One of the things you may hear while pushing, especially if you have been pushing for a while, is that “baby is rocking back and forth to get under the pubic bone.” But, what does this mean, and is there a way to facilitate this happening faster?
Let’s first understand how baby is moving through the lower midpelvis and outlet so we can visualize what movements may support this final portion of pushing to crowning and baby.
Cardinal Rotations: How Does Baby Move Through the Pelvis
When baby is moving through the pelvis, they make different rotations so that they can fit their head and body through the three main pelvic levels: inlet, midpelvis, and outlet. Baby aligns their head to fit with the widest spaces of the pelvic levels.
When baby enters the inlet, or the top of the pelvis, they tend to be in an occiput transverse position, or the back of their head is towards either hip (usually left). This is usually abbreviated to OT, occiput transverse, with either the left (LOT) or right (ROT) side.
As baby rotates through the next pelvic level, the midpelvis, they tend to move from this OT position through OA, or occiput anterior, where the back of the head is towards the front of the pelvis. This internal rotation from OT to OA is when baby is rocking under the pubic bone. Once they reach OA, their head fits under the pubic arch and then tends to stop “moving back in” with pushes.
But, getting from this OT or LOA/ROA position (baby is diagonal towards the front) to OA can take some effort. It may feel like you’re taking two steps forward and 1.5 steps backward with every push!
How can we help baby finish this rotation so we can finally meet them??
Create more space!
If baby is trying to move from OT/LOA to the OA position, we can create more space in the lower midpelvis more so on the side baby is rotating from. This is usually the left side. Sometimes, there is an overemphasis on if you are pushing, then we need to open the outlet with both legs in internal rotation at the hip. But we want to create space based on where baby is at, not what is happening during labor. If baby is not yet at the outlet, or in an OA position under the pubic bone, we may not want to focus on creating space in the outlet quite yet. Rather, we want to focus on creating space asymmetrically in the lower midpelvis so baby can finish their rotation to get under the pubic bone.
Two movements you can try depending on your mobility and fatigue include:
Half-Kneeling Lunge (lots of mobility and feeling pretty energized)
Can be done with an epidural depending on movement capability. If you cannot get yourself into the position, it is likely not a safe position.
Focus on left leg forward first, push through a few cycles (2-4 pushes per contraction). Then switch legs, if needed.
Side-Lying with Single Leg Knee Press (less mobility or feeling more fatigued)
Can be done with an epidural fairly easily.
Try left leg on top first but follow your intuition as well. Which side feels better for you? Switch legs, if needed after a few push cycles.
Half-Kneeling Lunge
In the half-kneeling lunge, bring the left leg forward, and you can tilt the head of the bed up so that you can lean on it with your upper body. Trying to reach the surface that your foot is sitting on may be more challenging.
Movement Cues:
Drive Femur Back or Hip Crease Back
Rotation towards front leg (internal rotation emphasis)
You need to be able to get yourself into this position, or it is likely not a safe position. If you have an epidural, this movement is still an option but only if you can get into it without any assistance. If someone needs to physically place you in this position, it is not safe.
As you lunge, we want to focus on driving the left femur back into the socket; this will emphasize the opening of the posterior pelvic outlet (aka creates more space where baby is at). You can either drive the femur back yourself, or your partner can actually push firmly against your knee as a counter pressure.
Next as you drive the femur back or the hip crease back, you want to think a slight rotation towards the front leg. This rotation is happening at the hip. So think the pelvis is shifting on top of the femur internally.
These movements combined will create more space at the bottom of the midpelvis, and can help baby finish their rotation to OA. Push here for a few contractions, until you either want to change positions or feel a shift, then return to whatever your preference is for pushing positions.
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Side-Lying with Single Leg Knee Press
In the side-lying position, focus on applying counter pressure to the top leg. While holding the leg, place the palm on the knee and think drive the femur directly back into the socket. As you do this, you will notice that the hip moves into an internally rotated position, or closed hip position where the angle between the femur and the pelvis is less than 90-degrees. When doing this counter pressure technique, it helps to create more space in the lower midpelvis. This asymmetrical opening usually feels great for someone who is pushing and whose baby is still trying to get under the pubic bone. Plus, the extra space can help baby finish their rotation to get under the pubic bone!
I’ll use this technique on my clients who have less mobility or feel fatigued, to create more space in the lower midpelvis when baby is rocking to get under the pubic bone. Usually, we start to see baby crown shortly after applying the technique with some effective pushes!
Learn more pushing techniques in our childbirth education courses. We offer our courses in-person at our facility in Aberdeen NC; virtually via zoom from the comfort of your home; and online in a self-paced course with pre-recorded videos. Our 90-minute pushing webinar is offered every other month, where we break down the mechanics of pushing and helpful strategies to approach pushing with confidence!