What Would Have Happened?

I think I am posting an unanswerable question here but nothing ventured, nothing gained!

Last time I had a hospital birth which I was quite happy with because I'd done lots of reading and worked out my preferences/priorities beforehand. As it turned out, I used pain management techniques until I was about 7cm, then had an epidural, then pushed for more than two hours then forceps.

As it was a posterior labour, I figure that next time if the baby is not posterior, and with the help of a doula, there's a good chance I'll be able to manage drug-free.

I'm also weighing up the pros and cons of a homebirth but want to know what would happen if the baby got 'stuck' as happened last time? Presumably, after a certain point, I would just transfer to hospital?

I know also that I should have been doing lots of stuff to persuade my posterior bub to get into a better position but, what if that didn't work?

Fiona

I'm not sure if having one posterior bubs means a higher risk of having another one or if it is independent of one another. I guess it would be your responsibility to advise the midwife delivering at home with you about your past and they will either advise you against having a home birth or they will have a hospital possibly on standby in case somethng was to happen??? Good question.

Hi Fiona,

I think that most babies would rotate prior to being born. The epidural you had, and as such the immobility, would have affected the baby being able to get into the optimum position for birth. At home, you won't have an epidural or drugs which limit your mobility so will likely not strike that problem again. Posterior is just a variation of normal, it's not an emergency and just because one bub was posterior doesn't mean your next one would be. Hope that helps.

Fiona my first DS was posterior also and I ended up with a vacuum extraction as well as an epsiotomy(sp). My second DS was also posterior but because he was my second I actually birthed him posterior as he didn't turn and all I used was gas, so it is possible to birth posterior bubs, with a bit of back pain tho.

Also if you have a homebirth, I'm sure the midwife would be able to get you in to a position where bubs wouldn't get stuck, but in that event if it happened then I'm sure that you would be rushed to hospital.

I hope that I've helped some.

hugs xoxo

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Hi Fiona,

I think that most babies would rotate prior to being born. The epidural you had, and as such the immobility, would have affected the baby being able to get into the optimum position for birth. At home, you won't have an epidural or drugs which limit your mobility so will likely not strike that problem again. Posterior is just a variation of normal, it's not an emergency and just because one bub was posterior doesn't mean your next one would be. Hope that helps.

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I think so too.
I have a friend in Canada who has birthed all her babies at home, and they have all been posterior. No dramas at all ;)

It is entirely possible to give birth to a posterior baby. In fact, there are some advantages to undergoing a posterior labour at home.

Posterior labours will last longer, because the position the bub is in means it takes logner for them to descend. In a home birth situation, you are comfortable, there are no time limits as long you and the baby remain healthy, and you and the baby will remain healthy for longer because you are able to eat, drink, and rest as you need to. As a result, it is possible to have a long and gentle labour, which is what many posterior babies need to gradually move down the birth canal and be born.

You are also free to move around at a homebirth in a way that, even in the most natural of hospital births, you are not. Homebirth midwives are adept at monitoreing your progress and the condition of your baby unobtrusively, and do not interrupt you when you are in the flow of your labour. That mobility, and the opportunity to really focus on your labour, can help during a posterior bath.

And finally - water, water, water! Posteroir labours often involve strong back pain. Homebirth and waterbirth often gpo hand-in-hand, and even if you're not planning a waterbirth, you still have a shower or bath at your disposal without having to share it with other women. Many women find water fantastic for back pain.

And to answer the crux of your question - the unlikely secnario that what, if despite all of this, you did not progress? Your homebirth midwife will be experienced and will be able to continuously monitor and assess your health, and the health of the baby. They will ensure that, if either you or the baby are getting too tired, that you are transferred to your booking-in hospital in adequate time to allow for any necessary interventions.

Hope this answers your question.

A study that came out recently showed that epidurals resulted in more posterior bubs so if you had a possie baby and an epi I guess it wouldn't have helped much more... but possie babies are completely birthable as schmickers said.

My 10 pound posterior baba was born at home in water with me in an upright postition. She turned into an anterior position, after 2 hours of labour and then just flew out like a bunjee jumper, no second stage at all. I was at home so no chance of drugs which I am so glad about, because the posterior position was more painful than either of my other 2 labours.

I also think that if you employed a independent midwife, they would be talking to you about optimal positioning well before your due date to try and avoid any of that if possible. I am constantly amazed how often I hear about people going through the hosp system that get no information on the subject :(

Also, as for bubs getting stuck, My grandparents next door neighbours birthed at home (in a rural town) and her bub got stuck (I think mild shoulder dystocia) but the midwife was able to make suggestions and help manage the situation and everything was fine. I have heard about midwives in BC's managing this too without the need for medical intervention.

Are private middies equipped with emergency gear? Like forceps? I know they carry oxygen...

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Are private middies equipped with emergency gear? Like forceps? I know they carry oxygen...

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Independently Practicing Midwives carry emergency equipment that enables them to get IV access, administer emergency drugs, such as syntocinon, and give emergency fluids in the event of a haemorrhage. They also carry oxygen, in case the baby needs oxygen support when they are born, and resuscitation equipment.

Midwives do not carry forceps because using forceps is a surgical procedure, and is performed by an obstetrician who is trained in their use. But more to the point, an independently practicing midwife is trained to recognise a situation developing where intervention, such as forceps may be necessary, and do one of two things - either manage the situation to prevent the complication, through repositioning the mother, the use of aromatherapy, relaxation or visualisation techniques, water for pain relief, or a myriad of other natural techniques, or much more rarely, determine that the situation cannot be managed at home and arrange for your transfer to hospital.

Some women may feel, after previous birth experiences, that such emergencies come on in a matter of minutes and need immediate attention. In actual fact, this is not the case; birth complications are preceded by many warning signs, and an independently practicing midwife, as part of her job, will be constantly communicating with you and your chosen birth partner(s) to appraise you of your progress. This is quite different to a hospital birth where you do not have that rapport with your midwife, and as a result they often do not communicate their concerns or worries with you until the last minute, thus giving the impression that it all fell to pieces in a matter of seconds or minutes.

When a baby's head is descending the tone of the deep pelvic floor muscles help it to turn correctly into the birth canal. My early labour was posterior, but DD turned before descending. Even when babies are born face-up, still in the same OP position, the deep pelvic muscles do much to ease the head down and through the bones. When we have an epidural the tone of those muscles is greatly diminished and they cannot help the baby to turn as well - these are not the muscles at the vaginal opening but the ones higher up, inside, round the cervix. As a result of this one can suffer "deep transverse arrest" where the head is coming though the pelvic bones at the wrong angle and becomes stuck. In this situation forceps are often used to turn the head and then deliver the baby.

As others have said, without the epidural this is very unlikely to happen. You'll be able to move freely and push more efficiently if you can feel it all.

There's no reason to think the next bubs will also be posterior. Have you looked at Spinning Babies website? There are lots of tips on how to help bubs move and there's always moxibustion and acupuncture too. And if, after trying all these things, baby stays posterior, you can go into labour knowing bubs is in the best position for him/her. Babies ar smart and will always try to come out the easiest way - if baby's had every opportunity to shift and has stayed OP then that must be the best way for them to come.

I think my (UK NHS) midwives would allow one to push for 2 hours with no progress or until i asked to transfer (whichever was first) before suggesting going into hospital. They also keep you moving and changing positions to try to help "unstick" bubs if progress is slowed. Crawling on the floor is incredibly effective at unsticking babies apparently!

Bec

My first was posterior and ended up being forceps (I didn't have an epi) but my 2 babies after that were not posterior and didn't need forceps.

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The epidural you had, and as such the immobility, would have affected the baby being able to get into the optimum position for birth.

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I didn't have an epidural or pain relief to speak of (gas - hah! does nothing at 9cm LOL) but towards the end was buggered and had given up so was on syntocin to assist with pushing stage. So I was in the dumbest of positions - on my back, legs in the air, no room for pelvis to open and no gravity to assist my posterior bubba. Still managed to get him out without assistance, so I can only IMAGINE how much easier even a difficult presentation would be with better positioning and a midwife's (rather than OB's) assistance.....

And ditto what everyone else has said (thanks for the info on posterior births Michael, the more I read puts my son's birth into an informed perspective).

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(thanks for the info on posterior births Michael, the more I read puts my son's birth into an informed perspective).

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Ditto!

My Mum had my sister at home and she was a 10 pound posterior baby. I don't think posterior automatically means you need forceps or anything.

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And ditto what everyone else has said (thanks for the info on posterior births Michael, the more I read puts my son's birth into an informed perspective).

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My pleasure. Posterior births are just a variation along a spectrum of natural birth. Posterior births aren't even considered "high risk", although there is no doubt that they are certainly hard work.

Hi guys

Thanks for all your responses.

Hoobley - I'll be reading the Spinning Babies website religiously next time around!

Michael - I don't think I could have coped with a slower labour LOL - I had 72 hours of pre-labour and went into established labour having had 7 hours sleep in 3 days so that was the main reason I had the epidural. I'm not saying the pain wasn't a factor (!) but basically I wanted a rest. Plus I'd had an unstable pelvis since week 28 and 3 months later it's still ouchy so I regard that 4 hours as the most blissful pain-free half-day of my recent life! Anyhow, I suppose my real question was how likely is it in a normal epidural-less labour that babies get stuck regardless of whether they're posterior or not? Given that forceps were invented because babies do get stuck and that until recently around 15% (from memory) of babies were birthed using forceps, it seems reasonably common? Or are you saying that in the majority of cases babies can be unstuck by using different positional techniques?

Sorry to harp on about it, just really curious! Plus I'm going to see my ob in a couple of weeks so want to ask him about it too.

Great responses, everyone!

Fiona your OP really shows the difference in perspective between the different models of care. What is "you're having a painful posterior labour so you need an epidural; your baby is stuck so you need forceps" in the medical model becomes "you're having a posterior labour so we need to be patient and help you stay upright and mobile so your baby can rotate, the birth pool may help you while your babe is doing the work of rotating; your baby isn't stuck, he's just completing the job of rotating and when he's ready he'll start his descent; you can use your body and gravity to help him" in the midwifery model.

So, because of the differing perspective and the different solutions and tools used at a homebirth, it's very unlikely that your homebirth midwife would diagnose your babe as being "stuck". She would be more likely to regard what happened in your first birth as a case of Failure To Wait than "failure to progress".

Posterior bub + more painful labour + epidural = less gravity & mobility = surgical birth is an equation we see a lot with first time mums with posterior bubs in the medicalized birth system. You did a superb job, outstanding effort, quite an uphill battle for a first timer to birth a posterior bub on her back! Next time, at home with a midwife and birth pool and freedom of movement, even if the Optimal Foetal Positioning has no effect (it did work for me I must say) and you have another posterior labour, it's likely that you'll find it easier next time, with a different model of care - you did so much good work the first time. It may well have played our differently if you'd been home for bub#1, or possibly you may have transfered, as sometimes happens with first time posterior labours -but thus we learn and become wiser and stronger for next time. I'm a big believer in the good work you do with your previous birth paves the way for more confidence for the next time. There's no learning curve like a birth hey?

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Anyhow, I suppose my real question was how likely is it in a normal epidural-less labour that babies get stuck regardless of whether they're posterior or not? Given that forceps were invented because babies do get stuck and that until recently around 15% (from memory) of babies were birthed using forceps, it seems reasonably common? Or are you saying that in the majority of cases babies can be unstuck by using different positional techniques?

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I'd have to hunt around for specific statistics, but my educated guess would be - extremely unlikely. However, finding evidence or statstics to back this up (and you all, by now, know how much I like evidence) will be quite difficult.

This has to do with the historical nature of obstetrics in the western world, and while this may sound like I'm going to launch into a bit of a rant, believe me, I'm not - but it will help to understand some things about labour and birth are managed in the obstetric model of care.

Ever since statistics and research about birth has been collected - and we are going back to Victorian England, here - the people who have collected those statistics have been obstetricians. They started collecting statistics and research at a time when women's rights did not exist, when the right to medical care was determined by wealth, and when even the most refined of gentleman doctors would not think twice about the way they treated women. Obstetrics was driven by profit in the early days. Look up obstetric forceps on wikipedia; initially, they were so well protected by their creators that they refused to even use them without a screen erected to prevent anyone else from seeing what they were and copying them.

Our body of research, now, is based on principles that were introduced back then and have been around for so long that they have become accepted as conventional wisdom. They are principles that include things such as: birth is inherently dangerous. Birth should be managed by people trained in surgery. Many births will require some sort of surgical intervention. During a birth, the mother and child should be closely monitored.

Some princples have fallen by the wayside as we have become, in many ways, a more enlightened society. We now accept that women have the right to have their partners, or even signficant others, with them during their birth. We now accept that women have the right to keep their babies with them after they are born, and not be separated from them unnecessarily. We now accept that there is a place in the birth process for the father or chosen partner.

So, when you ask questions about "normal" or "natural" birth and we look for answers we can justify using research or statistics, the problem is that those statistics don't exist; all of the research into obstetrics is based on obstetric principles that were invented in a time where understanding of the birth process was essentially flawed - it treated it as a disease, which it is not. In a way, it is a classical piece of "men are from mars, women are from venus" thinking - men have to solve a problem if it is presented to them. The problem being that women have pain in childbirth. The (at the time, quite possible well-meaning) solution: anaesthetise them, initially with chloroform, since with more modern drugs. The next problem - anaesthetised women find it difficult to stand, to walk, or to balance. The solution: lie them on their back. After all, they are "sick", so to speak - they are having a baby. A new problem - women push for hours and hours and get so exhausted that the baby gets "stuck".

My gut feeling, and this feeling is now being backed up by research into homebirth, the type of birth that is possibly the closest we can get to a "normal" birth, is that the actual incidence of "failure to progress", the medical term for a birth that lasts a sufficiently long time that the mother or baby become dangerously exhausted, is very, very low. Many studies into homebirth reveal that the incidence of transfer due to failure to progress is lower than 1%. And that even when there is a failure to progress that the midwife cannot manage through the means at her disposal, independently practicing midwives recognise this earlier than their hospital-based colleagues and transfer their clients as appropriate.

Once more example that I often use - think of human beings as a race. Other smaller mammals have five or ten young at a time, at each birth, and left unchecked, will give birth once a year from sexual maturity until they reach old age. Larger mammals, like horses and cows, have one young at a time but, once more, left unchecked, will mate every time they go into heat. Humans, on the other hand, can manage their fertility to a degree; and even if they don;t, are only fertile a small number of days each year. And, yet, our population grows exponentially, and continues to outpace most other animals on earth. If our birth process was so fraught with danger; If we really DID need a caesarean for 50% of births (which, by extension, implies that if those births occurred naturally, mother and baby would not have survived) how have we survived as a race? If every single time we give birth we run a 50/50 chance of not surviving, how have we spread to cover the face of the earth?

Food for thought, anyway.

Quote: Given that forceps were invented because babies do get stuck and that until recently around 15% (from memory) of babies were birthed using forceps, it seems reasonably common?

There's a difference between using forceps because a baby is actually stuck, and using forceps because of a failure to wait and a failure to trust in women's birthing wisdom and bodies. 15% use of forceps does not mean 15% of babies got stuck; it means that 15% of women had forceps used on them whether they truly needed them or not and and irrespective of their own wishes. I've just come from a chat with my mum - forceps were used for all four of her births in the 60s - she did NOT "need" them, but they bullied her into it and made her feel that her body "Might Not Be Able To" push her babies out so they were "just going to do a lift out (patronising pat on the head) - it'll be easier for you". She always wondered if perhaps her body just might not have been able to push her babies out so probably it was for the best .... I was horrified at what was taken from my mother. They used forceps because it was a Good Technique and because it was What They Were Taught. Also, the "largest episiotomy they could cut", in my mother's words, was not considered a negative outcome at all. In some hospitals today, an episiotomy is still not considered an adverse outcome.

I wonder what the actual rate is for the judicious use of forceps, in rare and genuine cases of CPD, after a woman has been supported in labour with plenty of privacy, emotional support, unrestricted movement, gravity and mobility and access to deep water, and the labour has become obstructed, and the Making Space techniques of the hip lift, sacral hinge and sit bone spread and assymetrical positions like lunges and the Proposal Position have all been tried, and plenty more TIME has been tried, and extra carbs and sugar and rest and privacy has been tried, and a ventouse has been tried or ruled out. How many forceps deliveries are performed on women who never had any of those basic human rights for birth, or had epidurals but were never offered access to a birth pool instead of an epidural, and were lying on a bed, tethered to machines, instead of being able to move their bodies instinctively and actively??

Quote: "Or are you saying that in the majority of cases babies can be unstuck by using different positional techniques?"
Many positional techniques, discussed in The Pink Kit and elsewhere, can increase pelvic capacity by 30%. Or 3 cubic centrimetres. That's huge. Relaxation, breathing and confidence also have a significant impact. Deep water (a proper birth pool not just a shallow bath) can help significantly too. All these should be tried, and time and patience added before forceps are resorted to. That's only going to happen if you are a well-informed and tough mama who, when the staff say to you: "Your Baby Could Die If We Don't" can respond with: "And I Could Sue You If You Do."

In the case of severe and actual foetal distress (much less likely to occur when a mother has the basic human rights of birth met and has not had drugs or epidural or is restricted to bed), there's a case for expiditing the birth through surgical techniques - forceps or caesarian - to save the life of a baby who is actually being compromised. That does happen (rarely - even more rarely when the woman is in a low-tech, high support environment), and I don't think there is a mother alive who would not consent to such intervention in such circumstances. But 15% of babies don't get acute foetal distress and need expidited, surgical delivery in places where proper support and autonomy is given to birthing women and to the process of normal physiological birth. So not all of that 15% of women having forceps is because of actual foetal distress. I would venture a guess there's a lot of Failure To Wait and We Don't Trust Women Or Their Bodies going on in that percentage.

40% of Aussie women don't need caesarians. 80% of first time mothers don't need epidurals. 15% of Aussie mothers don't need forceps. What we do need, really need, to birth safely, we are NOT GETTING! Less than 2% of Aussie women have access to a birth pool for comfort and pain relief during labour. Many Aussie women are expected to give birth safely and normally WITHOUT such things , or with restricted availability of such things as:

* continuity of care from a known, self-chosen midwife
* govt funded homebirth for those who choose that option
* privacy
* continuous emotional support from a woman experienced in birth - family member, friend or doula
* unrestricted mobility
* gravity
* nourishing food and fluids on demand
* hot water - birth pool
* able to walk around outside next to nature (very important for the labour progress of some women)

Great posts re: forceps here!

I just wanted to add that the growth in use of forceps coincided with the practice in the Victorian era, of literally tying women to the bed, on their backs, during labour. They were actually invented around 1600 and kept a family secret for over 100 years, after which they were in more common use in cases such as face or brow presentations, where mum might be genuinely exhausted by pushing so long (i have a friend who delivered her brow baby vaginally after a 7 hour labour - it was her 6th kid and nearly 6 hours of that labour was pushing!). They remained in this "last-resort" use for another century or 2 and then grew in popularity as obstetrics became a man's realm (rather than women using female midwives) in the Victorian era.

The Victorians removed sex and sexuality from as many areas in life as possible and did much damage to the knowledge about and culture surrounding birthing in the process. Which of course, given it meant mum is pushing baby uphill through a 20% smaller pelvic opening, led to a lot of "stuck" babies! In the 1950's it was still not uncommon to wait until a woman was fully dilated then give her general anaesthetic and remove the baby with forceps without even letting her push. The use of forceps exploded during the Victorian era and yet mortality for mums and babies under 12months didn't change during Victoria's reign because birth injury to both and serious infection in mum (due to dirty instruments and poor hygiene practice) grew as fast as deaths due to "stuck" babies fell. Sometimes science makes more problems than it solves.

Bx

Wow, that's fascinating Bec!

Very interesting discussion!

My last baby was posterior, she was born in hospital and my Ob had me turn over on all fours and baby rotated by herself without any problems at all. Wish I could've stayed in that position to deliver as it was comfortable but alas my Ob needed easy access so it was back on my back on the bed for the rest of the birth.

Seriously considering homebirth next time. :)

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Ob needed easy access so it was back on my back on the bed for the rest of the birth.

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To me that is selfish..... that you had to get into a position of convience for your OB...... He/she should have just got in a position where you could be comfortable.

If you do consider a homebirth, you won't have to worry about that kind of thing :)

Hi Fiona,
Thanks for replying to my post "Need OB Sandringham" I had just been reading the "Spinning Babies" website which I was going to recommend to you, but I can see someone already has. It was fantastic! Very interesting! It seemed to help me piece together (what I feel) were all the factors that had probably caused my baby to get stuck. I am feeling so much more confident with the fact that I will most likely be able to have a normal delivery with my next baby, and have decide to give my OB the flick and try find an experienced MW or Doula to support and help me birth instead.
Good Luck. Hope it helps.
mum ingrid

Hi muming
That's excellent news - glad you're feeling more confident. Yes, sounds like your ob was WAY too eager to do a caesar. I'll definitely check out the Spinning Babies site if I'm lucky enough to have another one.
Best of luck for the birth - let us know how you go.
Take care
Fiona

just my 2 cents, ds was posterior, and the midwife i had also worked as an im. i had got an epi before she arrived as the previous midwife had told me to push even when i told her i didnt' need too and so i got out of my 'zone' blah blah blah.
anyway, the one who is also a im turned ds while he was in the birth canal as i was pushing. if she had been there earlier i probably wouldn't have needed the epi and could have stayed on my hands and knees and it may not have been a problem.
the ob said my pelvis was shaped so as to make it likely i would always have posterior babies, but having bookmarked spinning babies and decided to birth at home next time, i am hoping it won't be an issue!