lot longer than if there's a 45 degree turn to do. Now the problem with this is that the hospital system has a really heavy focus on time and so if it's perceived that either through a delay in dilation of your cervix or the length of time you've actually been in labor is unusual then you might get a diagnosis of failure to progress or what I like to call failure to wait and this is where the pressure from the system comes to accept things like artificial rupture of membranes where they break your waters before they're ready or induction of labor with a medication with an artificial oxytocin so it could be syntocin or opitocin that depending on where you are but also with longer labors if your care provider is telling you yep nope you are not progressing if they've done a vaginal exam and they tell you that your cervix isn't opening at the pace in which they believe is normal then women start to get despondent and frustrated feeling like they're laboring and laboring and nothing's happening.
[14:41] And so really, we don't know exactly if posterior labors take longer than anterior labors. In fact, that has not really been studied. There's some evidence that the cervix dilates differently in a posterior labor, and that's unfamiliar to your care providers. And perhaps the labor doesn't take longer. It's just a different time frame for the cervix to dilate. And because of this, if women do accept induction of labor and then labor gets stronger, of course, as it does with induction of labor, that's the idea, women might then opt for an epidural. So you can see how this cascade of interventions can take over if the pattern of labor is different to what a medical system would consider to be normal, inverted commas, normal. So normally, culturally, in our Western maternity care systems.
[15:40] It's expected that your cervix will dilate in a linear fashion and not have plateaus and slow down and speed up. It's also expected that your labour pattern will have a regularity. So care providers talk about contractions being gradually getting closer together and gradually getting stronger and longer. But if you have a posterior baby, that contraction pattern can look different. You might get a really big, strong contraction that lasts for ages and it's really strong and it's really long. And then it might be followed by a little one that's not so bad and that time period might be inconsistent. And so that kind of labor pattern does not fit the normal parameters of labor progress that most care providers have been trained to recognize as normal labor. And so it doesn't make sense in a medical mind because we are trained to assume a particular pattern of labor is normal and anything that deviates from that is considered abnormal.
[16:40] But that's not necessarily true. It's just their perspective. I mean, I have a little bit of a theory as to why a woman's body might throw out those different types of contractions with the posterior labor. And I think part of the intention of the contractions is to rotate the baby down into the woman's pelvis in a position that it's going to come out in. And so if the baby's posterior, I think the body kind of knows what kind of pressure and power to apply to that baby in order to achieve a successful rotation down into the pelvis and out of the woman's body. So a posterior labour pattern can be different but.
[17:20] Not necessarily pathological, but it is in the eyes of a medically trained person. The next thing that can happen is actually a different part of the baby's head is putting pressure on the cervix and on the bag of waters than if the baby was in an anterior position.
[17:38] And sometimes, not all the time, but a baby in a posterior can also have what we call a deflexed head. So the ideal position for a baby to come down and through the pelvis is for it to have a flexed head which means that the baby's head is really pushed forward and down its chin is sitting on its chest and it's really got its head tucked in and down like it was doing a forward roll and that means the smallest part of the baby's head is traversing the pelvis and doing that rotation that's not always the case with with a baby in a posterior labor and so you might find that your waters break earlier in labor or in pre-labor before you've even started labor, pre-labor rupture of membranes or early labor rupture of membranes. And so there's a longer duration of your waters being broken in labor. And then paired with the thought and fear that posterior labors can take longer, and then if you've got an induction going, or if your labor pattern doesn't fit normal parameters those three things also put you at risk of an increasing number of vaginal exams from your care provider who's going to be super curious about the cervix and how it's dilating and if you're progressing in labor again this is not based on research but this is what you're going to be exposed to if you've got a care provider in in hospital system.
[19:07] And so paired with having ruptured membranes and an increased number of vaginal examinations, you actually may be at higher risk of a uterine infection for yourself. Because the more vaginal exams you receive, the increased risk there is of an infection in your uterus. And certainly that shows in the stats that women who have posterior labors are at increased risk of a uterine infection. Now, I don't think that is because of posterior labor. I think that's because of how clinicians care for women who are experiencing a posterior labour. So that is a medically caused infection and side effect. So just know that if you have a posterior labour and it's taking a bit longer and the pattern is a bit different to what your care providers used to and your orders are broken, all of those things are going to predispose you to more vaginal examinations, which is going to open you up to the risk of an infection.
[20:05] Not saying it's right, just saying that's what could happen. The next thing that could happen is that you could experience more discomfort and pain during your labour contractions. This could be in your back, in your legs, other places.
[20:22] This is contentious, can I just say. And we've heard from Sarah Langford in episode 118 about women's experiences of posterior labour. And in fact, we've never formally asked women what their experience of posterior labour was like. So we're making all these assumptions based on midwives' stories and of passing down of stories about posterior labour. Maybe they're absolutely correct and the historical passing down of knowledge has been accurate. It, but Sarah's work is going to be the first work to actually hear it from women and to understand their experience of a posterior labour. So it can be more uncomfortable, but again, that's in comparison to an anterior labour. So it's not always going to be uncomfortable, but if you're prepared for it, then you'll have a lot more tools and we'll talk about that as we go down. The challenge here is if you do have back or leg pain during your labour, that in hospital there's only a certain number of things they can do to help you relieve pain. Many of them are pharmacological and medicine-based tools.
[21:39] So what they find is that women who have posterior labours are more likely to opt for or require or request epidural pain relief or pharmacological pain relief. Now this opens up another issue.
[21:54] When you have an epidural... The integrity and structure of your pelvic floor muscles or the pelvic bowl change part of the role of the pelvic bowl is to flex your baby's head as it descends through the pelvis and we just talked about how sometimes with babies that are posterior positioned they have a deflexed head which means they're more likely to be looking up and their chin isn't bent down deep into the baby's chest. And so a big part of the baby getting into a flexed head position is the integrity and function of the pelvic floor. Well, that all changes during an epidural. And so potentially this could open women up for their babies to actually not have the physical capacity or the internal pelvic structures that they need to rotate and turn into an anterior position because they haven't been able to adequately flex their head forward because the pelvic bowl is a different shape than usual. And so where women are more uncomfortable in labor, this not only impacts the women's decision for pain relief, but her care provider needs to be more proactive.
[23:04] More hands-on, more helpful in offering support and options. And one of the challenges for midwives in hospital is that they're time poor and they're expected often to be caring for multiple women at a time. So it's quite impractical in the system for your midwife, unless you've got one that is from a midwifery group practice, or they're not too busy that day, or someone who's really invested in being hands-on and present with you, then it's possible that you're not going to have constant one-to-one uninterrupted access or care from a midwife. And so then women are left kind of floundering.
[23:48] Not knowing how to manage these labor sensations. So a way to prepare would be to either prepare your partner to be really hands-on and aware that this could happen or have a robust friend who you know is going to be able to support you 100% like that or hire a support person like a doula or a birthkeeper, somebody whose only job is to be present with you and assist with these kinds of things. Okay, so as I spoke about how the baby needs to have a flexed head to get through the pelvis adequately, and a deflexed head can be a factor in posterior labors, there's a greater possibility in the posterior labor of the baby entering the pelvis in a way that makes it difficult to be born vaginally. Now, again, I'm not saying that this is inherently caused by the baby or the woman's body, but that potentially we interrupt and interfere with these posterior labors, creating situations where the baby can't adequately descend through the pelvis in the proper flexed way. And that can include epidural, syntocinon, and different approaches to positioning and labor.
[25:02] So this could lead to a diagnosis of what we call deep transverse arrest where the baby's wedged in the woman's pelvis in a way that won't allow it to rotate and come out anteriorly and it gets stuck. A diagnosis of cephalopelvic disproportion where the doctor or whoever's caring for you says that your baby is too big to fit out of your pelvis and this all puts the baby and the woman at increased risk of needing an instrumental extraction, so with forceps or vacuum.
[25:35] Again, I'm not saying that this is normal and a usual part of posterior labor, but potentially this is the end result of the other cascade of intervention. And so as a result, statistically speaking, posterior babies are exposed to more forceps, vacuum extraction, and also cesarean sections as a result of malposition. And again, malposition, everyone's like, no, it's not malposition because posterior is not pathological. Those are the words you might hear though. You might be told your baby is malpositioned. So just be aware. I'm not saying that's what I think. I'm just saying this is what could happen. The words that could be used around your experience. Now next, this is something I've observed at home with babies who are doing a big rotation around in order to get into a position to be born is that the heart rate can look abnormal to what your care provider is expecting. So for me, I've witnessed with women whose babies are rotating and changing position series of a lot of accelerations in labor. So maybe the baby's heart rate is above 160 for a bit longer than you might be comfortable with based on your training.
[26:50] And then some dips and these really unusual patterns on the CTG if you're using a CTG or if you're listening to the fetal heart rate. I don't really know and actually nobody knows by research what a normal fetal heart rate pattern should be, full stop, let alone what a normal heart rate pattern is for a baby who's doing a big rotation if they're rotating around from a posterior position. But what I've observed is babies who are rotating who have been posterior and are coming around and doing those big changes that happen or descending into the pelvis in a posterior position and are actually going to be born posterior instead of anterior and that can happen in about 5% of babies. Consider that that could be just a normal physiological part of a posterior labour but also know that if the CTG or intermittent auscultation.
[27:44] Records a heart rate that your care provider believes is pathological this could also trigger interventions and here's what I'm saying about the increased interventions for posterior babies is are we just getting frightened because it's a different fetal heart rate pattern to what we're told is normal or is there actually something wrong with your baby so just know that if the baby's posterior and if you're a midwife caring for a woman at home who's having a posterior labor know that you might be confronted with these different heart rate patterns than what you're used to and so it's going to require some clinical reasoning and intuitive thought about if this is a result of the baby rotating or if there's something actually going wrong that you need to intervene with. Now the research would say that babies who are posterior during labor or born posterior are in poorer condition after birth and require higher acuity care at special care nurseries and have a longer recovery time and a more chance of injury. So huge disclaimer here.
[28:51] When this research is done and we presented with statistics, again, it's entirely possible that the increase in operative and instrumental births and the increased use of syntocinon and epidurals, which are known to stress babies, there could be an increase of poorer outcomes because of the interventions and not necessarily because of the posterior positioning. But when they presented in the research, they say, posterior baby, this is the outcome. therefore must be posterior baby. They're not necessarily correlating the complications with the whole cascade and sequelae of interventions that occur for babies who are in a posterior position. And also where babies are born by cesarean section and through instrumental births and where labors are considered to be pathological, then there's going to be more people in the room when the baby's born. So there could be an obstetrician, extra midwives, a pediatrician. And when that happens, you increase the medical mindset in the room. And therefore, when the baby's born, the baby's more likely to be getting medically managed after birth care.
[30:07] And that includes rapid cutting of the cord and usually separating the baby from the mother for or a period of time until the care providers are confident that the baby is well on paper, according to them. And so then when we look at the statistics and say babies are born in poorer condition after posterior labors, let's just consider.
[30:31] That this is not a fundamental element of a posteriorly born baby or a posterior labor, but maybe for what we're doing for these women and babies.
[30:42] Okay, I feel like I've just filled you with doom and gloom about posterior birth. And this is why I've been super cautious and spent many hours, many, many more hours preparing this episode than I normally would. And you can have a look at the resource folder as well as to where I got a lot of this information. and the resource folder also allows you to explore a number of perspectives on posterior labour and birth.
[31:13] But what we do know is babies who are in a posterior position during labour or who are born posterior have an increased risk of being born by caesarean section or instrumental birth. Women are at increased risk of severe tears probably because they're at increased risk of instrumental births like forceps and vacuums. And usually there's an episiotomy done with these. There's also an increased risk of induction of labor, what they call maternal exhaustion, epidural use and injury to the baby because of instrumental births. And then as a result, a longer hospital stay and a longer recovery period. So it all sounds very dire for posteriorly positioned babies but there are things that we can do firstly we require a complete mental shift in our beliefs about posterior labors and births because in the system they're managed as pathological in which case you become exposed to a lot more medical management in your labor than if your baby was in an anterior position and I know I'm being generalized there are midwives listening to this now saying I don't do that that's not me maybe it's not you but your workplace is not like you either so you're also an anomaly in your workplace.
[32:35] All right, so now that I've told you all that, let's talk about practical strategies for posterior labour. You could seek to prevent posterior labour in the first place, but actually the research suggests that somewhere between 30% and 50% of babies are actually posterior, either before or at some time during their labour. And that's not surprising because babies rotate through the pelvis and change positions during labor. So let's assume that at any one time, most babies potentially are going to be in a posterior position. And I'm in the camp where posterior labor is not necessarily pathological and a posterior position is not necessarily pathological, but it can become pathological as a result of the positioning. But it also fits outside of the medical definitions of normal as we've been speaking about through the rest of this episode.
[33:36] So although posterior position isn't necessarily a complication women at the very least need to know that if their baby is posterior they're going to be presented with challenges within the system if they want to give birth to that baby physiologically. So I'm not saying we should actively seek to rotate all the babies anteriorly But I do think that we as care providers are responsible for at least informing women that medicalised birthing locations and many care providers will see it as a problem and will pathologise this woman's labour and birth. And it's a little bit of the same reason why some women will choose to try and turn their breech baby's head down, for example.
[34:17] A breech baby can definitely come out vaginally with a skilled care provider who isn't scared of it, but women know that most care providers are scared and don't know what to do in that scenario and that if they present to hospital with a breech baby that they'll be exposed to systematic pressure and limitations to their birthing options and they will more likely than not end up with a cesarean section or a poorly managed vaginal breech birth. And so although breech is not a pathological position, a woman might want to turn her baby because of what might happen to her if she presents to hospital with her baby in that position. So for me, it's the same with posterior position. It's not necessarily pathological, but you have to be aware of what you might be exposed to if your baby is diagnosed as posterior and if the pattern of labour is not following what your hospital service would consider normal and you present there, you might be seen or your labour might be seen as an issue that needs fixing.
[35:23] And so women have a choice. Do I try and turn the baby because of the limitations of the system or do I fight for the support that I'll need for my labour when my baby might persist to be in a posterior position. And I hope the nuance of this has come through well enough through this episode. There's no right or wrong answers here. It's not black or white. It's so vaguely great.
[35:48] So how do we prevent or mitigate the possibility of a posterior position or work with it for the most optimal outcome? That's the question. So firstly, you might not be able to. Your baby might need to come through your pelvis posteriorly. And we can't really know if that's the case until you've actually had multiple babies. If you had three babies and they've all come out or you've labored with a posterior position, maybe that's the way that your babies have to go to traverse your individual body anatomy. Secondly, maybe our bodies are not perfect. And there is something going on in there that has forced the babies to adopt a posterior position. We're certainly more sedentary. We sit down more. We drive more. Our lifestyles are very different. And that has caused changes in how our bodies function. So what if, and I'm not pinning the blame on women here, I know some questions are going to come through and comments are going to come through that I'm blaming women for posterior, but I'm not. I'm just saying what if our pelvic or core muscles have changed along with our lifestyles? And maybe, for example, your psoas muscle that traverses the structures of your pelvis are holding tension and preventing the baby from moving. Or maybe the fascia of our bodies and of our uterine muscles and core muscles and pelvic muscles.
[37:18] Maybe they're in a state. Maybe the bony pelvis is twisted and malaligned.
[37:25] And we spoke to Gal Tully about spinning baby's techniques in episode 115 and also acupressure and acupuncture techniques in episode 116. And these could be helpful tools to deal with these things. If there's something happening in your body that can be corrected and your baby doesn't have to traverse the labor journey in a posterior position, maybe there's something you can do about that. And I also love body work during pregnancy, such as chiropractic and osteopathic adjustments. And we spoke with Liz and Kate in episode 61 about this and the importance of maternal alignment in episode 60. And remembering we also spoke with Felina Hallinan regarding techniques of internal pelvic release work and rebozo techniques in episode 90. So those could be some episodes to help with practical techniques. And I've listed them in the show notes if you want to go back and listen to them. If a posterior position is something that you're worried about, and if you think that maybe there's something going on in your body that you could change and adjust to prevent posterior positioning, these are the episodes that I would suggest listening to. And you know, there's been this old wives or old midwives tale that, you know, women should scrub the floor and maintain forward leaning positions whenever they can when they're sitting to avoid reclining.
[38:50] But honestly the research is not really on the side of this and you can have a look at the resources in the resource folder if you're on the mailing list based on what i've read i would favor sitting comfortably however you want and favor doing lots of varied and functional movements through the day being barefoot or wearing barefoot shoes as a way of encouraging alignment rather than employing these last minute rescue efforts by crawling around on your hands and knees doing housework or leaning forward and not reclining. I think it's missing the point. The other thing you can do to mitigate the possibility of a posterior labour or positioning is to be prepared to avoid an epidural in labour.
[39:39] Knowing that the epidural could actually accentuate the issues around posterior labour because of the impact that it has on the pelvic bowl muscles and it can inhibit the baby from adopting a flexed head position. But if you do need to use it, there is some evidence on side lying with an epidural with a peanut ball between your knees and then flipping from side to side every 20 to 30 minutes. You could try that, it'd be better than lying flat on your back and at the very least will have no impact on the position of your baby but still will allow that movement and an opportunity now if you don't have an epidural on board.
[40:25] Again midwives tails would say use upright forward leaning positions for optimal fetal positioning, But again, that's not where the evidence lies in terms of altering fetal position during labour.
[40:43] So what I'm going to suggest is to just move in a way that feels most comfortable to you. Your body can tell what is the best position and it's usually the one that feels best and easiest to use. So in labour, movement is all part of labour. So we're not supposed to be still. Your body will likely want to use different positions for each contraction and you'll be inspired to move differently as labor goes on. So you might be in one position for resting and another one to work through a contraction.
[41:16] So rather than thinking, oh, I have to walk around or I have to stand up or I have to lean forward, rather than using prescriptive positions during your labor, trying to think which position will rotate my baby. Choose the one that feels easiest for you and is the most relieving and it's probably the same one as will facilitate rotation of your baby. Now I will say that I have worked with women whose babies are in an awkward position and have caused their labors to continue on for a long time and been uncomfortable and we've used kind of these rescue positions, like a head down, bum up position for a period of time. So there are some therapeutic interventions that we can give to try and alter the position of a baby. But just know they're not heavily researched, but I have seen them be effective. So with positioning, I do think it's about experimentation and doing what feels comfortable and just individualizing it for each particular woman, not being too prescriptive with what kind of positioning you're going to use if the baby's in a posterior position.
[42:25] And in fact, if as midwives, if we stop thinking that the whole idea behind helping a woman through posterior labor is to actually rotate the baby and get our mindset more into how what we want to do is actually encourage the baby's head to be in a flexed position, right? So that it can do its own rotation, that might be a more helpful way of thinking about how you can help a woman. And so this really does rely more on the musculature and structure of the pelvic bowl. And the one thing that really changes the function of this is the use of an epidural. So for women who are experiencing posterior labor or an uncomfortable labor or what we would consider an unusual labor pattern, potentially if we take our focus off trying to turn the baby and increase our focus on trying to help them use strategies that are going to avoid an epidural and stay as mobile and active as possible, that's possibly a better solution and a more effective solution than trying to just turn the baby. But if additional pain is part of your labour story, you could also consider sterile water injections. And we did an episode about that with Nigel Lee way back in episode 20.
[43:42] The next thing I would recommend, and as we've seen, the major things that can impact what happens to you while you're experiencing a posterior labour is firstly the place where you choose to give birth, and secondly, your care provider. So if you can, if you know your care provider ahead of time, quiz them about their opinions and feelings about posterior position in labour, and also check if they feel skilled to assist with posterior labor and if they're willing to journey with you through that. Are they comfortable with the physicality that might come with being a midwife for a woman whose labor might be longer and more uncomfortable? Do they have skills such as acupressure, spinning babies, sterile water injections, tools like the TENS machine or some strategies to help with labor comfort like a birth pool and skills in water birth?
[44:36] It's great if you are prepared for posterior labour, but consider what might happen if your care provider is not prepared. So if you have the capacity, and I acknowledge that a lot of people listening to this are not going to have met their care provider ahead of time, but if you do it's worth having this conversation considering how many babies are statistically likely to be posterior at some point in the labor. So you yourself could also have a toolbox of labor management strategies that don't include medication if possible, and that could include the TENS machine, heat packs.
[45:15] Labor supporters who can help massage you and support you and encourage you like a doula or a birth keeper or a robust friend or a well-prepared partner. Make sure you take massage oils have lots of pillows available available birth pool as an option something to hang from like a birth sling all these strategies can help with movement and pain management and that those are the things that are going to give your body and your baby its best opportunity to do whatever it needs to do through your labor in order to birth your baby vaginally.
[45:52] Now, the other thing that the research talks about is something called maternal exhaustion. And that's basically where the woman is getting tired with the labor process, that it's taking a lot out of her. Either she hasn't had a lot of sleep or she's been malnourished and dehydrated by the process. So small, regular sips of fluids, including electrolytes, because not just water, because if you're sweating and working really hard you need an electrolyte balance. In between contractions try and make it so that the room allows for you to rest in between. So labor is this incredible process where you have to do something really hard for a minute, your contraction, and then it fades away as much as possible and you get two or three minutes maybe more of rest period.
[46:46] Now the problem is in hospital and with some care providers they see that as an opportunity to talk to you and interrupt the labor process but those are really important rest times so the rest is as important as the activity and make sure that you are guarding and protecting and using those rest periods and having micro sleeps so potentially have a sign up to say do not disturb have your care providers and your support team be really protective of that rest time. And those are some ways that you can manage maternal exhaustion, what we call maternal exhaustion. Small frequent snacks can also help if you feel like it, but we don't always feel like eating during labor. But those things can be helpful for managing that.
[47:36] Okay, there are so many more things that I want to say about posterior labour, but I realise that I've been speaking to you for the good part of an hour. So that's what I've got to you today on how to prepare for posterior labour and birth. And what I would love is if you have more questions or you want to share your experiences of posterior labour, that this space is actually open to a lot of input from women and people who have actually experienced a posterior labour. There might also be care providers out there who have amazing strategies for assisting women through a posterior labour. And so if you're on Instagram, go to atthegreatbirthrebellion and I'd love to continue the conversation there because I acknowledge that this is a sweeping episode over posterior labour and birth and there's so much more to explore and let's do that together. And I will see you in the next episode. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
This transcript was produced by ai technology and may contain errors.
©2026 Melanie The Midwife
