Optimal Fetal Positioning

Mary Nolan's comments on Jean Sutton's approach to childbirth, considering how positions in pregnancy and labour affect the birth process

Jean Sutton of Birth Concepts explains things all expectant parents should know about the co-operative engineering process that is human labour and birth.

During the past few years, as I have written and taught about making the birth process safer and easier for both mothers and babies, I have found that many of the things we now believe to be normal cause undue difficulty and stress to everyone involved. Much of the useful traditional knowledge, mainly held by women, was devalued and then discarded as the so-called 'scientific' methods took over.

As old books have been consulted, some startling information emerged. Did you know that in 1932, Corkill, a New Zealand doctor who wrote textbooks for midwifery students, said the following? 'In public practice (that is, in our St. Helen's hospitals) around 4% of women will need help to give birth, while in private practice or clinics, the number will be higher.' Had he already noted the effects of lifestyle on the way women gave birth?

We have organisations such as NCT, Active Birth, Parents' Centres, all trying to make the chance of a normal birth more realistic. Still the statistics show increasing numbers of interventionist deliveries.

Why do I think that I have anything useful to contribute to the situation? Well, for most of my life I have been involved with reproduction in many species, of which humans are only one - the most fascinating to be sure, but equally the only ones who have so many problems. In short, everything living on this earth has a safe birth plan written into its genes. When this is adhered to, things go well. Just look in your garden - leaf and flower buds open in the correct sequence into perfect specimens. Bad weather, insect damage or even spraying with the wrong material or at the wrong time may destroy the pattern.

Chicks of all birds hatch in the same way - peck right round the shell, use one leg and the opposite wing to push the halves apart, and out they come. Again, the way the mother broods them must follow the proper sequence - if they are not turned regularly the embryo may stick to the shell lining and be deformed.

Animals also must follow the rules. The ones who stay still while giving birth are having more than one baby at each birth - in other words, a litter. When the norm is only one offspring, the mother is restless and active. As we well know, the mother also always has her legs lower than her spine - no stranded beetle postures used by creatures other than man.

Understanding the process

Do we really understand the birth process built into our own genes? To do so, we must look closely at the various parts of the process, from the way the baby should enter the maternal pelvis, to the ways the mother can help or hinder its efforts. To be successful, the baby needs the maximum amount of space in his mother's uterus and pelvis at exactly the time he (or she) asks for it. He makes very determined efforts to achieve the correct position for birth, but is often resisted by a mother who has not learnt how to help him.

A normal birth

Let us look at what should happen in a normal birth. The baby enters his/her mother's pelvis in what is medically known as the LOA position - that is head down, back between mother's left hip and umbilicus. This is described in all textbooks as the 'normal' position. It is made easier because the uterus near full term leans slightly to the right at the top and has a curve to the left at the lower segment. In the books, this is called right obliquity and dextro rotation.

The mother's abdominal muscles are relatively stretchy and the lumber lordosis (curvature) of her back increases. Thus, as long as the mother maintains postures that keep her knees lower than her seat, her pelvic brim is kept as wide open as possible and the baby finds it simple to engage at the correct angle. He (or she) is able to flex his neck and bring his chin well down on his chest. This makes the occiput the leading part of his head - reducing the diameter to 9.5cm from 11.5cm.

First babies should make this move at about 36 weeks gestation while they are still relatively small, so that the maximum hormonal and physical stimulation is given to the cervix when Braxton-Hicks contractions increase. Subsequent babies may wait until 40 weeks or even until labour begins.

Once labour begins, the mother must respond to the pressure from the baby's head by altering her posture. Pressure is the baby's way of saying 'I'm short of room'. This is one of the reasons why so many women find relief by leaning on the kitchen work top during a contraction. The front of the pelvis is kept low and open, allowing the baby to move its head under the sacrum and turn its face towards the mother's back. The mother may feel a need to raise one or other foot as the baby descends. First stage ends with baby facing directly backwards, at the pelvic 'spines' and with his (or her) shoulders sideways across the pelvic brim.

Following a period of rest, the second stage begins. With her knees still below her seat, the mother finds something stable to grasp. Her hands are above her waist. She arches her back and her knees lower and rotate outwards. Now her lower lumber vertebrae and the sacral prominence (the Rhombus of Michaelis) move backwards, pushing out the wings of the pelvis as they do and making room for the baby's shoulders to rotate as the head is born.

The pelvic outlet space increases to around 15cm, enough for the largest baby. The head has skimmed the pelvic floor, and there has been no deliberate 'pushing'. The baby has brought his posterior, or left, shoulder out first, which means that if his mother is unaided he will slide safely face down on the floor or bed. With a minimum of fuss, a new human has entered the world.

What are the key points?

Achieving a straightforward birth requires that the mother, her professional attendants and her support people understand the complex relationship between the mother's pelvis and the baby's head. Once that happens and the babies are given the conditions they need, many babies will tuck themselves up in the optimal LOA position and move easily through the mother's pelvis and into the world.

Understanding and Teaching Optimal Foetal Positioning, by Jean Sutton and Pauline Scott (second revised edition, 1996), is available through Rob and Julie Sutton (email, Birth Concepts, 75 Trelawney Avenue, Langley, Berkshire SL3 8RG. Send an A5 stamped, self-addressed envelope, plus £10 to the above address.


Mary Nolan, NCT antenatal teacher and tutor, comments:

Jean Sutton's interest in birth and the way things work were stimulated as a child by a family background of farming and engineering. She started her working life at 17 years of age as a nurse aid in a rural maternity hospital in New Zealand. She subsequently trained as a general nurse and then returned to maternity care.

Jean argues the case for optimal fetal positioning on the grounds of common sense, 30 years' experience and close observation as a midwife, and the principles of mechanical engineering. She refutes the need for research into the effectiveness of optimal fetal positioning; the evidence to which she refers is the instinctive knowledge about how to give birth which women have demonstrated since time immemorial.

Jean also draws on anthropological studies, which reveal that women who are not experiencing childbirth within a medical model of care assume certain positions to help their babies to be born easily. The burden of research, Jean argues, should therefore be shouldered by those whose practice does not include showing women how to achieve optimal fetal positioning during pregnancy and does include encouraging women to give birth in semi-recumbant positions.

Mary Nolan's comments on Jean Sutton and her approach to childbirth were first published in Modern Midwife, January 1997, vol.7, no. 1.

Published in the NCT publication New Generation Digest, June 1997

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