by Alison Ewing
OPEN KNEE-CHEST. From hands and knees position mother lowers head and chest to the floor. Knees should be apart and further back than hips. A bean bag can help the mother to retain this position for 30-45 minutes.
GORILLA STOMP. Have mom stomp up and down stairs to center an oblique baby. This is the same stomp we use to bring down a high baby or stimulate ctx. One of our dads named it the "Gorilla Stomp"- make sure there is a spotter below her on the stairs, flat footed, have her set her feet wide apart and stick her tail out a little. Then she stomps down the stairs one at a time, placing her feet wide and swinging her hips from side to side as though she were trying to hit the sidewall of the staircase. Really heavy footfalls. Do a drop squat at the bottom of the stairs. Stomp up the stairs, again placing her feet wide apart, taking the steps two at a time if she can. Some short moms can't manage that.Do a drop squat at the top. I've seen one or two trips up and down the stairs center a baby perfectly.
DUCK WALKING.OR STOMP STOMP SQUAT. Mum walks flat footed, picking her knees up high with each step. Shakes her tail, like a duck. Squats at end of ctx. Good for getting the humour quotient up.
OLD TIME MIDWIVES PUSH TECHNIQUE. Have a multip try pushing with a contraction or two even if they're only 6 or 7 cm. I had a G5 P3 recently stuck WAY up there in an OP position, and couldn't get the head to descend far enough to spin on the soft tissue even after a long painful time of standing and squatting. One of our older docs suggested I have her push a time or two even though she was 6 cm....you can guess what happened on the next ctx. It sure worked! Ann Shields in Germany
ANN SHIELD'S EPIDURAL TECHNIQUE.( can be used without the epidural) This works well with too heavily epiduralized patients. Sit them absolutely straight up with their legs Indian- style, and tie a sheet or towel onto the birthing bar. Have them rock back and forth from on hip to the other, holding onto the sheet for stabilization (since the bar is usually too far forward to grab onto in this position). I suspect the alternating weight on one acetabulum at a time moves the spines out of direct opposition and gives the head a little more room. Also seems to work well for asynclitism but not as well in either malposition as all fours. Anne shields in Germany.
HANDS AND KNEES. Mum leans forward over a birth ball a chair or the back of the birth bed, if it can be adjusted that way. Put something soft under the mother's knees and help her to get as comfortable as possible so that she can stay this way while swaying and rocking her hips or tilting her pelvis through as many ctx as possible.
SHAKIN' THE APPLES. 1) Mom is in hands and knees and she rocks back and forth keeping her back parallel with the floor at all times. 2) You (or her partner or anyone really) sit behind her with your arms extended in front of you with fists made. 3) When mom rocks back she bumps into your fists (which you are holding steady). Your fists hit her at the bottom of her pelvis. She can bump into you as hard as she wants, yet you never go and bump into her. This little 'jolt' also helps to dislodge the OP baby. ilana (who learned this from the wonderful ladies in Alaska)
SLOW DANCING. Mother slow dances with a partner, usually with hands over the partner's shoulders. This enables her to be supported while she sways and circles her hips. Partner can also move mothers hips for her while she hangs from his/her neck.
OLLIE'S TECHNIQUE. Put mum flat on floor with a rolled blanket/pillow in the small of her back to arch her belly out and hyperflex her back. Baby doesn't like and will turn sometimes. Ollie Anne Hamilton, LDEM, CPM
ANOTHER FOR EPIDURAL OPS. On a flat bed, Mom on side (preferably left, but doesn't matter) with lower leg straight and upper leg pulled way up and on a pillow or two (give ample room to tummy). Lower arm behind and upper arm up and over the pillow her head is on. Now lower the head of the bed into shock position (head lower than feet). This give baby lots of room to move, turn and the head-lower-than-feet helps baby disengage from pelvis to make turning easier. Connie Banack
PENNY SIMKIN'S TECHNIQUE. There's a difference between the mechanics of the side lying position and the semi-prone position. If you're recommending which side the mom should lie on to turn her baby from posterior, it matters which of those two positions the mom is using. If the mom is side lying (really on her side, with her legs one on top of the other, and her body perpendicular to the bed) suggest she lie on the side that puts the baby's back "toward the bed". Try this with your doll and model pelvis to see what I mean. Gravity tends to pull the back of the baby's head down toward the bed, so he'll (hopefully) rotate from OP to OT. If the mom is semi-prone (rolled forward so her top leg is in front of her bottom leg, and her belly's more toward the bed) suggest she lie so that the baby's back is "toward the ceiling". Gravity will tend to pull the back of the baby' toward OT, and from there toward OA.
SIMILAR IDEA FROM OB NURSE. When I have a mom who's not bringing the baby down well or who is "stuck" at a certain level of dilation, I routinely turn her to her right side. When I say right side, I mean FAR right--I tell her to try to lay on her stomach! This almost always works to rotate that baby right into an OA position, she progresses and baby descends and delivers. If the baby doesn't tolerate the far right side, I have mom try the far left. It seems the most important part is that she is almost on her stomach. This is especially useful if you have determined that baby is OP
VICKI TAYLOR'S PANCAKE FLIP. Two contractions on left side, two on right side, two on hands and knees, and two in knee-chest. Rarely have I had to do more than two cycles of that to turn a posterior. Turning a posterior with the mom on in an upright position is difficult because you lose the flexibility of the sacrum.
FIGURE EIGHTS/ BELLY DANCING. Mother swinging hips in a figure 8 like a belly dancer.This can also be done to mother on hands and knees with helper moving mother's hips in a figure eight during a contraction. Works well on a birth ball too.
CAT STROKING. Mom should do a couple dozen slow, deep pelvic rocks while on her hands and knees. Really let her tummy hang and exaggerate the movements. Then she gently puts her hand on the baby's back and strokes and clothes" him toward the center of her tummy and even to the other side if the baby turns easily. (Almost always this means mom moves the baby from the right side to the center).
The tummy hanging and the slow deep rocks help the baby move upward so he has more room to turn. And if you move the baby's back then the head will follow. I think mom should do this rather than us, because she knows how much strength to use. I've helped mom stroke sometimes though just to give her the idea of how to do it. Gail Hart Should be done between ctx.
HOT COMPRESSES. Also I have used hot compresses to the lower abdominal muscles to relax them and aid in the repositioning, as the lower uterine segment gets tight.
JUDY JONES' DIAPHRAGMATIC RELEASE. It is easy to recognize a persistent posterior baby. You cannot feel the back on palpation, rather only little lumps and bumps of limbs. To do a diaphragmatic release, it is best to have the mother lie on her back. If she is in advanced pregnancy and this makes her very uncomfortable, you can have her lie in a recliner or semi-sitting position. If you use that position, place a small pillow or adequate support behind her lower back.
One hand will go horizontally across her lower back where the uterine ligaments attach. This is where you would put lower back pressure during labor. You do not need to press, as just the pressure of the mother lying on your hand will be sufficient. (Be sure you take off any rings you may be wearing, for your hand's sake!)
The top hand will go on top of the abdomen, horizontally just above the pubic bone with the thumb upward. Just rest it lightly on the abdomen, no pressure. Then all you have to do is wait. Things may start right away or it may take several minutes before you feel anything. What you will feel is a motion beneath your hands. For the hand in back it will feel much like it does when there is a contraction taking place during labor as you feel the muscles tighten and contract beneath your hand and release. For the top hand it will be either a waving motion or a circular motion under your hand. At first you will think you are just imagining it, but you are not. The best description I can give is that it feels as if the mother has a tennis ball in her abdomen that is being bounced back and forth between your hands. As it hits one hand it will roll across it or around underneath it and then bounce back to the other hand. Sometimes the motion is so great that it will actually make your hand wave on the abdomen. Sometimes the mother will feel things inside, sometimes not. What she feels may not be located where your hand is located. The movement under your top hand may stay all in one place or move around. If it moves, try to gently follow it with your top hand to keep it centrally located under your hand. Do not move the back hand. Sometimes it will move around in a circle, sometimes off to one side, or even clear down to a hip. It all depends on the muscles that are involved and the type of injury that precipitated all the spasm of abdominal muscles. Our muscles really only know how to contract and shorten, not how to relax and lengthen. They depend on another counter muscle to contract and pull the first one out of contraction. Abdominal muscles do not have as many counter muscles, so this technique allows the muscles to relax.
You continue the diaphragmatic release as long as you feel motion under your hand. Usually it will just fade away and you will no longer feel it. Sometimes, if you end up over a bony prominence, it will end with a vibration. The process takes some time, often at least 20-45 minutes. But if you consider the time you save in labor, it is well worth it. You may need to repeat the process over several visits. I usually start at about the 6th month unless I have a mother with a history of car accident or several prior posterior babies. This procedure has also been used this technique to turn breech babies. I use it for transverse but find it less effective for breech. I usually use a tilt board for breech and then do a diaphragmatic release after the baby turns. It works marvelously well for posteriors. I have never done one where the baby did not turn to anterior. However, on some occasions, after a few days the baby will turn back to posterior and you will need to repeat the process more than once. The more severe the history, the more likely you will need to do it several times before the baby will stay anterior.
Posterior babies use to be the worst problem I had in births. The long hard back labors wore us all out and occasionally ended in transfers for maternal exhaustion. I am thrilled not to have these any more. Now my biggest problem is cervical lips! But I am working on a solution for that also, using evening primrose oil!
I do believe every midwife should have this valuable tool, the diaphragmatic release, in her bag of tricks. It is so easy and non-interventive. It is much better than other suggestions I have seen of putting your fingers in the baby's suture lines and trying to turn the head! --Judy Jones
STANDING LUNGE Mother stands with one foot flat on the floor and the other foot at right angles on a foot stool or low chair. She turns her body to face the chair, rests her hands on her leg and leans forward onto that knee during or between ctxs. She may need someone to support her while doing this. The lunge will feel more comfortable in one direction than the other, that is the better way to lean. Do it over several ctxs.
STANDING LUNGE 2 Mother stands with one foot flat on the floor and the other foot at right angles on a foot stool or low chair. She remains facing forward, away from the chair. remaining upright she leans sideways toward the chair lunging so that the knee on the chair bends. Slowly count to 5 then return to upright . The mother should feel the stretching on the inside of both thighs. The lunge will feel more comfortable in one direction than the other, that is the better way to lean. Do it over several ctxs.
KNEELING LUNGE Kneel with one foot flat on the floor lean forward onto the raised knee during ctxs.
SIDE LYING LUNGE. If a woman can't get out of bed because of hypertension or because she has had an epidural, I have had great results with a side-lying lunge. Mom lies on one side with three or four pillows stacked in front of her tummy. Her top knee is bent and placed on top of the pillows at as strong an angle as she can stand. Her lower leg is kept straight and angled back on the bed as far as she can stand. She'll look like a hurdler lying down. Turning from side to side about every half hour, repeating the position, is very effective. The nurses in our area hospitals are starting to use this position because they've seen how well it works. -Marla Lukes, certified doula, Minneapolis, MN
TOILET SITTING. Sitting on the toilet for a few ctx can turn a baby as the mother has been acculturated to let go of the pelvic muscles since toddler hood. Make her comfortable with a chair stacked with pillows or with a pillow over the back to encourage forward leaning position. Alternatively she can sit facing backwards with pillows to keep her comfy.
ANOTHER FOR SUPINE MUMS. To rotate an occipitoposterior baby, put the mother on her side in Trendelenburg's position (supine on a table which is tilted head downward 45 degrees or less). The first time I tried it, the baby rotated and delivered quickly. It probably gets the baby's head "unstuck" from the birth canal and helps it rotate easier. Most mothers can tolerate this position better than knee-chest, and it seems to work better. We put a large wedge under the mattress of the bed. A beanbag could also work. Margie Riley, Midwifery Today Issue 46
WALCHER'S POSITION. Some moms with a posterior baby seem to instinctively arch their backs once they begin pushing. This probably pulls the sacrum away from the occiput and opens up the pelvis a bit more. The following trick for helping a mom arch her back: Take a towel or blanket and roll it up. Have the mom lie flat on her back with the small of her back directly over the rolled-up towel. Her back will be arched pretty steeply. She needs to stay there through at least three contractions, maybe more. Some women find this very uncomfortable, but some women find it feels better or that the pressure on the sacrum feels great.
TUMMY TUCK or BELLY LIFTING. The mother stands with her feet apart and her hands tucked under her belly. When the contraction starts she bends her knees, thrusts forward her hips (pelvic tilt) and lifts up her belly by pressing inward and upward with her hands. The belly lifting can be done by someone else, but I prefer to support the mother from behind while she does it. When a mum has an OP baby it feels great to do this trick. When this was what she needed labour can progress very quickly . What I like about it is that it is something the mothers can do for themselves.
ROBOZO TECHNIQUE. The shawl ( long rectangular) is laid open horizontally (east/west) on the floor and mom lies vertically (north south) in the middle of the shawl; the rest of the shawl spreads out equally on both sides of the mother. The width of the shawl should reach ~ from the middle of mom's back to just below her butt. The midwife and her assistant, or another midwife, stand on opposites sides of the mom and lift up their end of the robozo. Mom's hips at this point, are cradled about a foot off the ground. Her feet are still on the floor. The midwives then get a rhythm of gently pulling the robozo upwards and back and forth between them--it reminds me of a see saw . They count off maybe two or three "rocks," and then one of the midwifes will give a sharper and higher pull which makes mom's stomach kind of "lurch" to the opposite side. This is done 2-3 times and heart tones taken. If baby is say, ROP, the midwife on the mom's right hand side will do the "lurch tug" until baby is approaching an anterior position. Some midwives will stop at this point and have mom labor for about an hour on her side to get the baby to complete its rotation OR they will continue to use the robozo until baby is anterior.
ROBOZO PICTURES. http://www.mother-care.ca/rebozo.htm
STERILE WATER PAPULES. NON PHARMACOLOGICAL PAIN RELIEF. http://www2.coastalnet.com/~coyotemidwife/SWP_PAPE.htm
OLD TIME DOC'S TECHNIQUE Here is the technique, as described, only slightly abbreviated. He uses the rectal rather than the vaginal approach for 2 reasons: 1) it is (he states) easier to appreciate the posterior fontanel rectally 2) it does not require the membranes to be ruptured nor will it accidentally rupture an intact bag.
1. The patient lie on her back in an ordinary bed. 2. The doctor stands on the patient's right and a nurse on her left. 3. Inhalation analgesia (Trilene in this case) is administered. 4. Using his right index finger, the doctor, by means of a rectal examination, located the posterior fontanel. 5. The patient was then rolled over to her left side by the nurse, the operator meanwhile keeping his finger constantly in contact with the posterior fontanelle. 6. The docotr performed two (bimanual) movements simultaneously while the mother was being turned over to her left side by the nurse. a) he exerted pressure upon the baby's anterior (left) shoulder with his left thumb to cause the shoulder to roll forwards from right to left clockwise (if one was looking up at the maternal pelvis from below). b) the right index finger of the accoucheur.....exerted light tangential pressure at the posterior fontanelle to guide the foetal occiput round from the 7 o'clock position to the 12 o'clock position, the manipulation being very similar in force and direction as that used in
a telephone; it is quite as quickly and smoothly completed as that. The movement of the patient's body, combined with the two simultaneous light movements of the accoucher's hands on its body and head, easily and gently rotated the foetus.....the description takes far longer to read than to perform." he also notes that this does not require full dilation of the cervix to perform.
VALERIE EL HALTA (very short version). Put her in knee-chest at 2 cm with her head to the side on a pillow and keep her there for 20 minutes to a half hour, making sure her belly is away from her knees enough to allow the baby to float out of the pelvis. Get your fingers in there and apply pressure to the baby's head until it turns. Once in position, break her BOW so the head will stay. If it doesn't work the first time, keep trying after a rest.
V E H"S TECHNIQUE V. LONG (slightly edited).
Posterior Presentation - a pain in the back
By VALERIE EL HALTA The Birth Center Valerie El Halta is a Certified Professional Midwife with NARM (North American Registry of midwives). She has been practicing midwifery for 20 years and has helped birth over 2,500 babies. She is co-director of the Birth Center in Dearborn, Michigan.
Assisting in Anterior Rotation Prenatally: 1) Have the mother do the "pelvic rock" exercise at least three times a day. 2) She may assume a knee-chest position for twenty minutes, three times a day. 3) Have the mother lie on a slant board (as with a breech position) several times a day for thirty minutes at a time. 4) Have the mother take warm baths and gently encourage her baby to "roll over". We have found it very effective for the mother to visualize her baby in the correct position and to talk to her baby, telling it to move as well. One time we had a particularly stubborn baby, who liked the way he was lying just fine. The mother had suffered with previous posterior labour 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 over, baby!" and he did.
Assisting Anterior Rotation During Labour: 1) When it is verified that the baby is in a posterior position, the first thing that I do is 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 well if she is not in advanced labour. We make sure that she is well-supported by lots of pillows and giver her lots of encouragement and emotional support. Often, while in the knee-chest position the contractions 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 the 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!
If labour is more advanced when the posterior is identified, say 4-5 cm, if 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 to anterior. If the posterior has not been discovered until complete dilation, or if the above methods have not been applied in early labour, the baby's head may still be turned to make delivery more likely. Again, placing the mother in the knee-chest position, with knees slightly apart, the midwife may place her hand into the woman's vagina (remember, your hand is smaller than the baby's head!). Attempt to lift the head up by grasping the head firmly, waiting for a contraction and turning the baby into an anterior position. As soon as the head is corrected, hold on tight and when the uterus contracts again, urge the mother to push very hard! If the amniotic sac has not previously ruptured, rupture it now. This will assure that the position remains fixed and the baby will usually be born very rapidly. This procedure is both safe and sane, yet it must be acknowledged that it will take some physical strength to turn this recalcitrant little head against the force of a good contraction.