Wednesday, December 18, 2013

Course of fetal position changes

What can you expect for your baby's position at any given week in pregnancy?

Before 24 weeks and sometimes to 28 weeks, the baby is often in the transverse lie. The baby floats in the womb and until the head grows heavy with all those baby thoughts, the baby may not be in a vertical lie (up and down) until 6 or even 7 months. Some of these babies then flip breech but most go head down (cephalic).
Sometime between 26 to 28 weeks most breeches flip head down. When a breech baby first goes head down, they almost always settle down on the mothers right side first. 

A common right-sided position for the baby at this stage is called Right Occiput Transverse. In this case, transverse means baby is facing the side since the other word, "occiput" precedes transverse. For some women baby is on the right side only a few days, for others it will be some weeks and maybe their babies never go to the left.

With balance, and the increasing hormones of pregnancy to soften the abdominal muscle fibers, the baby will 
settle Left Occiput Transverse or Left Occiput Anterior. Sometimes it takes labor to make this happen these days. Ideally, baby is in their final position for birth by week 34 of pregnancy.

For the mama with a twist in her lower uterine segment or other pelvic torsion, the baby may not switch to the left without daily body balancing activities and sometimes, needing professional body work to make it happen.
These women are untwisting lower uterine torsion, and increasing balance for the womb and pelvic floor.  Fetal repositioning to a left-sided presentation can happen when the twist unwinds. Keeping the torsion from returning also may take a few daily activities and good maternal body mechanics.

Few people, even providers, know this path of baby positions. Why? Because: 
A.) Fetal position changes are not observable with the eye, 
B.) Fetal position changes don't happen with the same timing or exactly this way for everyone, and 
C.) Flexion and Extension are often not considered to be associated with left and right since there are a few exceptions confusing the picture.  

People, even providers, think much of fetal position and repositioning is random, that babies are head down only because of gravity and often ignore uterine "balance" which effects shape, except in the extreme cases of bicornate uterus or something on the level of variation that can't easily be ignored. They aren't aware of right obliquity, even though it was in the obstetrical literature in the 1800s and before. 

Right obliquity is what makes the baby have 
a long, straight back and lifted chin aiming the top of the head into the pelvis when on the right 
and gives the nice, curved flexion aiming the crown of the head down when on the left. 

"Balance" is what allows the uterus the most room for the baby to move to the left. Gravity would encourage baby to settle on the left whenever, and for as long as, there is room is available for baby to rotate. Uterine surges encourage rotation as labor strengthens when there is enough balance for strong contractions to overcome the slight bit of torsion. The first job of labor is to help baby into the pelvis. See more about Engagement in pregnancy or Engagement in Labor at

Friday, December 13, 2013

Arm first- what is baby's position?

A woman's labor is progressing. The water sac releases amniotic fluid. The midwife/doctor examines the woman's cervix. Suddenly, the plan changes from the "routine miracle" of a second birth to an emergency cesarean. Why? The midwife/doctor finds an elbow coming first. Here's the mother's story with slight edits, including those to conceal her identity: 

My 2nd [baby was] 9 lbs 11oz...emergency c-section.  I had contractions all day and went into the hospital  where my water broke (I had extra water) and baby turned, ended up transverse and they said I was 6 [cm dilated] and wheeled me away...not really a part of my birthing plan and since it was my first surgery...I was scared; My midwife did say once they opened me up with my 2nd they saw baby head down but arm over head. All went well overall though the recovery was MUCH MORE difficult than my previous vaginal [birth].  My question is...once my water there much I can do (as long as everything looks good) to keep this [3rd] baby in position? 

Yes, baby's position can change in labor and even after the water breaks. Fetal position is most commonly determined at 34 weeks and we know that maternal exercises, positioning and sometimes body work can be used to improve fetal position when necessary.  Even after  the water breaks.

Baby's position responds to the shape of the uterus and variations in the shape of the uterus that might alter a baby's position is most often determined by tense and loose ligaments and muscles supporting the uterus and pelvis. Read that twice. The soft tissues determine baby's position and the bony pelvis determines whether the position matters to how the baby is born. 

Having an arm present first is a clue that baby is lying sideways in the womb. But a clue is a clue and not always the reality.

Transverse lie seems to be a situation where several forward leaning inversions in  36 hours help. But I don't think she had a transverse lie from this description. It was a reasonable assumption.  If I'm wrong, please forgive me. An ultrasound would have been necessary and yet I have seen ultrasounds mis-interpreted in labor after the water had broken thinking a head down baby was coming and a breech came instead an hour later. 

On my website under Baby Positions about transverse on the drop down links. And the instructions on Forward-leaning Inversion (Inversion)  are detailed to tell how to do it and how not to and when not to. Inversions can be appropriate even after the water breaks in some situations, and I would include this one whether baby was transverse lie or had a compound presentation.

I have questions about how she knew the diagnosis of transverse was correct, or did they feel the elbow and assume baby had moved sideways? That is what I assume from the finding after the cesarean.
A compound presentation means a limb is coming along side the head. In the women giving the description above, baby's arm was up by the head and bent so that the elbow was coming first.

A technique to help compound presentation is putting the mother into Knee Chest with the rebozo over the entire bum "shaking the apple tree," as Ina May calls it, would help soften the pelvic floor muscles and buttocks muscles to make room for the baby to descend with contraction surges. 

This second solution for compound presentation and not for a transverse lie. 
A long time will be needed for pushing. Directed pushing is often necessary, meaning a woman is coached to push hard and long. She might pull on a towel or sheet as she pushes. 

The mother above, in my opinion, has an excellent chance of vaginal birth after a previous cesarean (VBAC). My suggestions would include to walk briskly, balance the body with the various balance activities, including Forward-leaning Inversion, and go forward expecting the best. 

If I were her midwife, I would expect a happy, vaginal birth considering the story details shared with me here. I hope she can overcome the curse of the emotional toll of having had an emergency cesarean and be free to be present with her pregnancy today. Present and joyful, she can enjoy her birthing, expecting a lovely VBAC!

Changing the Earth by supporting Birth
