OPTIMAL FETAL POSITIONING

Optimal Fetal Positioning, Avoiding a Posterior Baby

www.spinningbabies.com

‘Optimal Fetal Positioning’ is a theory developed by a midwife, Jean Sutton, who found that the mother’s
position and movement could influence the position of the baby in her womb in the final weeks of
pregnancy. Many long and difficult labours result from ‘malpresentation’, where the baby’s position
makes it hard for the head to move through the pelvis. A ‘malpresentation’ can also result in post-date
pregnancy or the starting and stopping of labour.

Changing the way, the baby lies could make birth easier for mother and child.
The ‘occiput anterior’ position is ideal for birth – This is the position that lines up the baby so as to
fit through your pelvis as easily as possible. The baby is head down, facing your back, with his back
on one side of the front of your tummy. In this position, the baby’s head is easily ‘flexed’, i.e. his chin
tucked onto his chest, so that the smallest part of his head will be applied to the cervix first. The
diameter of his head which has to fit through the pelvis is approximately 9.5 cm, and the circumference
approximately 27.5cm.

The position is usually ‘Left Occiput Anterior’ or LOA - occasionally the baby may be Right Occiput
Anterior or ROA.

The ‘occiput posterior’ (OP) position is not so good. This means the baby is still head down, but the
back of the baby’s head is against the spine. Mothers of babies in the ‘posterior’ position are more
likely to have long and painful labours as the baby usually has to turn 180 degrees (all the way round)
to facing the back in order to be born. He cannot fully flex his head in this position, and diameter of his
head which has to enter the pelvis is approximately 11.5cm, circumference 35.5cm.
This means that often posterior babies do not engage (descend into the pelvis) before labour starts.
The fact that they don’t engage means that it’s harder for labour to start naturally, so they are more
likely to be ‘late’. Braxton-Hicks contractions before labour starts may be especially painful, with lots of
pressure on the bladder, as the baby tries to rotate while it is entering the pelvis.
Sutton notes that the rate of posterior presentation has increased drastically in the last few decades,
apparently in line with changes in the way women use their bodies. Sitting in car seats and leaning
back on comfortable sofas, together with less physical work, have combined to produce an increase in
posterior presentations. Paying attention to your posture in the last few weeks of pregnancy can help
to reverse this trend.

Since keeping reasonably active in pregnancy, and practicing

good posture isn’t going to do anyone any harm, this theory at least deserves to be considered.

When do you need to start doing something about this?

Pay attention to your posture at the time when your baby may be starting to ‘engage’, which means
its head will be descending into the pelvis. This means for the last six weeks of your first pregnancy,
and the last two or three weeks of subsequent pregnancies. In your second and later pregnancies, the
uterus is roomier, and the baby will not normally start to descend into the pelvis until later; often not
until labour starts.
What position is your baby in? This is important because you need to know when your baby moves
into a good position, so that you can encourage it to stay there! You can learn to tell what position your
baby is in, by asking midwives to show you what to look out for, and by practicing feeling for the baby
yourself. When the baby is anterior, the back feels hard and smooth and rounded on one side of your
tummy, and you will normally feel kicks under your ribs. Your belly button (umbilicus) will normally poke
out, and the area around it will feel firm. When the baby is posterior, your tummy may look flatter and
feel more squashy, and you may feel arms and legs towards the front, and kicks on the front towards
the middle of your tummy. The area around your belly button may dip in to a concave, saucer-like
shape. If you feel the baby move, try work out what body part was moving. Remember that heads feel
hard and round, while bottoms feel soft and round! It may take a lot of concentration and trying to work
things out at first, but you soon get the hang of it. You may find it easier to feel your baby’s position
if you lie on your back with your legs stretched flat out. This is a good time to practice belly mapping.
Visit www.spinningbabies.com and print out a belly map. Practice belly mapping with you and your
partner. After you have marked kicks and where you feel your baby’s back on the map, you will have a
visual picture of how your baby is positioned in your belly.

If your baby is posterior, you may find that you suffer backache during late pregnancy (of course, many
women suffer backache then anyway).
You may also experience long and painful ‘practice contractions’ as your baby tries to turn around in
order to engage in the pelvis.

Practical steps to avoid posterior positions

The baby’s back is the heaviest side of its body. This means that the back will naturally gravitate
towards the lowest side of the mother’s abdomen. So, if your tummy is lower than your back, e.g. you
are sitting on a chair leaning forward, then the baby’s back will tend to swing towards your tummy. If
your back is lower than your tummy, e.g. you are lying on your back or leaning back in an armchair,
then the baby’s back may swing towards your back.
Avoid positions that encourage your baby to face your tummy. The main culprits are said to be leaning
back in armchairs, sitting in car seats where you are leaning back or anything where your knees are
higher than your pelvis.
The best way to do this is to spend lots of time kneeling upright, sitting upright, or on hands and knees.
When you sit on a chair, make sure your knees are lower than your pelvis, and your trunk should be
tilted slightly forwards.
Watch TV while kneeling on the floor, over a beanbag or cushions, or sit on a dining chair.
Try sitting on a dining chair facing (leaning on) the back as well.
Use yoga positions while resting, reading or watching TV - for example, tailor pose (sitting with your
back upright and soles of the feet together, knees out to the sides)
Sit on a wedge cushion in the car, so that your pelvis is tilted forwards. Keep the seat back upright.
Don’t cross your legs! This reduces the space at the front of the pelvis and opens it up at the back. For
good positioning, the baby needs to have lots of space at the front
Don’t put your feet up! Lying back with your feet up encourages posterior presentation.
Sleep on your side, not on your back.
Avoid deep squatting, which opens up the pelvis and encourages the baby to move down, until you
know he/she is the right way round. Jean Sutton recommends squatting on a low stool instead, and
keeping your spine upright, not leaning forwards.
Swimming with your belly downwards is said to be very good for positioning babies - not backstroke, but
lots of breaststroke and front crawl. Breaststroke in particular is thought to help with good positioning,
because all those leg movements help open your pelvis and settle the baby downwards.
A Birth Ball can encourage good positioning, both before and during labour.
Various exercises done on all fours can help, e.g. wiggling your hips from side to side, or arching your
back like a cat, followed by dropping the spine down.
(Nothing to do with baby positioning, but... if you’re swimming, make sure you have goggles, so you
can swim in a good position, with your face partially or wholly in the water as you dip down. Doing
breaststroke with your neck craned, holding your face out of the water, is bad for your neck and back
at any time, let alone in pregnancy when ligaments are loose.)

If your baby is already posterior...

When your baby is in a posterior position, you can try to stop him/her from descending lower. You want
to avoid the baby engaging in the pelvis in this position, while you work on encouraging him to turn
around. Jean Sutton says that most babies take a couple of days to turn around when the mother is
working hard on positioning. Avoid deep squatting
Use the ‘knee to chest’ position. When on hands and knees, stick your bottom (butt) in the air, to tip the
baby back up out of your pelvis so that there is more room for him to turn around.
Sway your hips while on hands and knees
Crawl around on hands and knees. A token 5 minutes on hands and knees is unlikely to do the trick -
you need to keep working at this until your baby turns. Try crawling around the carpet for half an hour
- while watching TV or listening to music. It is good exercise as well as good for the baby’s position!
Don’t put your feet up! Lying back with your feet up encourages posterior presentation.
Swim belly-down but avoid kicking with breaststroke legs as this movement is said to encourage the
baby to descend in the pelvis.
You can still swim breaststroke, but simply kick with straight legs instead of “frogs’ legs”.
Try sleeping on your left side but more on your tummy with your right leg over your belly. This is called
a modified “runners” position. It looks like this picture.

When your baby turns to an anterior position, you can encourage him to descend further into the
pelvis - by walking around upright, massaging your belly downwards, deep squatting, and swimming
- breaststroke kicking.
If your baby is posterior when you go into labour:
These movements can help the baby wriggle through your pelvis, past the ischial spines inside it,
by altering the level of your hips. They are also helpful if the baby is anterior but has a presentation
problem, e.g. his head is tipped to one side (asynclitism).
In early labour, walk up stairs - sideways if you need to.
Rock from side to side
March or ‘tread’ on the spot
Step on and off a small stool
Lunges (use a chair to raise 1 leg and rock from side to side)

The positions listed below may also help.

For the second stage:
Use kneeling or all fours positions. Kneeling on one knee can help.
Supported squatting in second stage, but the mother must be lifted quite high up; her bottom should
be at least 45cm (18 inches) off the floor.
Birth stool seats should be at least 45cm (18 inches) from the floor.
Avoid lying on your back, semi-reclining, sitting or semi-sitting. These positions all reduce the available
space for the baby to turn. Lying on the side is OK.
Is there any proof that this works?
Midwives and mothers who have learned about, and used, Optimal Fetal Positioning techniques are
convinced that it works. There is a wealth of anecdotal evidence in favor of it. However, there have not
been any trials or studies on the subject so far, because they would be extremely difficult to organize.
Practicing techniques to turn a posterior baby can take a lot of commitment on the part of the mother,
which could not be assumed in a randomized trial. There would also be ethical problems with a trial -
would mothers in the control group be told not to adopt upright or forward-leaning postures? Or would
they simply not be told that taking care with their posture could lead to an easier labour?
There has been one small study [4] which looked at the short-term effects of mothers adopting a
hands-and-knees position, compared to sitting, when their baby was in a lateral or posterior position.
Mothers were asked to go on hands and knees, or to sit, for a short period of time, and the position of
the baby was noted ten minutes afterwards. The study found that babies were far less likely to remain
posterior after mothers had been on hands and knees.
However, since the babies’ positions were only assessed for ten minutes after one session on hands and
knees, this study doesn’t tell us very much about the longer-term effects of alterations in the mother’s
posture. You can read the abstract in the Cochrane Pregnancy and Childbirth Database.

Some good evidence for the effectiveness of the theory comes from its author’s own practice. When
Jean Sutton was appointed Principal Nurse Midwife at a maternity unit in New Zealand, she emphasized
antenatal education on fetal positioning. The transfer rate from maternity unit to hospital fell from 30%
to 5 % and the forceps delivery rate fell from 3-4 per month, to 2-4 per year, over a period of several
years [2].
If your baby appears to be in a posterior position, you will probably need to put considerable effort
into persuading him to move around. It is no use spending five minutes on your hands and knees every
now and then, and then saying “I tried to turn him, but it didn’t work...”. Optimum Fetal Positioning
should be a lifestyle for you, for those last few weeks of pregnancy, not just an occasional distraction.
Adopting a ‘good’ position now and then will not make much difference if you are in ‘bad’ positions for
the ma jority of the time. The only person who can get your baby into a good position is you.
These positions are not only good for you and your baby during pregnancy, but good for everyday life
as well. Maintaining a “bad” posture standing or sitting will encourage your spine to move permanently
and it will take an extraordinary amount of work to help your spine to move and regain its curvature.

It may be that your baby is going to stay ‘sunnyside up’ and will just refuse to turn; perhaps that’s the
way he/she needs to be. Babies know more than we do on where they need to be. Your baby might
not be able to move to the anterior position due to a cord anomaly, placental position, or very rare
– the shape of your pelvis. However, it can’t hurt to try to get the baby to turn. These positions only
encourage your baby to do what it already knows how to do. It’s giving your baby the help it needs
in order to turn and get ready for birth. If you do end up having a posterior labour (and they’re not all
dreadful, but many are harder than they would otherwise be), at least you’ll know you did all you could
to make things easier for you and the baby.
Remember, you are the one in control of your body and actions. If all of us knew that we could do
something to encourage a quicker and safer delivery, we would practice those techniques from
conception. Not everyone knows that having a baby in the optimal position for birth not only makes
things less painful for mom, but less painful for baby as well.

Your baby is not a passenger in all this. Your baby has 7 cardinal movements it must complete and
primitive reflexes it must use in order to be born. Help your baby now by paying attention to your
posture.
Part of this theory states that a first-time mom will have a 6-8 hour labour and a second time mom will
have a 2-4 hour labour if baby is in the LOA position prior to and remains LOA during labour and birth.
It’s worth trying.
Posterior Babies - what mothers can do - from the UK’s Association for Improvements in the Maternity
Services (AIMS) www.aims.org.uk/posterior.htm
Spinning Babies – Easier birth through positioning. Learn how to map your baby’s position to help YOU
help your baby. www.spinningbabies.com
UK Midwife Archives page on presentation, from the Association of Radical Midwives (www.midwifery.
org.uk)
The Midwife Archives on the gentlebirth.org website have an amazing collection of wisdom and
experience on just about every subject related to pregnancy and birth. The pages on positioning start
at http://www.gentlebirth.org/archives/position.html
By Shiatsu practitioner Suzanne Yates (who also runs courses for parents and professionals in Bristol,
UK): ‘Exercise for relieving backache’ Shiatsu and Optimum Foetal Positioning, originally published in
‘Practicing Midwife’.
References:
All data and recommendations in this article are from [1] below unless stated otherwise.
[1] ‘Understanding and Teaching Optimal Foetal Positioning’ by Jean Sutton and Pauline Scott, in New
Zealand: Birth Concepts, 1995. Available in the UK from Jean Sutton’s daughter-in-law, Jill Sutton, for
£6 sterling - please send cheque made out to J Sutton with A5 or larger envelope, and 41p stamp, to:
95 Beech Rd, Feltham, TW14 8AJ. Available online from NCT Maternity Sales.
[2] Modern Midwife , January 1997 Vol 7 No 1, article by Mary Nolan
[3] Recommendations from other sources, including antenatal classes I have attended, and discussions
with midwives and antenatal teachers, which are not specified in Jean Sutton’s ‘Optimum Foetal
Positioning’.
[4] Hofmeyr GJ, Kulier R. Hands/knees posture in late pregnancy or labour for fetal malposition (lateral
or posterior) (Cochrane Review). In: The Cochrane Library, Issue 2, 2000

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