EBB 165 – Fetal Position During Labor with L&D Nurse, Ann Marie Gilligan

Learn about Ann Gilligan and Gilligan’s Guide here (www.gilligansguide.com). Follow Ann on Instagram here (www.instagram.com/gilligansguide). 

Learn about EBB instructor, Rhonda Fellows, Learn about Oily Doula MN here (https://www.oilydoulamn.com/) and follow Oily Doula MN on Facebook (https://www.facebook.com/oilydoulamn/) and Instagram (https://www.instagram.com/oilydoulamn/).

Learn more about Spinning Babies® here (https://www.spinningbabies.com/).

Rebecca Dekker: Hi, everyone. On today’s podcast, we’re going to talk with Ann Marie Gilligan about maternal positioning and its effect on fetal position during labor.

Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi, everyone. I’m super excited to introduce our honored guest, Ann Gilligan. Ann Gilligan is a labor and delivery nurse in Minnesota, who is trained in high-risk obstetrics and advanced fetal monitoring, certified through Waterbirth International and also, certified as a sexual assault nurse examiner. Ann has 30 years of labor and delivery experience, ranging from the start-up team for an independent birth center to working at a level three high-risk labor and delivery unit to working as a legal nurse consultant and prenatal yoga instructor. Ann has extensive experience caring for families who want an unmedicated birth as well as caring for people with high-risk conditions, such as pre-eclampsia, uncontrolled diabetes, post-partum hemorrhage, and sepsis. Ann has also traveled to Bolivia and Tanzania, where she taught high-risk obstetrics and maternal positioning for optimal fetal positioning. More recently, Anne becomes an Evidence Based Birth® Instructor in 2020, and is a Spinning Babies® Aware Practitioner. 

All of these experiences have come together in Ann’s web-based resource, Gilligan’s Guide, where Ann teaches physicians, nurses and families the importance of having an infant in the optimal position for birth, how to determine the position of the infant in utero, both prenatally and during labor, and how, based on her personally designed algorithm, how to get the infant into a more optimal fetal position during labor and beforehand. We’ve been so impressed by the work Ann is doing to support her patients in Minnesota as well as around the world, online, and we’re thrilled she’s joined us on the Evidence Based Birth® Podcast. So, welcome, Ann, to the podcast.

Ann Gilligan: Thank you, Rebecca. I’m so excited to be on your wonderful podcast and to share my information with everyone.

Rebecca Dekker: And I want to give a quick shoutout to your fellow EBB instructor, Rhonda Fellows, who said, “You have to get Ann on the podcast.” So, super excited.

Ann Gilligan: Yes. I’m fortunate to have met Rhonda at a birth and we clicked and we’ve been friends ever since, so wonderful.

Rebecca Dekker: Yeah. So tell us, Ann, why did you decide to go into nursing?

Ann Gilligan: So it started way back when, I’m 56 now, and at age 16, so 40 years ago, I would walk down to the children’s hospital and I was a … I guess we called them “aides,” and I worked in something called the milk lab, if you can believe that. We actually had donated breast milk from the community and I pasteurized it. And in combination with formulas that were specifically kind of reciped out for particular infants in the NICU, I created those formulas and pasteurized the milk and took them over to the NICU and that sparked my interest, at age 16, to go into the medical field.

Rebecca Dekker: So you were a teenager and you were inspired to go into the medical field. So, did you go to nursing school right away, then, after high school?

Ann Gilligan: I was premed at the U and it proved to be a little bit too much for me at that time in my life, so I actually … And I was paying for my education, so I dropped out for a year and then I went into a nursing program with the goal to be a midwife, but I ended up finding my true love, getting married and having children and, I guess, if I could change anything, I wouldn’t. From the beginning of my career to where I am now, I think I’ve made some really good decisions. And being a labor and delivery nurse and all the other vocations that you just mentioned have created who I am and have created my path forward, so I’m super happy with the way things have turned out.

Rebecca Dekker: So nursing is your passion rather than-

Ann Gilligan: Yeah.

Rebecca Dekker: Another-

Ann Gilligan: Nursing is actually … It’s who I am. I mean, I looked at kind of who I am as a person, I’m a caregiver, which is obviously important. I’m a pretty calm individual and Lord knows when you are a labor and delivery nurse in a high-risk setting, you have to stay calm. I’m never too confident, meaning my eyes are always wide open, right? You’re always watching for things to appear in front of you and to watch out for those silent things that could happen to your patient. I’m always learning. We are a group of individuals that have so much to share and to offer one another, and I think it’s really important to always be open to learning and learning from other people who have different specialties and expertise. And when you do have that expertise, it’s really important to take those certain skills or abilities and give them back through education. So, that’s been my passion recently is teaching the new RNT nurses to training the residents. Actually, on the 7th of this month, I’m training a bunch of resident doctors in maternal positioning, and I feel like it’s really important to do that once you have a specialty.

I truly believe labor and delivery nursing is one of the best jobs in the world. I mean, over the years, the past 30 years, I’ve witnessed thousands of deliveries and I could describe it as beyond gorgeous. I mean, I still cry at deliveries and I think that I am so privileged to have been included in the lives of all of these families. And I also think that when you are skilled in a certain thing, that it’s important to prepare the future generations. And seeing as I’m getting on in my career, I tell my young nurses and they are so smart. I mean, nurses who go into labor and delivery are, I believe, so incredibly bright, they’re so giving. They just have those certain qualities of the women that we hire. And when I retire, I don’t even really feel that old, but I feel like I’m getting closer to retirement, I tell these girls, you’re going to have to take over from me, so this is the stuff I want you to know and to be able to incorporate into your practice and take from me and pass it on to future generations because it is so important.

And, as you mentioned, my vocations, I’ve been a sexual assault nurse examiner and a legal nurse consultant, all pointed to me regarding my number one priority is safety, the safety of my mothers and my babies are my number one priority. And the second priority of mine is to always assure that my moms, my mothers all have the birth of their choice. So, for instance, when they come in and I admit them, I get down to their level of their face, wherever they may be and I talk to them about their preferences, their desires, their dreams and how they see this labor and delivery of their newborn coming to be, and it is so important. And then I take that information and pass it onto my next nurse, I feel like it’s just essential. So, safety and to allow that woman the birth of her choice is really, really important to me. 

And physical contact, and that’s what’s been so hard with COVID is I’m a very physical person. I think I developed that from my family. And I always want to do massage and touch, I know the healing qualities of those. And then when I leave my patients, I like to give them a big hug and that, of course, has been missing from my practice the last year with COVID, so that’s been hard.

Rebecca Dekker: So it sounds like you’re at the point in your career where you’re really focused on making sure you pass on this wisdom and experience and knowledge to the newer generation, so that your work can continue through them.

Ann Gilligan: Correct. It’s my goal right now, and so that’s why I so appreciate you having me on and sharing this platform.

Rebecca Dekker: So, thinking back to the beginning of your career, what was labor and delivery nursing like when you first went into the field? So that would’ve been the early ’90s.

Ann Gilligan: Yeah. I graduated from nursing school in ’89. I started my first job, actually, being a full-time night nurse in a very small hospital here in the Cities. And I was the only labor and delivery nurse, so I had a very seasoned nurse come from her evening shift to sleep in-house for me to ask questions to. So when I had a question, I would knock on her door, wake her up, she’d open the door, I still remember her face, and we would talk about the scenario and she would give me kind of some ideas and some information and then I would go about my way. And I feel like that has kind of created my way in which I practice today, of course, in my autonomy, my individual decision-making skills, they were all kind of heightened during that first year of being the only labor and delivery nurse right out of school. So, that was when I went in.

I have since noted big changes in our world of labor and delivery and one of which … I was actually at work last night and talking to the girls, some of which I’ve worked with for many years, and we talked about the fact that what’s happened to our space has changed. All of these remodels around the country have implemented big changes with the ability to be together as a staff. We’ve grown exponentially as far as the space allowed, which is actually very pleasant for the families, but we have been spaced apart and spaced in a way in which we don’t share our stories and our questions and our feelings and even discussion about our lives as much as we used to in the early ’90s, with smaller units. And that’s been a big change for us because I think it was so important to be able to say I’m …

And, also, we would actually look at the strips because they’re right there, the fetal monitor strips, and we would say you know what? I’m thinking that maybe you should do this, or I just have a suggestion here, and a lot of that isn’t done today because we’re so spread out in these ginormous labor and delivery suites and I can be 100 feet from the other nurse down the hallway. We used to actually open up the door and say, “Laurie, I need you in here,” versus now, we have a phone that, often times, we can’t get to because our hands are busy and it’s a little bit more complicated today.

Rebecca Dekker: I agree. I’ve noticed that as hospitals remodel around the country, I remember when they built a huge tower hospital in my city of Lexington, Kentucky and I remember when they were designing it, it’s very spacious and airy and light and everything’s spread apart and I remember thinking the nurse’s feet are going to be ruined by these super long hallways. Like you said, it kind of eliminates the team atmosphere because you’re not clustered together in a way that you can help each other, it was almost more designed for aesthetics rather than actual teamwork, which was-

Ann Gilligan: I agree. They should’ve asked the nurses, I think, a little bit more. I mean, it is a beautiful place and I think the patients appreciate it. And actually, for safety too, it’s better to have more space to move around and-

Rebecca Dekker: That’s true.

Ann Gilligan: Of course, when we have the NICU come into the rooms, it’s really important for them to have space. I kind of talked last night about what else we’ve seen, changes over the years and, of course, the biggest thing we’ll talk about is the caesarian rate going up and how we can change that. But the other things that we noted and I noted was episiotomy. Everybody used to get an episiotomy, and I remember one doctor in particular that would typically give her patients what’s called a left medio episiotomy and those are a little bit harder to come together because it’s not the natural midline separation of the perineum. Our goal, as labor and delivery nurses, would be to get these babies, essentially, out to their ears before we called this physician in for delivery because we knew that she would cut these LMLs and it would just make us cringe. So, that … episiotomy rate has actually gone down to … I mean, I haven’t seen an episiotomy in the last three years, so I feel like that’s a really good thing. 

Caesarian rate was lower than. The biggest thing, and, of course, this is right up your alley, is the fact that childbirth classes … I mean, 100 percent of me and my friends and family members would attend childbirth classes and on estimated today, it’s 25 percent of people are actually attending some type of childbirth class prior to going in. So, I feel like that’s-

Rebecca Dekker: Can you tell a difference, do you feel like your clients are less educated about the labor process when they get there?

Ann Gilligan: Yes. They’re less prepared physically, too, because I think when you have practiced the breathing and you have practiced the different positioning that we learned in my childbirth class. So, I do see that. Even anatomical and sharing with them kind of how their body works isn’t as knowledgeable as what it used to be. We used to do narrative charting, the computer age hadn’t even come about then, until the later ’90s, so we would stand and we would write our chart, our information about our fetal heart rate and our contraction pattern out by hand, a narrative charting, and that was so different. I mean, I sound like I’m ancient, but the computer age has made a difference. We also see a higher incidence of hypertension, which will relate to what I’m talking about with positioning too. So, those are the biggest things that we noted as a group. 

The biggest change was the rapid C-section rate and statistically … I’m kind of a statistics nerd just because of my legal background and I like to kind of … When I did my research in regards to Gilligan’s Guide, I really got into research. And if you look at the CDC and NHS data in regards to C-section rate, the jump was really kind of crazy from ’96 to ’11. So if you take the caesarian rate in Minnesota alone, from ’96 to 2011, it went from 14 percent in ’96 to 23 percent in 2011, with the U.S. current rate of caesarian of 31.7 percent.

Rebecca Dekker: I’m curious, is there anything else you’ve noticed in your clinical experience that may have contributed to that increase in the caesarian rate?

Ann Gilligan: With my background of 30 years and seeing this trend with my own eyes and witnessing thousands of deliveries, I have this perspective that very few have about what has changed. The incidence of occiput posterior babies, we used to have an occasional baby where we talk about the baby is, we would say, sunny side-up. I regard it differently today, I say the baby is looking at the sky or the earth, that’s just kind of my way of approach. But we would see an occasional occiput posterior baby. Now, when I go in, I go in often and help and assist in other rooms due to my expertise, but I go in and there’s so many. I would estimate 50 to 60 to 70 percent of the babies are either on the right side of the maternal side or occiput posterior. So we have studies from ’93 that say five to 10 percent of the babies are persistent, but I feel like that’s outdated and I feel like the change has really occurred in the last 15 years, where we’re having a lot more occiput posterior babies, which is why what I’m going to talk about is so important.

Rebecca Dekker: Can you talk a little bit about why having a posterior position baby can lead to a more difficult birth that might end in a caesarian?

Ann Gilligan: Yeah. First, I wanted to clarify kind of what the terms mean. So, when you talk about fetal lie, which is often discussed … These are medical terms and I just kind of wanted to explain it. So fetal lie is which way the baby is laying in the uterus, so we can talk about the baby laying across would be a transverse lie. Fetal presentation is what part of the baby enters the pelvis first, whether it be a breech, which is butt, whether it be a shoulder or a cephalic, which means head. So, that’s presentation. So an example of cephalic presentation, what I just said, is either a vertex or a brow. Now when I talk about fetal position, that means it’s arbitrary, right? It’s a chosen point in relation to which side of the maternal body, the left or the right. When I give an example of a presentation, I’m going to say a vertex baby, which is the presentation, and the position of the baby is either right or left. So, I’ll say a vertex presentation in right occiput anterior, which means the baby’s occiput, which is the back of the head, is facing the maternal right.

So, what we know from studies is the safest and most efficient way for a baby to deliver, and I’ll talk about the risks associated and what happens, is a left occiput anterior position. So the goal of maternal positioning is to get that baby in the left occiput anterior position due to multiple studies that have been done in reference to the dangers and the risks associated with a baby being in an occiput posterior position. So when I talk about the risks, as you had mentioned earlier, in relation to the mother, the maternal, we see longer labors, we see increased rates of third and fourth degree lacerations, increased post-partum hemorrhage over 500 milliliters, we see chorio and sepsis go up. Chorioamnionitis is an infection of the chorion. We see instrumental deliveries go up, which mean vacuum and forceps go up. Obviously, an increase in surgical births, caesarian births. And recently, they’ve actually seen a correlation between occiput posterior babies maternally having PTSD. 

In regards to the infant, we see an increase in meconium stained fluid, an increase in birth trauma, admissions to the NICU, a lower one minute Apgar, an increased rate of brachial plexus injuries, and the most important, that is kind of associated with the fetal heart rate pattern too, is we see acidemia, which is a lower cord gas pH, which can be quite dangerous for babies. So those are the things that have been studied, in particular, we know that happens more associated with an occiput posterior baby.

Rebecca Dekker: I was aware of some of these risks, but not others with a baby that’s not optimally positioned. One thing that we wrote about last year, Evidence Based Birth®, was post-partum hemorrhage and the third stage of labor at our article, evidencebasedbirth.com/thirdstage, and we wrote about how rates of post-partum hemorrhage have gone up around the world and researchers don’t know why and they’ve tried controlling for different things. And it was interesting that you mentioned the risk of post-partum hemorrhage goes up with posterior positioned babies and that you, in your career, have seen a dramatic increase in the percentage of babies that are positioned that way. So, wonder if there’s-

Ann Gilligan: Yeah. That’s why it’s so hard for me to not get emotional about it because these are things we try, as a hospital, as a system, as a country, to bring down, right? We try to bring down the C-section rate, we try to bring down the sepsis rate and we try to bring down our post-partum hemorrhage rate, but nobody is talking about the positioning and that’s why it’s so important for me to get this message out is that it relates to everything. I’m skilled in fetal heart rate tracing interpretation and I raise my hand and I say okay, what about the malpositioned infant? Because, often times, when I do positioning, when I assist with positioning and the maternal body turns this baby, the heart rate goes from, what we call, category two to category one, right? Because-

Rebecca Dekker: Improves the baby’s heart rate.

Ann Gilligan: The baby’s heart rate improves. So there is a direct correlation that I see, visually, and my peers see, visually, happen all the time, but there’s no talk about it. So-

Rebecca Dekker: What is the actual rationale for why a baby in a less than ideal position would lead to all of these side effects or increased risks? Is there a physiological reason why?

Ann Gilligan: I’ve taught several classes recently, but this one was at the actual first class about two years ago, two and a half years ago, that I taught to a group of physicians and I asked the question, does anybody know the first cardinal movement of birth? And not one hand went up and I was surprised, I thought oh, I’ll have a bunch of people answering and we’ll talk about cardinal movements of birth. And in the end, their answer was they were never taught that in medical school, so they actually don’t understand the cardinal movements of birth and what needs to happen. The answer to the question is engagement. So, you have to have engagement in order for the rest of the six cardinal movements of birth to occur, which is descent, flexion, internal rotation, extension, restitution and expulsion.

So, for instance, we have a huddle every day, right? Two times a day, where we all come together as a group, the nurses and the physicians, we stand around the nurse’s desk and we talk about each patient and this is really a great time to kind of come together and to discuss solutions to problems and suggestions as to how to prepare for the birth. And we always talk about dilatation, but we talk about the parity, we talk about the patient and why she’s here. But in particular, we talk about the dilatation, the effacement and the station of the baby. And that’s all fine, but we need to also start talking about the position of the baby because of the relevance to all of these other comorbidities that I just mentioned. And when we start talking about that, we’ll understand that as the baby comes through the pelvis, it rotates clockwise. So, as the baby comes through and rotates clockwise, physiologically, when you have a baby that’s malpositioned, it doesn’t allow for that turn to happen, that internal rotation is actually what is missing, also. And when you don’t have internal rotation, you don’t have that baby come out looking at the earth, like I call them, or an occiput anterior position. So it’s all related to the physiological process of the birth and the birth canal.

Rebecca Dekker: And if a baby’s occiput is presenting in a posterior or to the right, you’re saying it’s not going to do the cardinal movements as well or it’s going to-

Ann Gilligan: Correct.

Rebecca Dekker: Be more likely to kind of get stuck because it’s the larger part of the head coming through first?

Ann Gilligan: Right. So you have a deflexed head, for instance, in an occiput posterior baby or what they call a military position, so the occiput is not leading the way. When you measure the circumference of the occiput, which is the back of the head, versus from the forehead to the back, you’ve got a two or three centimeter difference there. The perfect scenario is when the baby goes into the pelvis with its head tucked … Excuse me. Its chin tucked-

Rebecca Dekker: Chin tucked.

Ann Gilligan: Down to the chest and rotates from an occiput transverse position to an occiput anterior position and that is what enables the baby to come through with the ease and the safest way for the baby to come through.

Rebecca Dekker: And does that also help the birthing person dilate faster, because the head’s able to descend faster and put pressure on the cervix-

Ann Gilligan: Right. We see-

Rebecca Dekker: Which helps the dilation?

Ann Gilligan: All sorts of cues along the way that baby might be malpositioned and one of those cues, I’ll talk to you specifically about all those cues, but one of those cues is when you do a vaginal exam, you can actually feel that space, posteriorly, because the head is not centralized on the cervix. There’s a certain feel you get when you feel a baby and you know that baby’s in the right position because that baby’s just … The circumference of that whole occiput has filled that space beautifully and has sat on the cervix in order to dilate it beautifully all the way around. And yes, that has a complete correlation with dilatation and descent.

So, our goal is to do what we can to antenatally, intrapartumly, during labor and to get that baby in what we know as the optipal … The definition for optimal position for delivery is the baby in the occiput anterior position. So what I knew way back when was … I figured along the way, with my readings and my teachings, is this bony pelvis, it has the ability to change the shape. In the front, we have the pubic symphysis, which is filled with cartilage, we have the back, we have the sacrum, which, on either side, has the sacroiliac spaces in between the ilium bones. Those are movable and-

Rebecca Dekker: We’re talking about the maternal pelvis?

Ann Gilligan: The maternal pelvis, correct. The bony pelvis in the maternal body. And when you have that relaxin going through, surging through during the intrapartum period, you have the ability for those bones to move. So, the whole philosophy behind the maternal positioning is knowing that the bony pelvis has the ability to move and change shape, and the soft tissue, in particular, the uterosacral ligament, the broad ligament, the round ligament, the psoas muscles, the gluteal muscles, and our two diaphragms, our pelvic diaphragm and our respiratory diaphragm. They’ve done their job, right? They’ve maintained the pregnancy, but during the labor and delivery process, it’s time for them to relax and balance and to stretch to create space. So, that anatomical knowledge of mine was all put together to develop my guide to enable the baby to get into the optimal position.

Rebecca Dekker: That is so fascinating. Is there anything else about the pelvis or anything else that you want to share?

Ann Gilligan: Yeah. So in reference to the position of the fetus in the uterus, there is something else that is very important to note and that is something called asynclitism. And what that means is the baby’s head has shifted over, it’s not in the middle of the pelvis, it’s anywhere in between the maternal symphysis pubis and the sacral promontory, which is over on the side of the hip. So when you have a baby that is off to the side versus going straight into the top of the pelvis, which we’ve-

Rebecca Dekker: So they’re kind of going in tilted?

Ann Gilligan: Correct.

Rebecca Dekker: Because that happened to me in my first birth, which was a very long labor and pushing process with a small baby.

Ann Gilligan: Yes.

Rebecca Dekker: Yeah.

Ann Gilligan: So that is a big deal and that is something that you want to pay attention to, too. So two things is where’s that occiput, and whether or not the baby is asynclitic or not. So, those two issues are very important when assessing. So when that baby is, as you said, Rebecca, with your first, if it’s a persistent asynclitic, meaning the baby continues to … And I call it your iliac crest. It’s almost like it’s pushing into your hip and many of these women have pain on one side, and that persistence of that baby continuing to push into that one part of the hip can prevent that internal rotation of the baby and therefore, the rest of the delivery process.

So, Gilligan’s Guide is a guide and it’s an actual algorithm on a piece of paper that, over the years and with my experience and with all of my education, I have taken the different maneuvers and I’ve developed a couple of my own that will help you determine the position of the baby, and then correct the malposition of the baby. And then I also, on the bottom, I refer to second stage, which is your pushing stage, once you’ve been dilated to 10 centimeters and you’re ready to facilitate the delivery. I’ll talk about things to suggest if things are not progressing or they’re going slow, then you can attempt these different positions. So, essentially, that’s what Gilligan’s Guide is.

And I want to just note that … nothing is wrong with you or your baby if the baby is malpositioned. As I said earlier, this is something that is just … It just happens and it happens for a number of reasons. There are risk factors that will bring a baby into the occiput posterior position and some of these, you can’t control. The first one is this is your first pregnancy, a primigravida. The gestational age of your baby is over 41 weeks, that puts you at a risk factor. Having a baby over 4000 grams is a risk factor. Having an anterior placenta. I often ask my patients, do you know where your placenta is? Because if you’ve got an anterior placenta which is right there in the middle of your uterus, it is a risk factor for having a baby in a posterior position or on the right side because … Just think about it anatomically. You’ve got this big, juicy, blood-filled organ in the way and it just prohibits that rotation. Epidural anesthesia, which is something I want to talk about down the road here a little bit, is a risk factor for having a baby in the occiput posterior position.

So the goals of Gilligan’s Guide is, essentially, to soften the tissue with warm water, which, in essence, decreases the tone of the pelvic floor. You want to create space for baby to rotate. You want to help the baby tuck its chin, because we know that when the baby has its chin tucked, think about how heavy that head is and if that head is hyper flexed back, it makes it harder for that baby to rotate. So, one of the steps is actually helping that baby tuck its chin. And the final step is to actually rotate the baby. Because you’ve done those proceeding steps, then the baby will, in essence, rotate on its own. 

And what’s really important for me is I always place the success on the mother. I never say, “Oh, look what great thing I just did.” Although they say, “Oh, my gosh, thank you so much,” many times, women have gone hours in labor and nothing has been done as far as maternal positioning. You always have to realize it is the maternal body that is doing this rotating, that’s the magic of it. And I say afterwards, I look at her in the face and I say, “Look what your body just did. It’s amazing what you just did,” because you need to empower them by their abilities. They’ve been torn down sometimes, to say that maybe they’re postdates and they need an induction, it’s like why isn’t my body working? Well, your body is working, and look what it just did. So, that’s the beauty of it.

Rebecca Dekker: So you can go to your website, gilligansguide.com and just click on the guide to learn more, and this is something that you provide to all your clients who work with you?

Ann Gilligan: Yeah. What I’ve started to realize is that antenatally, there are things you can do to optimize that position of your baby. And so I see women antenatally, right about 34 weeks is the perfect time, because then I kind of start talking about anatomy and physiology of their body. I have an Instagram called Gilligan’s Guide. I give them lots of information about … Spending time in a lounge chair maybe isn’t such a great idea. Yes, you’re tired, but let’s alternate that position a little bit and what position is the best to aid your baby? 

Babies are smart, they want to get in the right position, but sometimes it’s made a little bit harder with a woman sitting in a 90 degree chair for eight to 10 hours. Maybe it’s a little bit harder when you go from that chair to a lounge chair and watch TV for the rest of the night. The weight of the baby, that heaviness of the back, is going to be towards the maternal spine and therefore, the baby looking up. So if you think about things that you can do to your body, antenatally, you can be more proactive in your pregnancy so as when you get to term, your baby is going to have a higher chance of being on the left side of your body when labor starts.

Rebecca Dekker: And I know, like I mentioned earlier, my first baby was poorly positioned or malpositioned, asynclitic, and she was a relatively small baby, only six and a half pounds when I was in labor, but had an extremely long labor and very long pushing phase of three or more hours. And with my second baby, because of that, it really opened my eyes to the importance of the baby’s position during pregnancy, I’m getting chiropractic care to help because I do have a tilted pelvis because of my scoliosis. 

I forget who recommended to me, and there’s no research on this, this is totally anecdotal, but my baby was posterior towards the end of my second pregnancy and they recommended to just crawl, spending a lot of time crawling. So, I would just get in my basement floor with my toddler at the time and just crawl around, chasing her, and I tried to do that for half an hour, an hour every day and it helped. So, my baby was in a correct position or a better position when I went into labor and had a very smooth, easy birth with a nine plus pound baby. So, to me, it was interesting, the difference and the position between those two births.

Ann Gilligan: Yeah. Just simply by opening up the degree, the angle from the maternal spine to maternal femur in a sitting position. If you think about always having your knees lower than your hips, which actually opens that angle to 120 degrees, you’re going to be tilting the pelvis in a way and allowing that baby more space to rotate. And then simply by paying attention to your baby, tuning into when your baby is actually moving, because it’s not going to help much if your baby’s sleeping, but if your baby’s moving, say you’re driving along and you’re really uncomfortable because this baby is … And, of course, many of the seats in the car are bucket seats, where your hip is lower than your knees, right?

Rebecca Dekker: And kind of slouched back.

Ann Gilligan: Slouched back, poor posture. So, these babies are moving in the car and realize that. If you can, allow yourself to get out of the car and to lean over the car or to do certain things to enable that baby to get in a better position. Because, as I said, babies are smart, they want to be in a better position, but we’ve limited that space by that sedentary sitting position. So these are all things that you can do, antenatally, which is … One of the physicians in one of my classes said, “Is there anything I can tell my patients to do before so we don’t run into this problem?” And I said, “Absolutely.” So I’ve made a guide that we are going to produce and to give to people antenatally, and I think those little baby steps are actually going to help the situation that we’re in. So it’s really incredible, things that you can do because of how brilliant the maternal body and the babies actually are. We have to give them credit, but we have to think about ways in which we can help them.

Going back to the Gilligan’s Guide, in the beginning, when I come in and I assess my patients and what I teach my new nurses to do is … We give report and it’s very thorough and we hit all the safety points, but one of the things that’s omitted is actually putting your hands on the belly and doing what … Something is called Leopold’s. Now Leopold’s is literally 110 years old, it has never been changed, it was developed by a physician. And I don’t do Leopold’s like that, like you see the four different Leopold’s applications of your hands, your full hand on the fetal body. What I do is I take my fingertips, which are full of mechanoreceptors, right? The fingertips are the most insensitive part of your hand. And I tap them, starting at the top of the baby, at the top of the fundus, almost like I’m playing the piano, right? I mean, I don’t know how to play the piano, but it’s almost like I’m playing the piano. I’m tapping my fingers on the top of the baby and then I’m going along down the side of the baby. The back will feel just like a back, it’s amazing.

I had a midwife recently say, “What are you doing?” And I said, “I’m doing Leo …” Or I call it modified Leopold’s. And she said, “I’ve never seen a nurse do that.” Well, ACOG really encourages nurses, labor and delivery nurses to do Leopold’s because it tells you so much. And then you take your hands down and you can actually feel if it’s breech, which we all have heard of the stories of babies being discovered breech, when mom has been laboring all day and she’s now eight centimeters and now we can feel that it’s the bottom versus the head. So, this will help you determine it.

So at the top of Gilligan’s Guide is viewing the abdomen. I actually have the support person come down to the bottom of the … I lay the mom flat, just temporarily, and then I bring the support person to the end of the bed and we both look up at the abdomen, and that will tell you where that baby is lying. The baby’s heaviest part is the back, right? So if the baby is on the right side, you’re going to see that shape of the abdomen over on the right. And I’ll often ask the mom. Right? Mom’s going to know. “Mom, where’s your baby? Where do you think your baby’s back is?” And I can’t even tell you the percentage, it’s very high, where once I’ve confirmed it via the modified Leopold’s, she’s right. And then I ask the significant other, “Where’s that baby? Can you show me it?” And they’ll say, “Oh, it’s over on mom’s right,” and I’ll be like, “Yeah, that’s where the baby is.” So, then, you go and do the modified Leopold’s, then you do your vaginal exam.

You’re going to know so much more about your patient than just doing an exam from below, based on that. And the more you do it, the better. My nurses will say, “I’m not good at that. I don’t know,” but I’m often brought into the rooms to help confirm. I had a situation where it was a young nurse, I had trained her and she came out to get me at the end of the long hall and said, “Could you come in and help me? I just did Leopold’s on a patient. Could you come in and help me determine the position of the baby?” And I said, “Absolut …” She was just getting ready to do, what we call, ripening of the cervix with Cytotec, which is a little pill you put in in the posterior fornix behind the cervix. 

And she didn’t do it yet, she was assessing the position first. The mom was postdates. She said, “It just feels funny to me,” so I went in and the baby was … Back to that, we talked about the fetal lie, the baby was transverse, meaning the axis of the body was running horizontal to the mom’s spine. And if she would’ve given that Cytotec, there could’ve been a complication, such as hyperstimulation of the uterus and even the possibility of having a cord come down because of the position of the baby. So, I commended her over and over and over for her ability to note that that position of the baby was as such, prior to giving the Cytotec. We ended up doing positioning, brought the baby head down, then she gave the Cytotec, which was a much better situation.

So the ability to do a modified Leopold’s is essential for labor and delivery nurses, and physicians who … Certified nurse, midwives use Leopold’s guide the most. The nurses and the physicians, the least. And I think if we all improved on our skills of modified Leopold’s … There was a study done by Sharma in 2008 and it was a very small group, I think it was, like, 244 women, but it was estimated that you can determine the position of the baby, meaning where is that occiput, 100 percent of the time by doing this modified Leopold’s. So, yes, ultrasound is gold standard when you really want to know, but if you got good at this, where I feel like I’m very good at doing this modified Leopold’s after doing hundreds of them, you can determine the position of the baby, which is so important.

Rebecca Dekker: And now that you’ve been teaching these concepts to other healthcare professionals, how is that going?

Ann Gilligan: What I have seen a change in is we are talking about positioning every single day and it warms my heart. I come in and I hear stories from nurses saying, “You will not believe what happened last night. My patient was stalled at six centimeters, I came on, I did positioning with this mom, she went from six to complete in an hour and baby came out occiput anterior.” This happens on a daily basis. Can we talk about epidurals just for a few minutes?

Rebecca Dekker: Yeah.

Ann Gilligan: Okay. I wanted to mention epidurals because, first of all, I love them, I had them with my first, but I want to emphasize the importance of optimizing their use. So I truly believe there’s an appropriate time to get an epidural. Our studies, our research have all indicated that if you get an epidural when the baby is still high, you will have a higher incidence of occiput posterior at the time of placement and I want to explain why that happens. It’s because of the relaxation of the uterine musculature in the pelvic floor. When you have a baby that is on the right side to begin with and high has not come into the engagement or the pelvis yet, you’re going to have a rotation that goes the opposite direction. Now, many times, you hear people say, “Oh, get her an epidural. Everything will relax, baby will rotate.” Well, in actuality, what happens is it rotates. If the baby’s not on the left side, the baby will rotate from the right side to looking up, occiput posterior, which we know of those risks associated with occiput posterior baby.

So the chance of the internal rotation, which is part of that cardinal movement of birth, goes down because you don’t have that firm floor for the occiput to push against, it’s all relaxed, right? That’s what happens with an epidural, the muscles relax. You don’t have that tone for the baby to hit against to cause that internal rotation, so, therefore, the baby rotates the opposite direction to the posterior position. And when we look at the percentage of epidural use in this country, it’s right around 75 percent to 80 percent, which means it equates to 75 to 80 percent of women in bed for the duration of their labor, which, when I talk specifically about maternal positioning, it can be done with epiduralized patients, but it’s optimally done with women standing. When you have an epiduralized patient … We say epiduralized, it’s kind of funny. But when you have an epiduralized patient, the mother is not standing and she doesn’t have the ability to get into the tub, which is one of the first things that I encourage in Gilligan’s Guide, but you can improvise.

So I encourage people to get the warm blanket from the blanket warmer and place on the lower uterine segment for five to 10 minutes to warm that area to mimic the warm water. So, you can improvise with a patient that has an epidural. But what we do know, based on studies, is that when you get an epidural, you run a higher risk of having an occiput posterior baby. But if you get an epidural at the right time, when the baby’s on the left side, that baby will do what we all hope happens with an epidural, the baby will rotate. So if the baby’s on the left side, that rotation just needs to happen a little bit clockwise to fit into that pelvis in an occiput anterior position. The rotation is typically in the mid-pelvis and then it’ll come out looking at the earth.

Rebecca Dekker: So, part of the informed consent process of getting an epidural might include finding out what position your baby is to help you decide on the timing of the epidural because once you get it, there are some things you can do to change the position, but it might be a little bit harder.

Ann Gilligan: Yes, and that’s perfect for you to say because … So, say, that’s part of her birth plan, which you want to honor. So she has gotten to the point in her labor where she feels that the epidural is something that she would like. Well, there’s something that we have to do, from a nurse’s standpoint, in order to get her ready for an epidural and that is to give her a bolus of lactated Ringer’s. When you get an epidural, your blood pressure can go down a bit, and so one of the things that the anesthesiologists have requested on the order sheet is to give her a bolus of lactated Ringer’s. Well, that bolus takes approximately 30 to 45 minutes, so during that time, I’ll say, “Okay, here. Perfect. Your baby is not in the optimal position, we’ve got 30 to 45 minutes, let’s go through Gilligan’s Guide, let’s go through some maternal positioning, let’s get your baby in the right position.” 

And then by the time that bolus is in, and I’ll kind of watch it go down and we’ll kind of count the 100 CCs as it goes, to know that that time is coming, they’ve got to have a goal. When they’re at that point, when they have given it their all, they really need to know that it’s coming, that relief is coming. So, I will use that time wisely, 30 to 45 minutes, versus giving them fentanyl and putting them in bed, versus doing nothing and having her be frustrated and to be scared. I use that time wisely to get the baby in the right position. We have the tools to do this. Get the baby in the right position for birth, then get her the epidural and the baby will rotate from that left side to the occiput anterior and you’re going to have a shortened length in the labor, you’re going to have a much safer delivery and respect to mom and baby.

Rebecca Dekker: So that makes sense. So rather than delaying the epidural, you use the time that you’re waiting for the anesthesiologists and getting the IV fluids in to help optimize the baby’s position before the epidural is placed?

Ann Gilligan: Right.

Rebecca Dekker: Okay.

Ann Gilligan: And the signs of a malpositioned baby, I wanted to mention and help your viewers kind of … Help them figure out because, as I said, the modified Leopold’s is a skill and you want to start now, start today, start on your shift, start doing it on every single patient and you will get better, I promise. I can do it with my eyes closed. Actually, I actually do it better with my eyes closed. Always ask permission of the patient before you do it, explain why you’re doing it. I’ll have nurses come to me and say, “This patient … I’m sure this baby’s posterior, but she doesn’t want to do any of the positioning,” and I have never had a patient tell me that she doesn’t want to do the positioning. Mothers want to do what’s right for their babies. I think the problem is is they maybe haven’t had it explained it in the right way, so you want to explain how easy it’s going to be, how safe it’s going to be, how effective it’s going to be and they always say, “Yes, let’s do it. Let’s make this an easier process.”

But the signs of a malpositioned baby, other than feeling it with your own fingertips, are those stop and start labors. I work triage a lot and I had a patient come in the other day that was sent home in the morning at three centimeters. It was her second baby. She came back to me in the evening, around six o’clock, and the first thing I did was check her cervix, it was still the same. But I also noted one of the signs of malpositioned babies, she was having severe back pain with each contraction. Now, of course, every patient with back pain doesn’t have an occiput posterior, but that is a sign of a baby with a malpositioning. For my admission process, I said, “Here’s the deal. I checked you, let’s get off the cart. It’s the worst place for you to be, is on that darn triage cart”-

Rebecca Dekker: The stretcher kind of-

Ann Gilligan: Correct.

Rebecca Dekker: Yeah.

Ann Gilligan: “Let’s get off. We have to do a 20-minute strip on baby, right? Safety first.” So I’m monitoring the patient, but she’s standing up and I ensure her that this position that I’m going to help her get into is going to eliminate that back labor, and that position is when she is in an A shape versus an L shape, of her spine to her femur, leaning over the cart with her elbows on a pillow during the contraction pattern and kind of rocking her hips back and forth. So, therefore, the baby is hanging down in a hammock-like form, her pelvic inlet is open, she’s created that 120 degrees, she’s provided movement with that rocking of her hips. Literally, five, seven minutes, two contractions, the pain in her back lessened, eventually went away.

20 minutes into it, when I was done with my admission on her, we have to go through a series of questions. She was … No longer back pain and actually feeling a little bit of pressure. So, I know that baby went zip, rotated, got in the right position, was actually putting pressure on her perineal tissue and her pelvic floor. And I called the charge nurse, got her a nurse, got her over to labor and delivery, she delivered within an hour and a half to two hours. I went over and saw her and she’s like, “That was amazing.” I said, again, “Look at what you did. You leaning over like that created this perfect environment for your baby to rotate.” So, realize that you have the ability and the time to do this positioning.

The other signs of a malpositioned baby are an early pushy feeling. We have many women that maybe start feeling pushy at about seven to eight centimeters, and the reason why you feel early pushing when you’re not complete is because that occiput is actually pressing on the rectum, it’s pressing on the wrong part of your pelvic floor because of the position of the baby and it creates this early pushing. And that’s really, really hard, when you’re told that you shouldn’t push because that cervix is not fully dilated. Think about repositioning this baby and getting that mom more comfortable so she doesn’t feel pushy prior to being 10 centimeters, because we know that that will … If she pushes too early, might swell that cervix up.

Having an anterior rim of a cervix present or persistent is also another sign of having a malpositioned baby. If you’ve got a mom that is nine centimeters, nine centimeters, nine centimeters for hours, having that anterior rim present, think about getting that mom in a better position, optimizing that position to rotate this baby and you’re going to have that anterior rim. We have many physicians and providers that will get rid of that anterior rim by actually pushing it back. I feel like if you can do positioning, it’s much better than actually doing the physical reduction of the anterior rim. So, all these women that are having this start, stop labor, what we call Braxton Hicks in their full term, that can be normal, it’s your body kind of rehearsing, but it can also mean that your body is working to get this baby in the right position for birth. So, think about maternal positioning during that stop, start labor, particularly these women that are coming in and out of triage and their dilatation stays the same.

The biggest thing is the contraction pattern. So I’ll walk into my unit, and this is how crazy and obsessed I am, I’ll look over at the central monitor system that we have in our hallway for the providers and nurses to see, and there’ll be 10, 11 external fetal monitor tracings going at the same time and I’ll look at that pattern of contractions and I’ll say, “That woman, this patient, that patient,” three or four out of the 10 would benefit from maternal positioning. Because when you have a uterus that has a malpositioned baby, say asynclitic, like you had with your first, that smooth muscle has a hard time efficiently contracting around that baby from the fundal area, pushing that baby down, is its direction, and the axis of the body is off to the side, you’re going to see an irregular pattern of contractions. So you’ll see, possibly, boom, boom, boom, space or nice big contraction followed with a little one, we call coupling. So if you see that, take that as a sign and do some positioning because that is the main reason for a coupling pattern or an irregular pattern of contractions.

Rebecca Dekker: So we’ve gone through so much information today, ranging from just the changes in labor and delivery nursing to the strategies you use to identify and care for people whose babies are malpositioned. Thank you so much, Ann, for sharing this wealth of information, I’m sure it’s going to be a must-listen, especially for labor and delivery nurses. I can see how just a lot of the stories and examples you gave of doing the initial fetal monitoring strip during triage, standing up and using that prep time for a epidural to ensure optimal fetal positioning, all these tips are just amazing and they’re going to be so helpful, especially for the new nurses out there and, also, for doulas and childbirth educators and midwives and we have a lot of residents and physicians who listen to you. So thank you so much, Ann, for coming on the podcast and sharing your knowledge with us.

Ann Gilligan: Thank you, Rebecca. I mean, there’s so much to talk about, I could go on and on and on. But I just think, to end it, there are four Ps, we always talk about the four Ps of labor and delivery, power, passenger, passage and psyche. So, as I said earlier, we’re always discussing dilatation, we’re always discussing effacement and station, but if we start talking about the passenger, I really, truly believe that we will make a difference in today’s world. We have a current maternal and infant crisis in the United States and if we start talking about position of baby and including that in our initial assessment, I truly believe we will make an improvement to our current situation of maternal and infant mortality and morbidities in this country. And I thank you so much for allowing me to share my information.

Rebecca Dekker: Thank you so much, Ann, again, for coming on the podcast and I want to encourage everybody to follow your work at gilligansguide.com and also, check out Ann’s Instagram page, @gilligansguide because it has a lot of very useful graphics and images you can use, both prenatally and during labor, to help your baby get into a more optimal position for birth.

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