– turn the baby using knee-chest position. Here’s a ‘common sense’ remedy that I have had some experience with. My experience comes from being a mother who has experienced back labor – and from working as an RN in Labor and Delivery with a lot of other mothers, some of whom also had the experience. I’ll try to tell you about this in regular lay language, but will also include some of the medical language the professionals use – so you’ll know what they are talking about when you hear it
When I had my first baby, I definitely had a labor with a lot of back pain – and heard during the delivery that he was in a ‘posterior position.’ I wasn’t a nurse at that time and didn’t really know what the doctor was talking about. So let’s start with where back labor comes from and what posterior presentation means.
First – baby’s position when labor starts
The head is generally the heaviest part of the baby, so it isn’t too surprising that if Mom is upright most of the time, the baby will settle into a position with its head (the heavy part) down. That’s good because it is also the biggest and hardest part of the baby. So when that head comes out, you can be pretty sure the rest of the baby will have no trouble following! And that head will fit through the bony opening down there best if it’s curled up with its hands and feet lying towards Mom’s back and the back of its head – where it’s the smallest around – comes through first. In this position, the discomfort of contractions is mostly in the the front, where the muscles of the uterus are cramping up intermittently to push the baby down and out. Common sense – right?
So where does Back Labor come from?
The problem comes up when the baby is in a ‘posterior presentation’ when Mom goes into labor. OK – ‘posterior’ is another word for ‘back side,’ isn’t it? So you think that might mean the same as ‘butt first’ – but it doesn’t! (When the baby is butt first, it’s called ‘breech’ position.) What we’re talking about is when the baby is head down. But you see, if the baby is turned with its hands and feet out towards Mom’s front, the top of its head (a little bit bigger around than the back of the head) is trying to come out first and baby’s back is lying next to Mom’s back! Common sense shows you what that means – the two back bones rubbing on each other make for – Ouch! – every time the uterus tries to push the baby out! Besides which, squeezing the bigger part of the head through makes for a more drawn out labor!
So—what can you do about the pain of Back Labor?!
Well, ‘common sense’ in our community today often dictates that you give the mother pain medication to keep her comfortable and help get the baby out if she can’t push it out herself. The help may well include medication to strengthen the contractions and coaching while pushing. It could also include some kind of surgical intervention like doing an episiotomy (cutting the vaginal opening wider), using forceps or a vacuum to pull on baby’s head while Mom pushes, or even Cesarean Section (cutting Mom’s ‘tummy’ to get the baby out).
With my first baby, it was handled pretty much that way. When my Lamaze breathing techniques weren’t keeping me under control, the nurses talked me into having an epidural anesthetic that numbed me completely from the waist down. We waited for a few hours while my cervix (the opening of the womb the baby has to come out) opened up. When it was big enough, the nurse had me start pushing the baby down. But I was completely numb and could not feel what I was doing although they told me I was making progress! Eventually I was taken to the delivery room where my legs were positioned for me (I couldn’t move, either). That’s where I heard the expression ‘posterior presentation’ and learned that in spite of all my pushing, the baby hadn’t turned around to the preferred ‘anterior presentation.’ So the doctor did an episiotomy, put forceps on my baby’s head and helped pull him out, still face up. (Most babies come out face down.) Two or three hours later the epidural anesthetic wore off to where I could move myself around in my bed. If I had known then what I learned later, I would have done it differently!
The ‘knee-chest’ position.
What I learned later (when I was working in Labor and Delivery) was another solution that used common sense and that I found is often very effective – and definitely less invasive. It is called ‘knee-chest’ position. I know, it is pretty ludicrous to think about a full-term pregnant lady managing to get her knees anywhere near her chest! But that is not quite what it means. As a labor nurse, I would have the laboring mother get off her back and up on her knees, then lean forward onto on her forearms, getting her chest down near the bed. See—knees and chest down, butt up in the air – Then her husband and I would continue to coach her with her pushing. It seldom took more than four or five good pushes to get the baby turned around to an anterior position. Then it would be quite quickly and easily delivered vaginally without any particular assistance.
Now here is what makes this a common sense solution.
I already mentioned that the heaviest part of the baby is the head – so it naturally turns with the head down as mother is upright most of the time. When Mom goes into labor, the head gets wedged more and more deeply into the pelvic bones. Well, the heaviest part of the rest of the baby is the body (not the arms and legs), so if Mom is laboring while lying on her back, the baby will tend to turn with its back ‘down’ towards Mom’s back – posterior presentation. If she labors leaning forward, of course, the baby will tend to turn with its back ‘down’ towards Mom’s front – anterior position.
If baby is still in a posterior position later in labor, its head is probably pretty tightly wedged into the bony pelvis. By getting Mom into knee-chest position, you use gravity in two ways. First, to encourage the body to turn towards the mother’s front. And second, to let the wedged-in head ‘back out’ of the pelvis just enough to give it room to turn the way that body is trying to go. Common sense – works almost every time – but if you are the labor attendant, be sure to set up your delivery table before you put Mom into knee-chest or you won’t have time. After she’s turned the baby around, it will be coming out pretty fast!
Contributed by Margaret Ida Havens, RN, CEEB, MEd.