Monday, July 18, 2011

Concerned about Your Baby's Position?

I’m sure there are a million thoughts running through your head right now, hopefully this will address some of them. This discussion will be geared towards a singleton pregnancy, but the ideas can be applied to a multiples pregnancy as well. There are a few notes about multiple positioning towards the middle of the article.

Let's talk first about what happens in the normal pregnancy. Somewhere in the middle of the third trimester baby should be in a head down position. A baby in a head down, butt up position is generally said to be in a vertex presentation. By 32-34 weeks (usually sooner), a baby should have settled down in this vertex position. Some babies shift positions after this time, but the usual pattern is head down, and staying there by that time. Also, baby’s size around that time tends to be such that there is less room to move and prevent future flipping (but not always). (Presentation is a word that you will often hear in reference to baby's position as well - just substitute the word position if that makes more sense for you!). You might hear or see the abbreviation “LOA” – it means Left Occiput Anterior, and it is considered the most ideal birth presentation. If you picture your baby curled up in the fetal position, LOA means that they are on your left side, head down, facing back towards the right buttock. (We'll touch on this more later.)

What does it mean that my baby is breech? In a breech presentation, a baby is presenting butt down, head up. For many reasons, this is not the ideal position for the baby to come through the birth canal. There are different types of breech presentations: A footling breech has feet poised to come out before anything else; A complete breech is tailor-sitting; A frank breech is folded in half, with the butt down and the feet up by the baby's head (it is no doubt as uncomfortable as it sounds, and can lead to hip problems as well); An incomplete breech is somewhere between a complete and a frank breech.

I’ve been told that my baby is lying across my belly. This position, also referred to as a transverse lie, is when your baby is lying parallel to the floor. It is more common in a woman that has already had at least one child, because with each child, the muscular walls of the uterus relax a little bit more (the same reason that second and third pregnancies “show” earlier).

My birth provider is telling me that baby is posterior. The term posterior means towards your back (anterior means towards your belly). With pregnancy, these terms are applied to the position of the baby’s head, specifically, the back of the head called the occiput. If your baby is posterior, it means that they are facing forward, with the back of their head (the occiput) towards the back (posterior) of your body.

I have twins/multiples. With multiples, your birth team is most likely to be concerned about the position of baby A. Baby A is baby that is seated lower in the uterus - the baby that will most likely come out first. If baby A is vertex, and your team is open to multiple vaginal delivery (it will depend on your state/birth location and providers), you will most likely be able to proceed with a vaginal delivery. If baby A is breech or transverse, you will likely be automatically shuttled the planned c-section route.

With any of these positions, your baby is in a less than ideal position for birth. (Note: Except for a transverse lie, it is still possible to birth babies in theses positions vaginally. There are some increased risks over “normal” birth with any abnormal presentation. There is no way to deliver a transverse lie baby vaginally. You should talk with your birth provider about his or her comfort level and policies and procedures with your baby’s presentation. Some providers will never allow a vaginal delivery of a baby that is breech, others will, some may allow a "trial of labor" to see if baby changes positions at the last minute. Every provider will have a different perspective, some of which may be dictated by your birth location (hospital deliveries tend to have the least amount of negotiating room for different presentation from normal). This is one reason why it's great to have a strong supportive birth team in place early on in your pregnancy, so you can be more proactive if things in the pregnancy don't follow the "normal" path.)

It is very important to remember that your baby is already smart and innately taking care of herself. If a baby hasn’t shifted into the best birthing position, there are reasons – some you have control over, but some that you don’t.

Some reasons for a less than ideal fetal position:

-Mom’s pelvis. The shape and position of mom’s pelvis is quite intimately related to the baby’s presentation. Rotation of mom’s pelvis can change the shape of the pelvic inlet (and outlet), or the path that the baby goes through during delivery. If your baby is not settling down into a good birth position, this is usually the most likely culprit.

-Placental position.
The placenta is ideally positioned in the upper part of the uterus, but not always. Sometimes the position of the placenta makes it difficult for a baby to get into an ideal birthing position. While the placenta is pretty flat, it still takes up space, and may be the culprit in a bad birth position as the baby tries to navigate around where it is located.

-Umbilical cord issues. The umbilical cord has an average length of right around 2 feet – however it can be shorter or much longer and still be totally normal. As baby is growing, she is swimming around in the uterus, and it is possible for her to get tangled up in the cord. It is quite common for the cord to be wrapped around body parts at birth, though much less common for the wrapped cord to cause issues. If the cord is short or wrapped just right, the baby will not move in a way to compromise his oxygen and food supply – so he may be remaining in the position because that is best for his survival.

-Uterine anomalies. Fibroids can take up space in the uterus, and they can also change how flexible the uterus is, making certain positions more comfortable than others. The shape of the uterus (such as a bicornate uterus) , as well as its position (tilted in forward or backward) can also affect how baby is positioned within it.

-Fluid levels. If there is an increased amount of amniotic fluid, quite simply, baby just has more room to swim around. She’s enjoying the swim, why stay in one position when she doesn’t have to? If there is a decreased amount of fluid, there is less room to move around in, and baby may be "stuck" in a position less than ideal.

The most common intervention for breech pregnancies in Western Medicine is what's called "External Cephalic Version" or just "version". During a version, a woman is hooked up to a monitor (it is VERY important that the baby is monitored throughout the procedure), and given a muscle relaxer. An OB (and usually a nurse or two helping) will attempt to force the baby into a head down position. Again, during the process, the baby is very closely monitored for stress. If the version works, and baby ends up in a vertex position, a restrictive bandage is placed around the top of mom's belly so that baby doesn't flip back upright. The effectiveness of ECV ranges from 40-70%, although the success rate is most often expressed in the 50-60% range. It is important that it is done later in the pregnancy because if it is done too early, the baby will too frequently spontaneously return to its previous position. Some of the complications of ECV can include placental abruption (where the placenta detaches), fetal distress leading to emergency c-section, and bruising and discomfort for mom, to name a few.

While the baby is monitored for his or her response during a version, ECV doesn't really honor the baby's intelligence. Instead, it imposes the assumed knowledge of the doctor onto the baby. The likelihood of it working can be increased when it is combined with chiropractic care and other methods, but if you decide to go this route, be prepared for the possibility of having an emergency delivery at the time of your appointment!

Being Proactive:
Chiropractic Care and Webster's technique -Webster's technique is designed specifically to deal with what we in Chiropractic call "In-Utero Constraint". As a chiropractor, I'm a huge fan of not only this protocol, but also with the philosophy behind it. Remember where I said earlier that every baby was incredibly smart already? This technique honors that intelligence - we do not force the baby to move into any position, we simply allow the pelvis to be as open as possible, so if the baby can move, it will. It has an extraordinarily high success rate, to boot.

Acupuncture/Moxa - Any acupuncturist can guide you with this. There are both needle insertion and non-insertion techniques with acupuncture, and moxa, or moxabustion, is burning of an herb at certain points to create a certain result. Moxa can be done on your own at home, but I recommend getting instruction from an acupuncturist first so you know exactly what you are doing. One note from Amy Mager, an acupuncturist in Northampton, MA. " Moxa turns babies so it is important to pay attention & stop the moxibustion if you feel big movement and go get the baby's position checked by your birth practitioner."

Inversion -Any position where you head is below your hips is referred to as inversion. You can do a very gentle inversion if you move from a hands and knees position to down on your elbows, remaining on your knees. Any more extreme inversion should never be performed while you are alone - it is very easy to get dizzy and light headed while you are pregnant - and putting your head below the rest of your body increases the instances of that happening. Women are often advised to put an ironing board on stairs, and lie on their backs with their head down at the bottom of the stairs. The problem with this type of inversion is that the weight of the baby, uterus, amniotic fluid and sac are all being forced towards your spine by gravity. So while this position can get a baby up out of your pelvis, it often doesn't allow the freedom of movement that having mom in a forward facing position does. With forward facing positions, kneeling on a couch or a bed, bending forward, and getting assistance to the point where your elbows are on the floor is one option. The height of the couch or bed will dictate how extreme this position is. Another option is doing hand stands while in the water. Again, with anything beyond the gentle inversion, make sure you are not alone! Of course, it's always a good idea to get instruction from someone experienced in these techniques so you know exactly what you are doing.

Hands and knees, pelvic rocking - Getting on your hands and knees, like any forward inversion process described above, allows a baby to float out of the pelvis and could possibly give them more room to turn. Pelvic rocking in a hands and knees position is just like it sounds - you can rock up and down (like the cat/cow yoga move), as well as side to side (think of a puppy dog). All of these moves should feel pretty good - and will give your body a nice stretch in the process. You may find that baby is more active in one position or another, or likes one movement in particular. Stay with those moves - that is your baby telling you something!

Belly dancing - if you know some, that's great! What's more important than actual moves, however is getting your hips moving and flowing back and forth, side to side. Just like with the pelvic rocking on your hands and knees, follow what your baby is telling you! Put some fun music on and dance like no one is watching!

Birth Ball - sitting on a birthing ball and moving your hips around, side to side can be great in opening up the pelvis and help with getting your babe to move around a bit. This is a great alternative to belly dancing if standing or being fully weight bearing is an issue for any reason. Also, getting rid of your usual chair and replacing it with a birthing ball is a good idea.

Positioning yourself
- Certain positions should be avoided, especially towards the end of pregnancy. Positions which tilt the pelvis backwards (like sitting in a lounge chair), and leaning backwards or lying on your back for extended periods are all on that list. Chances are, you're already avoiding that last one anyway. Squatting is a great activity during labor because it opens up the pelvic outlet, and can make getting the baby out easier. However, if your baby is in a less than optimal birth position, squatting will tend to drop them more deeply into the pelvis, which can make it more difficult for them to turn. (Remember that inversion postures work in part because they bring the baby up out of the pelvis where there tends to be more room to turn.)

With all of these procedures, remember that you are opening yourself up to allow baby to do the best for herself. The point is not to force what you think is best onto baby's position - it's to open yourself up, and allow the baby the most room possible to move as he or she knows is best. Use your time in any of these positions to foster the connection with your baby that already exists. Spend time in meditation, and most of all, honor what your baby is doing. Honor the innate intelligence already at work inside that little body. That innate intelligence is already doing what it will do throughout your baby's life - adapting and promoting life.

Keep in mind that the baby is in the position he or she is in for a reason. Sometimes we find out those reasons, sometimes we don't. The hardest place to find can be that of acceptance when we don't know the reasons. Even when you don't know the reason, your baby's intelligence does. When you find that place, whatever happens, you will also find a peaceful acceptance for the outcome.

Some online resources:

ICPA - this is the website of the International Chiropractic Pediatric association, and it is full of great information (I recommend bookmarking the page, as you'll find yourself referencing it both before and after childbirth). There is a search feature that you can use to find a Chiropractor near you that specializes in working with pregnant women and infants and children, and who may be certified in the Webster Technique.

Spinning Babies - this website is full of great information, some of which I've shared above. It is not the easiest site to navigate, however, so don't go there when you're tired or short on patience!