Posterior/back labour can be more painful supposedly yes - but I've had at least one and possibly two and I did both without pain relief so definitely not completely insurmountable if that's your goal! I found gas and air really helpful with DS1, wished I had it with DS2, will ask for it this time. I think what it actually is, is that it causes the pain to be different, which makes standard ways of trying to cope with it redundant and this is the problem, if you don't know your baby is back to back or whoever is supporting you is unaware of tips to manage this. So it helps to know how to identify it, and if you do identify it, how to manage it and why the advice is different than for a standard labour.
The first thing to be aware of is apparently it's extremely common for babies to be posterior before labour, but turn once they engage in your pelvis, so don't panic and think everything is going to be terrible just because your baby is posterior at 35/36 weeks. And again even if your baby is posterior when you go into labour, don't panic and assume it means doom. It's manageable, it just means you need different techniques.
I'm planning to ask at all my later appointments and also when I get to hospital in labour what position they think the baby is in. Your midwife should be able to tell by feeling your uterus. You can also get the hang of how to feel this yourself! The baby's back feels very obvious once you get to the last few weeks if it's pressed up anywhere towards the front, and it's also helpful to think about where you get the most kicks as this is normally opposite to where their back is facing. Baby's back to your left side (LOA = left occiput anterior) is apparently the most common position and you'll feel a hard solid mass there - that's your baby's back. A pointy sticking out bit can be a head or bum. Smaller sticking out bits that move or "poke" in response to anything touching them are likely arms or feet.
If you know you want an epidural then it doesn't matter too much what position your baby is in. These tips are more for if you're planning to go unmedicated, haven't decided, or want to hold off on pain relief until later on in labour for example. That's why I'm comparing them to "normal" unmedicated labour tips.
Normal position progression of labour:
Early labour (1-4cm ish) tends to go slowly in first time mums anyway. Can be 12+ hours or even multiple days, although may be shorter. Don't worry - the majority of this will be absolutely fine and manageable and you may not even be sure whether you're in labour. Rest, sleep, eat, try not to get excited and tell everyone/use up all your energy. Towards the end of this stage, things can start to get tricky especially if it's been really long and/or you haven't slept, but generally if your baby is in a good position then things starting to get more intense, contractions becoming more frequent/regular likely means that you've moved into the active stages (4-10cm).
If you've spontaneously laboured before, you can expect your early labour to be shorter than the previous time/s. Some people say it's roughly halved each time - I think that's an extremely rough estimate, but there does seem to be a tendency for this stage to shorten with each birth.
During early and active labour, the pointy part of baby's head (the crown) is directly pushing on the top of your cervix. This causes every contraction to put pressure on the cervix which helps it to open. You don't have a lot of nerves in your cervix, so this pressure doesn't cause pain. You will still of course have the pain of contractions. Because the baby is above the cervix, gravity REALLY helps! You want to be upright as much as possible. All of the standard tips about massage, movement, water, affirmations/mental images "down baby", TENS etc can really help.
As you get into the later stages (cervix fully dilated), the baby will come down into the birth canal with each contraction and the back of baby's head pushing on your rectum causes you to push like you're desperate for a poo, which in turn helps the baby to come out.
Posterior labour progression:
The pointy part of the baby's head is not putting any pressure on the cervix. The cervix will open anyway, because the contractions and hormones of birth will cause this to happen, but the baby's head isn't helping, which causes the early stage in particular to be longer - the 12+ hours / several days scenario is more likely. Instead, the head is pointing directly into the inside of the small of your back. This causes contractions to feel different with the pain in a different place, perhaps in your back, perhaps radiating down your legs, perhaps all over your body. Gravity/being upright/on your back will make this feel worse. Instead, you want to be on all fours, leaning forward over something, or lying on your left side. This helps gravity take the weight away from your back and reduces the pressure on your spine. Spending time in a hot shower or leaning over a birth ball can really help. TENS might not help or might need to be in a slightly different position to normal. Because it can be hard to rest during this stage compared with "normal" labour, you might become discouraged or tired before you get into the active stage (4+cm)
You will probably need a lot of encouragement/support to get through a longer first stage. Try the old "paracetamol and a bath" (or even co-codamol if you're OK to take it) as rest is likely to be quite important for conserving energy. If you want to sleep (a good idea!) try lying on your side with a pillow between your legs. If things are getting unmanageable and you want pain relief, be prepared to argue for it even if you are not yet the "magic" 4cm. Sometimes because of the indirect pressure on the cervix, the active stage of labour can go much faster, meaning you're not 4cm for ages so "not allowed" an epidural and then all of a sudden you're 9/10cm and it's "too late". So if you know or suspect your baby is back to back and you're really struggling and want pain relief but aren't yet 4cm, be prepared to argue this as a reason, and/or prep your birth partner to do that on your behalf! Or you may be able to have something like pethidine to get you over that hump.
Also, if you're stuck in the early stages for a very long time and you're struggling to cope, what has often happened is that your body has gone into a kind of stress mode, which then feeds back into itself and can cause a vicious circle of stress > panic > not coping > more pain > stress > panic > etc. So whatever you can do to interrupt that and bring yourself back to a mindset that you can cope will often help things start to move on. Again, this might be more useful info for your birth partner than for yourself. For me, with DC1 that was a decision to go into hospital and have pethidine. With DC2, it was asking for an epidural and getting through the process of having it put in, which I was anxious about. In both cases, actually I never got that pain relief I asked for (just flukes) but the thought that I would soon get some relief soon helped my body relax, which helped things to start moving. So whether this is a meditation technique, some kind of pep talk, a change of scenery, a clear and concrete decision to take some pain relief, it doesn't matter at all. Whatever gets you out of that cycle will help things move on.
Active stages is basically the same - leaning over / all fours is likely to be better than upright. Being in a birthing pool can REALLY help because of the weightlessness aspect. Again if you get into a stress/panic/fear/pain cycle, break that cycle. Have pain relief if you need it. It can actually help the baby to turn or things to move on by relaxing you.
In the later stages, because the baby's head is the wrong way around, the back of it will be pushing on your rectum at an earlier stage than it would if it was the front of the head, meaning your body may start to uncontrollably push before the baby is as far into the birth canal. You may be asked/told to stop pushing as you still have a cervical lip. If your body is pushing for you, this can feel really hard to do! You can use your mouth to help with this. Instead of pushing you can do a long slow blow outwards when you get the urge (in hypnobirthing this is called "breathing the baby down" or "down breathing") or if this doesn't help, making your lips soft and relaxed will help relax your body/cervix. So make a kind of "harrumph" sound like a horse, or a "brrrrr" sound like a telephone/shivering noise, when you get this urge and it can help it to pass and your baby to come down past that lip at which point you can push as much as you like! Gas and air can also help. Being upright/on back is no longer a problem as the cervix is now opened, but moving between contractions if your midwife can help can be really beneficial.
Cheat sheet / summary
- Early stage (1-4cm) likely to be longer and less able to ignore than normal. Rest on side with pillow between legs. Take paracetamol/co-codamol.
- Avoid upright/lying on back positions. Seek out forward leaning/all-fours positions/water.
- If getting into a pain/fear/exhaustion/panic cycle, change location and/or ask for pain relief.
- Be prepared to argue for "earlier" pain relief than normal, or consider medium-acting pain relief like pethidine which wears off after a few hours.
- Pushing urge can come too early. Relax mouth and/or use gas and air to stop pushing. Blowing or "brrrrrr" sound/lip movement.
- Move/get up/change position during the final stage in order to help baby come "around the corner". You'll probably need help or support to do this.
- If baby turns during labour you can revert to "standard" coping techniques.