Please take a moment to watch this video and read the article about the alarming upward trend in C-sections for first time mothers.
Ripple effect seen from rising C-sections in first-time moms
One in three first-time moms are now delivering their babies by
Caesarean section, according to a new study.
This has a tremendous ripple effect because most of these moms are
likely to have repeat C-sections, says lead study author Dr. Jun
Zhang. “C-section in first-time mothers is increasing and VBAC
(vaginal birth after C-section) is decreasing.”
Zhang is a labor and delivery expert at the Eunice Kennedy Shriver
National Institute of Child Health and Human Development, which funded
the research. He says his study, published in the American Journal of
Obstetrics & Gynecology, also found that 44 percent of women who
attempted vaginal delivery were induced, and in this group the
C-section rate was twice as high as women who were not induced.
More research is needed to determine whether inducing a pregnancy
leads to complications, which then make a C-section necessary, Zhang
says.
Zhang also says the study suggests that doctors may not be patient
enough. Researchers found that with first time moms attempting
natural delivery, the decision to deliver the baby by C-section was
made before the recommended three hours of “second stage of labor”
(when moms are pushing) or before the moms were at least 6 centimeters
dilated, both short of the recommended guidelines set by the American
College of Obstetricians and Gynecologists.
Zhang and his co-authors analyzed electronic medical records from more
than 200,000 births at 19 hospitals across the United States.
In March, the Centers for Disease Control and Prevention released data
that shows that 32 percent of babies in the United States are
delivered by C-section, which is the highest rate ever recorded and 53
percent higher than the rate in 1996. Some pregnancy complications
that could make a C-section more likely include the age of the mother,
the mother’s weight and twin or multiple pregnancies.
Zhang says scheduled repeat C-sections now contribute to almost a
third of all Caesarean deliveries. He says only one in six women even
attempted natural delivery after having a C-section in a previous
pregnancy. “Prelabor Caesarean delivery due to a previous uterine
scar (from previous C-section) was the most common reason for
Caesarean section,” the study said. According to an NIH panel of
experts on vaginal birth after Caesarean, the risk of uterine rupture
is a common reason for doctors to suggest a repeat C-section, even
though that risk is lower than 1 percent.
Carol Hogue, a maternal and fetal health expert at Emory University
in Atlanta, Georgia, was on the NIH panel. She strongly believes
that moms-to-be need to be better educated before they have their
baby. “C-section itself is not a benign thing,” says Hogue. While many
people may no longer view Caesareans as a major operation, she says
women need to remember that there are risks
for a mother because it is still major surgery, which can include
complications with anesthesia and scarring. ‘The process of labor
helps the baby survive,” Hogue adds.
Just last month, ACOG reaffirmed its guidelines that VBAC is a viable
option and urged physicians to counsel women who have had one or two
previous C-sections to consider delivering their baby naturally.
The study concludes that if fewer women were induced, if better
guidelines for the timing of Caesareans existed and if women were
better educated about their ability to deliver a baby after a surgical
birth, it could help lower the number of C-sections in this country.
I was inspired to share this letter from one of our students.
Deb,
People often talk about “defining moments” in their lives. I can now safely tell you that the conversation we had after class a few weeks ago in which you gave me Dr. Rodke’s name and hooked me up to talk to Trisca, the mother that delivered a vaginal breech baby, will always and forever be a defining moment in my life. After speaking with Trisca and meeting with Dr. Rodke, I made the most important decision I have made, to date, in my life. With only a week to go until my due date, I switched to Dr. Rodke’s care and will never look back. I felt an incredible weight had been lifted off my shoulders, and that I was, at last, at peace with my breech situation and ready to have my baby. I was so grateful to have finally found the support of a doctor that was going to allow me the opportunity to have a vaginal breech birth. My former doctor was not open to this and had set a date for a cesarean.
Last Friday, (June 25th) three days before my due date, and only one week after meeting Dr. Rodke, my daughter was born! I had the most incredible labor experience, all thanks to Dr. Rodke. From the time we arrived at the hospital to the time my daughter was born, was only 5 hours! And I was able to deliver my breech baby, vaginally and completely drug free, just as I had been wanting to all along. Add to that the fact that Dr. Rodke’s massaging during delivery made it so I did not tear at all and required no stitches, and I was truly in awe of her talent.
I cannot gush enough about my doctor, but I also cannot thank you enough for bringing her into my life. I needed to be reminded that I had a choice in how my baby was going to be born and who was going to help me with that. For that one post-it note with her contact information, I will be forever grateful.
Thank you for being a force of positive change in so many women’s lives, especially mine.
Anri
It can be easily forgotten that you, the pregnant mother, has the power and ability to make choices about how you would like to see your baby brought into this world, and how you choose to raise your child. Sometimes those choices are easy while at other times they can be met with resistance. By examining the choices that you will encounter during pregnancy, labor and delivery and motherhood, you have the opportunity to explore what is truly right you as an individual, regardless of what others think.
The decision to breastfeed, or not to breastfeed, is a perfect example of such a choice. Throughout the month of August, we celebrate National Breastfeeding Awareness month. The media is extra focused on highlighting and supporting the benefits and choice to breastfeed. In a recent article, Food For Thought which was published in the Boston Globe, a woman explains her experience as a bottle feeding mother. The article does not deny the health benefits of breastfeeding; however, it discusses the judgment that bottle feeding mothers face. What I find empowering about the article are those mothers that are swimming upstream against the popular choice, and who are doing so with courage and conviction.
This is not unlike the “Home Birth Movement.” Many people do not understand this choice and immediately dismiss it as unsafe or even careless, even though many medical studies have come to the conclusion that it is just as safe, if not safer, then a hospital birth for low risk women. Similar to the breastfeeding article linked above, going against the norm is not wrong, it is a choice.
Anri’s birth story is a wonderful example of a mother making a tough, but honest and authentic decision which honored the way she needed to birth her baby. Thank you, Anri, for inspiring others to look deeply inside themselves to find their true voice and stand by their decisions.
I can honestly say that one of my greatest pleasures is a good night’s sleep. When I get those precious 8 hours, I am like a new person: calm, rested, clear headed and energetic. Unfortunately, this is a rare occurrence. Several years ago my cat decided that it is important to wake me up with licks from her sandpaper tongue every 10 minutes from 5am until I finally submit and get out of bed. Friends joke that I will be well prepared for kids. My partner, Joey, remarks that “sleep deprivation does not need to be practiced.” With that, I greatly empathize with my pregnant students who frequently tell me their sleep troubles.
Here are some common topics often brought to my attention:
Vena Cava Syndrome
If I’m going to talk about sleep, I need to start with the whole “sleeping on the left side while pregnant” issue. I am shocked by how many students come in and have been told by their care provider that it is important to sleep on their left side, but have never received an explanation as to why. It is too often that a very concerned student asks me if she hurt her baby because she woke up on her back.
So why the left side? It is because of Vena Cava Syndrome. The inferior vena cava (a large vein that is responsible for the venous return from the lower half of the body back to the heart) runs slightly to the right of the aorta. When compressed by the weight of the baby, the blood return is compromised and the mother may feel light headed and nauseated. Think of the vena cava as a big hose, and the baby as a foot stepping on the hose. When the hose is compressed, the water can’t flow out- same idea as vena cava syndrome. This is easily remedied by moving so that the baby can roll off the vena cava. Since this vein is located on the right side of the body, it is recommended as the baby gets bigger, the mother sleeps on her left side. For some women, this never becomes an issue and they can sleep however they like throughout their pregnancy. Others are more sensitive to this and must modify their sleep position. As mentioned earlier, it is not necessarily dangerous if you wake up on your back. Bodies are smart, and signal the mother with signs of light headed-ness, nausea, heaviness in the chest or breathlessness.
Achy Hips
For those mothers requiring a modified sleeping position, side sleeping can take some getting used to. I recommend getting a body pillow and experimenting with how to use it. One suggestion I have to prevent achy outer hips is to NOT sleep in the fetal position. Even with the body pillow between your knees, you may find yourself waking up with hip pain. This discomfort is due to the pressure of the body on the greater trochanter of the femur. The greater trochanter is a process at the top of the femur (thigh bone). Check out the picture below. You will notice how the greater trochanter protrudes slightly outward. When sleeping with the hips stacked, like in the fetal position, a lot of weight is placed on that bony process and results in hip pain.
My suggestion to alleviate the hip pain is to extend your bottom leg and slightly roll towards your belly. Then, bend the top leg and rest it on a firm pillow or body pillow. This will take the weight off the greater trochanter and place it more towards the front of your hip.
Calf Cramps
If you have ever been woken up in the middle of the night by a calf cramp, you surely do not want to repeat the experience! If this should happen again, the best way to alleviate the pain is to flex your foot or stamp your foot on the ground. This will stretch out the cramping muscle. Avoid pointing your toes which will only tighten the muscle more. “The etiology is unknown, but a deficit of calcium or magnesium has been proposed as the cause” (Obstetric and Gynecologic Care In Physical Therapy 2nd Edition pg 157)
By simply adding a few extra foods to your diet that are rich in calcium or magnesium you can likely get rid of those nasty cramps. Here are a few ideas: dark leafy greens, nuts (almonds, cashew, brazil), wheat germ/bran, seeds and coconut water. It is also important to hydrate well.
Insomnia and The All Night Peeing Fest!
These two topics somewhat go hand and hand. Chances are at some point you wake up in the middle of the night to pee and then cannot fall back to sleep. One of the reasons for not being able to drop back into dreamland could be because of hypoglycemia - your blood sugar is low. According to Holistic Midwifery by Anne Frye, the explanation is that you may be hungry without even registering it. Seven to ten hours is a long time to go without nourishment. This long stretch of time between meals could cause the blood sugar to drop, and a small snack or even just a glass of milk could help you fall back to sleep. The author also suggests that a deficiency in B vitamin could also lead to insomnia. Here are a few suggestions for foods rich in vitamin B6: meat, brown rice, fish, wheat germ, whole grain cereals, and soybeans.
So now that we have the midnight snack under control, what about the need to empty the bladder all night? This next piece of advice actually came from the doctor of one of my students: Take a warm bath right before bed. She said it helps to fully empty the bladder. My understanding of this theory is that a bath helps to relax the sphincters and pelvic muscles allowing for full evacuation of the bladder. Maybe that is why so many little kids pee in the pool! Regardless of the reason, many students have reported back that this works for them. I would also recommend limiting fluid intake close to bedtime.
Anxiety
Having a baby can rank among the biggest life changing events that one can go through. It is no wonder that the mind is racing about the arrival of your new little one. While this pre-baby anxiety is normal and natural, it can also be disruptive to one’s sleep. In class we often start and end with pranayama (breathing exercises) and relaxation techniques that can help focus the mind and relax the body. It is difficult to relax when the mind is racing.
Here are a few pranayamas and relaxation techniques that can be done in bed to help you focus and fall back to sleep.
Sama vritti (equal breathing)
This pranayama is done by inhaling and exhaling for an equal number of counts. It can be a great exercise to create balance and focus since it requires the practitioner to remain conscious of the length of each inhale and exhale.
Also note- The traditional Sama Vritti pranayama is done with a retention at the top of the inhale and bottom of the exhale. That is not incorporated into the prenatal version of this exercise.
Deep Belly Breathing
Deep belly breathing is thought to be the best way to oxygenate and relax the body. Breathing deeply into the diaphragm brings energy to the Solar Plexus, the chakra that governs ego, emotions, and intellect. This technique is also one of the most useful for pregnant women to focus on since it cultivates relaxation and strength.
Deep belly breathing is done by breathing deeply through your nose, expanding your abdomen fully. Slowly and completely exhale through your nose, pulling your abdomen in so that all the air is released before taking another full belly breath. If you ever look at a baby sleeping, they naturally engage in this type of breathing.
Mantras
This exercise coordinates the breath with a particular phrase or word. For example, as you inhale you internally say to yourself “Let” and as you exhale you internally say “Go” and keep repeating. I personally find this helpful to quiet my mind when I notice that I am thinking of other things. Then, I just go back to my mantra and my deep breathing.
Progressive Relaxation
As a doula, I often use this technique to help relax the laboring mama. I go through the body from the top down and ask the women (or myself when I am experiencing insomnia) to relax specific parts of the body as the person exhales. For example, inhale- exhale “Relax your scalp.” inhale- exhale “Relax your forehead.” inhale- exhale “Relax the muscles around the eyes”….and so forth. This technique brings awareness to areas that may be tense but also helps focus the mind back into the body and the breath.
Hopefully these tips and tidbits will help you have a better night’s sleep so you can catch some much needed Zzzs.
Given the wide range of interpretation and accuracy of determining the due date, it is important to discuss with your health practitioner what his/her protocol is for passing the due date. Throughout my years working with the pregnant population, I have encountered some care providers that allow up to the full gestation period of 42 weeks before induction, while other care providers induce 10 days, one week or one day after the due date.
If the mother passes her due date of 40 weeks and would like more time before a conversation ensues about induction, she can ask can try some natural alternatives to induce labor. If the care provider is open to the mother’s need for more time, the expectant mother will likely go through a battery of tests to assure the continued health of both herself and her child.
Kick counts This is a completely noninvasive test that can be done at home, and can be reliable way to keep track of the baby’s well being. The mother is to count the kicks from the baby in a given time and keep track of the pattern. ACOG recommends to write down how long it takes the baby to make 10 movements.
Nonstress test This test is measuring the baby’s heart rate at rest and during an active period. It is done with an EFM (external fetal monitor) and an external monitor measuring uterine contractions.
Biophysical Profile This test combines the results of the nonstress test and an ultrasound machine to give the measured volume of amniotic fluid and to check the baby’s breathing, movement, heart rate and muscle tone.
Contraction Stress Test This test will measure the baby’s heart rate during a contraction to asses how the baby is handling the reduction of oxygen during the contraction.
Mother’s Blood Pressure and protein in urine The care provider will continue to monitor the mother’s blood pressure and check for protein in the urine to assure the mother is not developing pre-ecclampsia.
It is rather uncommon to actually pass 42 weeks of gestation. In fact, only about 7% of babies are not delivered by that point. Pregnancies bypassing the 42 week marker are referred to as “post-term pregnancy.” Note “post term pregnancy” is NOT defined as simply passing the due by a few day, but passing it by a significant amount of time. For mothers that do pass the 42 week mark, the care provider will likely want to induce labor to avoid serious complications that can arise with post-term pregnancies.
A main component of the prenatal yoga class is the exploration of pain management and relaxation techniques that can be used during labor and delivery. My favorite (and most effective) exercise is the mock contraction. This is a 60 second wall squat that is meant to simulate the timing of a contraction and is frankly, rather uncomfortable. I know that contractions are not experienced in the thighs, but maintaining this position for a minute will certainly make you figure out how to relax and get through it. In class we typically run through this pose two or three times. After the first time, I ask the students, “So, how was that? What did you do to get through it?” Sometimes I get blank stares, but often women speak up about what techniques and tricks they found helpful: breathing, rubbing the thighs, counting, rolling their shoulders, and the list goes on.
“Good!” I say, “These are all techniques that you can acquaint yourself with now to learn how you best deal with discomfort.” I go on to say “It is very unlikely that you will not experience some sort of discomfort or pain during labor.” This is where it gets interesting, and knowing smiles and smirks emerge from some students. “Unless you have a planned induction and get the epidural immediately, or have a planned cesarean, you will be dealing with contractions on your own for a while. Most care providers do not want you at the hospital too early. And even then, you will likely have to wait in the waiting room, go through triage, get admitted to the Labor and Delivery floor, and then have to wait for the anesthesiologist to arrive.” The smiles and smirks disappear.
Over the weekend, I attended a very long birth. We had intended to use the Birth Center, but as labor hit its 27th hour, the laboring mother opted for rest and relaxation by taking the epidural. After moving out of triage (which took about 45 minutes) and into a room, we ended up waiting almost 2 hours for the anesthesiologist to be available. There was a cesarean that was just getting started, and then an emergency arose which bumped us to third on the list. To withstand this two hour wait, we breathed, rocked, moaned, visualized, and created counter pressure with a hot water bottle.
My reason for telling this story is in no way meant to scare people, but instead to give a clearer idea of what may happen. Realistically, those wanting an epidural will still have to employ some pain management techniques for a period of time. It is much better to have a a variety of techniques learned and readily available than be surprised by the power of labor.
Think of learning these relaxation and pain management techniques as homework for you and your partner! You can either do the mock contraction or the One Minute Ice Cube test (I got this from my Lamaze training). This exercise requires you to put your hands in a big bowl of ice water for one minute. Again, it is very uncomfortable and requires concentration and support to get through it. On a side note- if you are practicing these at home with your partner- have the partner try a round of two- the exercises can provide some perspective and empathy.
There are so many ways to find some relief during labor. I have written blogs on several techniques and ideas that I would like to share as well as my top 3 favorite techniques.
Breathing and Progressive Relaxation
I find that deep breathing and systematically relaxing the body from the top down can be very effective in creating concentration and relaxing the body. Deep breathing helps shift the body into the parasympathetic nervous system which is the “rest and relax” state as opposed to the “fight or flight” response to pain.
Hot water bottle with counter-pressure and massage
The heat from the hot water bottle applied to the lower back or lower abdomen can create immediate relief as well as applying pressure or massage to the sacrum area .
Movement
Next time you stub your toe, notice the immediate desire to move around to relieve the pain. Movement decreases tension and relaxes the muscles which will lessen the perception of pain.
Hopefully your labor will unfold as desired. If there is a bit of a snag in the plan and you have to deal with unexpected turns, you will have the tools to get you to the other side.
As a doula, I’ve heard this lament time and time again: “I received the name of my doctor from a friend, and if I had known what to ask, I probably would have switched doctors a long time ago. Now I feel it is too late to change!”
Ideally, it’s best to have a very important conversation with your doctor at the beginning of your pregnancy — to make sure that the way he or she practices medicine matches up with the way you want to birth. If you’re already into your pregnancy and a relationship with your doctor, be sure to ask these key questions at your next appointment! When you’re in labor, it isn’t a good time to start negotiating your labor and delivery wishes. It’s essential that you feel heard, supported and respected — long before the big day!
What is your birth philosophy?
There are two basic philosophies to approaching birth. The first is the medical model, which emphasizes the pathologic potential of pregnancy and birth. As the art and science of managing pregnancy, labor, delivery and postpartum, this approach tends to lead to more managed care.
The second approach is the midwifery model, which subscribes to the idea that pregnancy and birth is a natural, physiological process that should be inherently trusted. This approach tends to have fewer routine interventions.
Neither of these schools of thought are wrong. It’s just important to find out ahead of time which direction the care provider tends to lean. If you’re approaching birth wanting to avoid most routine interventions, you should make sure that your care provider and the entire practice approaches birth that way. You can’t change the way your provider practices medicine, but you can change your provider.
How aggressively do you manage patient care?
In terms of a low-risk, healthy woman, how open is the practice to various birth options? For example: Is the practice going to let the laboring woman have intermittent monitoring, or are they insistent upon full-time EFM (external fetal monitoring)? When do they advise the mother to come to the hospital? Is she allowed to eat or drink freely throughout labor? Is the care provider open to non-traditional ways of pushing (i.e. side-lining, squatting, the all fours position), or do they prefer her on her back? Will the mother require mandatory IV fluids? Is the practice open to natural ways to augment labor — like castor oil, nipple stimulation, acupuncture or evening primrose oil?
Many of the routine managed interventions have been studied and determined not beneficial for the mother and baby. In fact, ACOG (American College of Obstetricians and Gynecologists) recently changed their guidelines in regards to only offering ice chips to laboring women. They are now supporting clear liquids, such as water, fruit juice without pulp, carbonated beverages, clear tea, black coffee, sports drinks and clear broth. However, many care providers still have not changed their practice to adjust to this new information.
Restricted food and beverage intake is just one of the many routine interventions still enforced without strong evidence of the benefit. Have a clear understanding what you — as a laboring mother — would like or not like, and go over it point by point with your care provider.
What kind of schedule will you be on?
Some of these decisions may be hospital protocol; others may be up to the care provider. Discuss the following areas of schedule ahead of time:
* How long can I labor before artificially augmenting labor (using pitocin), assuming the amniotic sac has not broken?
* How long can I labor if my water has broken?
* How long can I labor with labor augmentation?
* How far past my estimated due date can I go without being induced, assuming my baby and I are fine?
* How long am I allowed to be in the second stage of labor — the pushing stage?
* How long can I labor at home?
If you’re feeling resistance, ask a few questions that might help clarify the reason for the resistance, and possibly give you more time. (”What would happen if we wait? Am I OK? Is baby OK? Can we have more time?”)
What are the statistics or rates of the practice?
Taking a closer look at the rates and statistics of the practice will help answer a lot of questions regarding the care provider’s approach to birth. Inquire about the following:
* What is your c-section rate?
* What is your induction rate?
* What is your episiotomy rate?
* What is your instrumental delivery (forceps and vacuum extraction) rate?
* Does your practice work with more high-risk women than low-risk women?
These answers will color the statistics of the practice. If the practice primarily works with high-risk women, they may be more inclined to suggest an induction or cesarean birth, because they may be used to approaching birth in that manner.
When does your care provider arrive at the hospital or birth center? How involved is he or she in the labor process?
On several occasions, I have seen women ready to push, but were told not to since their care provider was not at the hospital yet. These births were not particularly speedy, and should have given the care provider enough time to arrive and be prepared. A mother should never have to fight her natural impulse to push her baby out, simply because her care provider is not present.
Some care providers are very involved with the labor process and check in often, or even stay in the room for a bit. Usually midwives are most involved in the labor process — but some doctors are wonderfully supportive, as well. A doctor once told me, “My teacher in medical school told me, ‘The most important thing an OB needs is a comfortable chair. Sit back and let nature unfold.’” This is the kind of support laboring mothers need — and deserve!
My latest published article as it appears on Mindful-Mama.com (Check out the website- it is really great!!)
Birth intrinsically brings some level of fear and anxiety, since it can never fully be planned. I have met very few women during my career as a labor support doula that have not expressed some sort of fear or anxiety about their upcoming labor. In fact, I remember a midwife once telling me that it’s those who don’t have any nervousness around labor and delivery that worry her most.
To begin to understand, address, and hopefully put fears to rest, a birth plan is essential. Creating a birth plan involves discussing how the parents foresee their upcoming birth, determining whether they have birth preferences, and generating open dialogue that identifies any fears and anxieties about the labor and delivery process. Commonly, fathers are concerned about the well-being of mother and baby. The mother is often concerned about how she will tolerate labor, how long it will be, or if the labor she envisions will be the labor that occurs.
Fear’s Role in Labor
Beyond the emotional drain of fear during labor, there is a biological response to fear. Labor progresses, in part, because the body produces oxytocin, stimulating uterine contractions. When all is going well, the oxytocin flows and labor runs smoothly. However, when the body is stimulated into the “fight or flight response” because the mother is afraid or feeling unsafe, the body overrides the production of oxytocin and produces adrenalin, which slows labor down.
While walking out of the front door on her way to give birth, one mother I worked with said, “Next time I pass through this threshold, I will be a mother.” For some women, that is extremely exciting. For others, extremely frightening.
It’s not uncommon for a mother who is in a nice, steady labor pattern at home to enter the hospital or birth center — with its unfamiliar smells, bright lights, noise, new people — and see her labor pattern space out or stop completely. This is due to the increase of adrenalin or, as some doctors call it, the “white coat syndrome of labor.” Going back to our roots in nature, most animals birth privately or in hiding. They don’t give birth in the middle of a room with bright lights shining on them. We, as animals, also need to find that comfortable, non-intimidating space so we feel safe to open up and birth.
Appreciating the Mother
The best support comes when those attending the labor and birth understand the woman. If a mother has expressed she is afraid of the pain, talking about different pain management techniques that can be employed often eases fear. If a mother feels shy about having a lot of people present during labor and delivery, finding ways to limit unnecessary traffic and create a quiet, intimate atmosphere where she feels less exposed is important.
Some mothers come into labor with the memory and experience of previous births. These births may have either heightened their confidence or diminished it, depending on how the first birth evolved. If it was a traumatic experience, listening carefully to the birth story, and pinpointing the fear that’s associated can help relax her for the next birth. By identifying these concerns ahead of time, a mother’s confidence can be built up, and she can understand that her fears and concerns are being heard — and met with a supportive response.
Of course, there are times when, regardless of preparation, subconscious fears are revealed during labor. One mother I worked with, who had a particularly rough labor, called me and requested a meeting a year after her baby was born. She told me that after spending a long time reflecting on her labor, she realized it was so difficult and long because she was subconsciously holding her baby in. She was deathly afraid of letting the baby be birthed, and having to take the responsibility of becoming a mother. This was the first time I had ever heard a woman say that. It took a lot of bravery and insight, and she isn’t the only woman who has had those feelings.
Building Confidence
One of the most successful ways of handling the natural fear surrounding labor and delivery is to make sure the expectant mother is aligned with a supportive birth team. The environment as a whole (a woman’s partner, doula, care provider and place of birth) should be considered carefully.
It’s also important for mothers to read and listen to positive birth stories. If a woman is continuously bombarded with negative, traumatic, fear-provoking birth stories, it will impact her ability to be confident that her body can successfully birth her baby. Stay away from the birth drama in TV shows, and choose Ina May Gaskin’s “Guide to Childbirth” instead for amazing, encouraging stories from other women.
Doulas Get Nervous, Too!
After 7 years, more than 80 births, and 5,000 prenatal students, I feel confident that I understand the mechanics of labor, common inventions and problems that may arise. However, I still get a touch of nervousness when I head into a birth — I want everything to go well for the parents. I don’t want to let them down. In response to my doula anxiety, I’ve created a personal ritual: Before I knock on an expectant mom’s door or make an appearance, I take a deep breath, close my eyes and ground myself. The best I can do is be fully present and open, and offer my knowledge and experience mindfully.
(Just received this from Choices In Childbirth!)
We need your help!
At midnight tomorrow, April 30th, the majority of New York City’s home birth midwives will no longer be able to practice legally. Unless immediate action is taken by the Governor and the NYS Department of Health the women that these midwives serve will be denied access to a home birth with their chosen provider and these providers will no longer be able to practice legally in NYS.
YOU MUST ACT NOW to save the home birth option for New York Women:
Call:
* 311
* Wendy Saunders, Executive Deputy Commissioner for the NY State Department of Health, appointed by Governor Paterson. 518-474-8390
* Larry Mokhiber, he Secretary of the Board of Midwifery (518-474-3817, extension 130)
And say….
With the closing of St. Vincent’s Hospital, half of the licensed, highly trained home birth midwives serving NYC have lost their Written Practice Agreement (WPA). St Vincent’s was the only Hospital in the city supportive of a woman’s right to choose a home birth and willing to sign a WPA. In the weeks since it’s announced closure, these midwives have reached out to hospitals and obstetricians all across the city looking for support, with no success. Please help us to save the homebirth option in New York.
For those looking to avoid routine interventions or put off pain medication, care providers commonly recommend staying home for as long as possible. This advice is very well intended, but the birthing mom’s partner will likely be called on to help make the final call about when to go in. That responsibility can be very overwhelming if he or she is unfamiliar with the sounds and movements of labor.
As a doula, I am well acquainted with the phone call when the partner says: “The last contraction was really strong - we are heading into the hospital NOW!” At this point, I usually ask if the laboring mom can come to the phone. I want to listen to her during a contraction and assess where things seem to be. One of the benefits of having a labor support doula, or anyone that is familiar with the mechanics of labor, is that they can recognize the “signposts” of labor and have a clearer idea of when to head to the hospital or birth center.
With that in mind, this blog entry is intended to help the laboring mom’s support team identify the signposts of labor.
Stage One of labor is defined as the cervix dilating from 0-10 cm and effacing (thinning of the cervix) from 0-100%. This stage is broken down further into: early, active, and transition.
Early Labor- 0-3cm
This stage may start subtly, with minor back aches or menstrual cramp-like feelings, and is often the longest. Contractions may start pretty far apart and last only 30-45 seconds. The mother may notice more of the mucus plug passing. As this stage progresses, the contractions will start to become more regular, longer, and closer together. The cervix will start to efface (thin out) more. This leads into the next phase: active labor.
In active labor, the mother may experience:
-Mild contractions, similar to menstrual cramps. These contractions are not so strong that you cannot talk through them if you needed to.
-Lower back ache
-Excitement
-Mild diarrhea
-Anticipation
During this stage, I recommend trying to ignore labor. It is so easy to get caught up in the start of the laboring journey, but you do not want to pull out all your pain management techniques too soon and be exhausted by the time you really need them. If labor begins during the night, try to keep sleeping. If it begins during the day, alternate between resting, a gentle walk or start a “labor project” - something that can keep your mind and time occupied as labor progresses. Bake some cookies for the nursing staff - it is nice to go in and make friends with them!
For the partner, I recommend keeping the laboring woman company and encouraging her to keep eating, drinking and emptying her bladder on a regular basis. This is also a good time to start organizing the belongings that will be going to the hospital or birth center. I also recommend giving a heads-up to the doctor, midwife, doula, babysitter etc.
Active Labor 4-7cm
During this stage the contractions are becoming more regular (5-2 minutes apart) and lasting about 60 seconds. There will be more “bloody show” (a mucus discharge that is tinged pink, red or brown), which is is a sign of cervical change. You will notice a shift in the mother’s mood; she will become more introverted and will be concentrating a lot more on her breath and her contractions. She may also need more support and pain management techniques at this point.
During active labor women may experience:
-Stronger contractions
-More intense backache
-Desire to talk less
-Mood shift to more serious and introverted place
-Apprehension and feeling unsure that she can do this
-Desire for support
-More “bloody show”
During this stage, the mother might turn her focus inward and will need to rely more on her pain management techniques. It will also be more difficult for her to talk through contractions. As this labor progresses, you will start to notice the sounds and the movements becoming more “primal”. If unmedicated, the mother will start to go into a pattern of movement that she finds comforting as the contractions build. Usually this position is a forward leaning one and is often accompanied by swaying of the hips of some kind. Many mothers start to use sound to release pressure, pain and tension. The sound may be sighs or low moans. When I see or hear this type of behavior, I consider it to indicate a “turning of the corner” from early labor to a strong active labor pattern.
The partner can best support the mom by helping her concentrate on her breathing, offering counterpressure or massage, helping her change positions and continuing to give her fluids. At this point she probably does not have the desire to eat. This is a good point to head into the hospital or birth center.
Transition 8-10cm
This is typically the most intense, but quickest stage of labor. Contractions are now 60-90 seconds long and occurring every 1-3 minutes. Fortunately, most women move through this phase in approximately 10-60 minutes. If the amniotic sac has not been broken yet, it will likely break in this phase or the care provider may offer to break the bag of water. During transition, the laboring woman will really need the help, support and encouragement from her support people.
During transition women may experience:
-Very intense contractions
-Nausea and/ or vomiting
-Rectal pressure and premature urge to push as the baby descends
-Chills and hot flashes
-Mood change, irritability, hopelessness, desire to give up, and self doubt
-Heavy bloody show
-Possibly even sleeping between contractions
If these physical and emotional “signposts” are evident and a home birth is not intended, I would strongly suggest making your way to the hospital or birth center at this point.
In unmedicated births, transition has its own distinct characteristics. When a woman who had found her groove and was managing active labor well, starts to get hopeless and even irrational, I can tell we are there. She will say things like: “I don’t think I can do this anymore,” or “I think I am done now - I want to go home”. This is a pretty good sign that she is almost ready to push. Other telltale signs of transition are the laboring mother expressing that she is experiencing a lot of rectal pressure or that she has a desire to vomit. She may have nausea, or hot/cold flashes, or even fall asleep between contractions.
If the mother seems really desperate and is starting to unravel, but needs to reach full dilation, I often suggest (if her water has not broken yet) that the care provider breaks the bag. The breaking of the water intensifies the labor and can give the mother that final push toward full dilation. Please note, I don’t recommend using this tactic earlier in labor.
Once full dilation is reached, the first stage of labor is complete.
The intention of this particular blog entry is for the partner to recognize the signposts of labor in order to help determine what stage of labor the mother may be in. So I will not go further into discussing the second stage of labor – pushing - or the third stage - the delivery of the placenta - since it is assumed that most women will have the help of a birth professional involved in the labor and delivery at this point.
Exceptions
As with anything else in life, there are exceptions to the rules. The two exceptions to highlight are the case of a posterior baby or a precipitous labor.
The first one, OP or Occiput posterior, is when the baby’s occiput is toward the mother’s back. This can cause tremendous back ache since the mother is feeling the baby’s occiput push against her sacrum. In a situation like this, the mother may experience intense back pain during contractions that are timing close together and even have rectal pressure. Identifying back labor can be confusing for most, since the level of discomfort the mother is expressing, as well as the close proximity of the contractions, are associated with active labor and progressed dilation.
Typically, OP labors are longer since the baby is not pushing the cervix open with the smallest part of their head, but instead trying to use their forehead. Should a labor start out as posterior, it is good to know that the incidence of persistent occiput posterior babies at delivery is about 5.5%. So the baby is likely to rotate anteriorly.
The second exception is, precipitous labor, which is a labor that from start to finish is under three hours long. In the case of precipitous births, the mother does not go through the stages of labor gradually. Instead, she feels the onset of contractions which will quickly grow in intensity and proximity. I admit, I have only seen this a few times during my doula career. It is estimated that only 2% of births are precipitous, and it is rarely the case for a first time mother.
If a mother or her birthing partner suspects she is having a precipitous birth, it is advised to get help or get to the hospital as soon as possible. However, if the mother has progressed so quickly that she is already feeling the urge to push, DO NOT try to leave your home. This is when babies are born in cabs or the side of the road! Instead, call 911 for the EMT- they are well-equipped to birth babies.
“Alternative ways” to measure dilation
I can not take any credit for coming up with these alternative ways to measure dilation. My friend Kim, who has a blog, Doula Momma, wrote about these finds in one of her blog entries. I found these two methods fascinating and unusual. So here they are:
Measure your cervical dilation from the outside! Think about the shape of the uterus. Before labor, the muscle of the uterus is thick evenly around all sides, above, below, behind. As the cervix starts thinning and dilating, all that muscle has to go somewhere – it bunches up at that top. The top of the uterus thickens dramatically the more the cervix opens. During a contraction, at the beginning of labor, check how many fingers you can fit between the fundus (top of your bump) and the bra line – you will be able to fit 5 fingers. As the top of the fundus rises higher during labor, you will fit fewer and fewer fingers. When you can fit 3 fingers, I usually tell mothers they can think about going into hospital as they will find they are around 5cm dilated. At 1 finger, you are fully dilated. (Awesome, huh!)
Understanding the bottom line. There is something called the “bottom line,” which is a shadow that extends from the anus up towards the back along the crease of the buttocks. It begins as 1cm and lengthens to 10cm, and it’s length correlates with cervical dilation. Why not look down there before inviting a stranger to put their fingers up inside you? It makes sense to me.
Hope these tips and signposts of labor help you and your partner have a confident, good birth!
As a Lamaze Childbirth Educator, I strongly subscribe to the Lamaze Approach to Birth. One of their key beliefs is: “Women’s confidence and ability to give birth is either enhanced or diminished by the care provider and place of birth.”
I chose to write about this topic because as a labor support doula, I have seen firsthand that certain hospitals tend to lean more toward a conservative approach than others. These more conservative hospitals may accommodate a large number of high-risk patients, and as a result, their general approach may be geared toward high-risk care regardless of the birthing mom’s needs. While many women put a heavy emphasis on choosing a care provider, they may not take into consideration what hospital or birth center the care provider is associated with.
I have interviewed a traveling Labor & Delivery Nurse that has worked at several different hospitals, as well as a mother of three that has birthed at a NYC hospital, a birth center, and at home. Both of these interviewees had wonderful perspectives on how the place of birth DOES effect your birth experience.
Rosalie Hunt is currently a Labor and Delivery Nurse at Weill Cornell on the Upper East Side of NYC. She completed the nursing program at John Hopkins five years ago and has been working in labor and delivery ever since. Her first experience out of nursing school was at Sibley Memorial, a community hospital in Washington, DC where she worked as a Labor & Delivery Nurse for 4 years. She moved to NYC and is currently working at Weill Cornell, a teaching hospital.
Right off the bat, Rosie explained to me some of the differences between a community hospital and a teaching hospital in terms of her experience as a Labor and Delivery Nurse (L & D Nurse). She explained that teaching hospitals are much larger, affiliated with a university, and they have higher level (3 & 4) NICU’s (Neonatal Intensive Care Units) as well as specialty maternal fetal medicine physicians that deal with high-risk moms. In the community hospital, the NICU level is lower, meaning that they could not take babies under 32 weeks, or twins under 34 weeks. Community hospitals are primarily designed to care for low-risk mothers.
Since community hospitals are not directly affiliated with universities, there are no residents or medical students, just the attending physicians, midwives, and nursing staff. The smaller staff allows for more intimate, direct care from the staff, especially the nurses. As a nurse, Rosie was the one that checked for dilation, and was the liaison between the laboring mother and the doctor. While at a teaching hospital, the patient may be visited and checked on by one or more residents and/or medical students, and there will be more “traffic” through the room. (Side note: I recently attended a birth at Mt Sinai here in NYC, and the doctor asked if a medical student could watch the birth. The doctor explained that this would be a good learning experience for the student, since the hospital so rarely saw unmedicated births.)
Even when deciding amongst different teaching hospitals, it is important to take a closer look at the intervention rates. They can indicate if the staff deals more often with the high-risk or low-risk patient. For example, New York’s St. Lukes/Roosevelt (which houses a birth center) tends to have lower risk women and lower intervention rates, 23% cesarean rate, compared to
New York Presbyterian Hospital (Columbia University) with a 39% cesarean rate and Weill Cornell close behind with 37%. Rosie explains that a low-risk laboring mother birthing at a “higher risk population facility” may be subject to more routine interventions intended for the high-risk woman. She also explains that with more routine interventions, such as full time EFM (external fetal monitoring), higher use of pitocin and more inductions, the nursing staff does not often have an opportunity to see unmedicated births. So for those looking to have an unmedicated birth, it may be of note that the nurses may not be used to seeing a natural birth and experiencing the sounds, movements and behavior that goes along with it. This may leave the nurse uncomfortable and not sure how to support the mother. Rosie suggests: “When looking for a place to deliver, look at your health, your pregnancy, and your philosophy and desires for birth and try to match it with a facility and practitioner where you are the norm and not the exception.”
The second interview was with Liz Fraser, a mother of three. Liz had her first baby, Liam, 4 years ago at Weill Cornell Hospital. Her second baby, Owen, was birthed 2 years ago at the Birth Center at St. Lukes/Roosevelt and her third baby, Sloane, last month at home with a midwife. Since Liz was in three very different settings for her births, I figured she can give a very personal account of what she liked and didn’t appreciate about the different settings.
Giving Birth In A Traditional Hospital Setting:
Deb: Did you find the staff was helpful and respectful of your wishes?
Liz: Once in the room, yes. But I do remember there being a reaction when I gave the birth plan to the admitting nurse.
Deb: What was the reaction?
Liz: She rolled her eyes.
Deb: Did you find the hospital protocol a hindrance to your wishes?
Liz: Luckily, I had the walkable EFM (external fetal monitor). Had it not been for that, it would have been really annoying being connected to the machine with limited movement the whole time. Our nurse also allowed us to have more than 2 people in the room [which is the norm]. Having the extra people really helped.
Deb: How was the hospital staff supportive?
Liz: The first nurse, I really liked. However, when the shift changed and the second nurse came in, the whole air of the room changed. The focus was not on me - the patient! I was just about to go into the pushing stage and she was reorganizing and straightening up the room. The attitude of the second nurse created a certain tension that had not been there before.
Deb: Can you talk about the pros of the hospital setting?
Liz: Having the immediate access to care was definitely a pro. It was my first time giving birth and I felt very confident in the care I was going to be given.
Deb: Can you talk about the cons of the hospital setting?
Liz: The potential for restriction: of movement, food, and support. I really lucked out since I had the walkable monitors, we snuck food in and I had all the people I wanted with me. I REALLY did luck out!
Giving Birth At The Birth Center
Deb: Did you find the staff was helpful and respectful of your wishes?
Liz: Yes, once we got to the Birth Center, but not in triage on the L & D floor. They didn’t really seem to care and were not very responsive. It was not until I vomited in the hallway that they seemed to pay attention to me.
Deb: Did you find the hospital protocol a hindrance to your wishes?
Liz: Yes, the whole 20 minute monitoring upstairs [in the L & D triage] was very annoying. But once we entered the Birth Center, it was like angels started to sing!
Deb: How was the hospital staff supportive?
Liz: The nurse was so helpful! It was so wonderful to have the tub filled and ready to go. There was no waiting and everything was ready for me to have my baby. I also really liked that Dr. Wong was there the whole time. She wasn’t putting any pressure on me, she was just there as things progressed.
Deb: Can you talk about the pros of the Birth Center setting?
Liz: It was not hypermedical and very casual. This helped me relax. As I said before, having the privacy and relaxed atmosphere was key for me. I spent a fair amount of labor in the huge whirlpool tub and then transitioned to the queen size bed. We could also bring in whatever food we wanted - although the smell of the food in the room didn’t really help me that much.
Deb: Can you talk about the cons of the Birth Center setting?
Liz: There were none!
Giving Birth At Home
Deb: What was your experience like giving birth at home?
Liz: It was nice not to have to go anywhere. That was really key for me. I figured, I am not getting medication, so what is the point of going anywhere. It also felt good not to have any routine medical procedures done. Cara, the midwife, unobtrusively checked the baby’s heart rate with the doppler scope. Other then that she just observed and gave me space to have my baby. I was not even aware of her medical supplies and instruments tucked away to the side
Deb: Can you talk about the pros of your home birth?
Liz: The experience itself as a whole, was very positive. I didn’t do this as a statement - it was just something I did. I liked being in my space with my people and then afterward, everyone [the midwife, and the doula- me!] left and we went on with our lives.
Deb: Can you talk about the cons of your home birth?
Liz: I didn’t think about the advantages the hospital and birth center provided. I was catered to in recovery from the staff. They had ice packs available at my request. I also had 24 hours between giving birth and going home. I forgot how nice it was to have the nurse’s support afterward. If the baby started crying, the nurse took care of him. At home, I didn’t allow myself the recovery time.
Deb: Any final thoughts you want to share?
Liz: Really think had about what kind of environment and experience you want and figure out what setting is going to provide you with that vision.
I couldn’t agree more with the two lovely ladies I interviewed. Take the time to figure out what you, as a mother, want out of your birthing experience. If the place, staff and care provider you choose does not approve of or have confidence in your birth preferences, you will be fighting an uphill battle. With so many options available, please take the time to think about what is best for you, your family and your baby.
A few weeks ago after a morning prenatal yoga class, three students were left talking about birth options. One student was expressing her strong desire to have a VBAC (“Vaginal Birth After Cesarean”) with her second child, while another, who was also on her second pregnancy, was hoping to have a vaginal twin birth. The third student, a first-time mother with a twin pregnancy, was contemplating having an elective cesarean instead of trying for labor and a vaginal birth.
The conversation went as followed: the first-time mother said she was leaning towards the elective cesarean because she is overwhelmed by the idea of labor and the pain involved. (With vaginal twin births, there is a slightly higher risk of birth complications and many doctors will offer their patients the option of going straight to surgery). This mother feels a cesarean will allow her to bypass the undesired experience of labor. The VBAC mother strongly disagreed and offered her opinion, saying that in her experience, a c-section should not be taken lightly - it is major abdominal surgery and for her, it was painful and timely to recover from. The second-time twin mom, who is also hoping for a vaginal birth, agreed and added that if the twin babies are in a good position to be birthed vaginally, that is the route she thinks is best for her. She suggested to the other twin mother that if the pain gets to be too much, she can always use an epidural and still have a chance at birthing vaginally, avoiding the risks and recovery process of a cesarean.
For some women, a planned, elective cesarean is the right choice. While it is true to say that cesarean delivery has gotten safer in the last 50 years, it is still not without risks. In making that choice, I believe it is best to be fully informed about the risks associated with this, as any, major surgery. As with all our choices, there are risks, benefits, and consequences to take into consideration. This is not meant to scare anyone. My true objective is to be impartial and offer the facts about this topic.
*Emergency hysterectomy - Certain complications, such as excessive bleeding, placental problems or uterine atony (loss of muscle tone), may require the removal of the uterus - a hystercomy. The chance for this procedure is greater from a cesarean birth than from a vaginal birth.
*Greater blood loss and hemorrhaging - Cesarean surgeries requires two incisions: the abdominal and the uterian. During pregnancy, the uterus has one of the greatest blood supplies of any organ in the body, which can result in greater blood loss upon cutting. The chance for blood loss with a c-section is twice as likely as with a vaginal delivery.
*Mortality - The mortality risk with elective cesarean (no emergency present) has recently been reported as almost 3 times the risk of a vaginal delivery.
*Accidental Cuts - Increased risk of damage by accidental cuts to internal organs, including the bladder, the uterus, intestines and uterus.
*Incision site - Chance of reopening up of the incision site.
*Blood clots in the legs and pelvis - This is a potentially serious complication, since the clot could travel to the lungs and cause pulmonary embolism. Luckily, there are warning signs that this is occurring, including the area surrounding the clot being swollen and hot to the touch. Hospitals often have thick leggings or compression devices for the leg after surgery to keep blood flowing and prevent a clot from forming. Getting out of bed to move around is also a preventative measure.
*Anesthesia complications - Three types of anesthesia are used for cesarean sections: spinal, epidural and general. The spinal and epidural are most commonly used for elective cesareans. They are generally low in risks and complications, but do have some common side affects such as headaches, shaking, itchiness, nausea, vomiting, decreased blood pressure with the potential for nerve damage and residual back pain. General anesthesia, due to carrying greater risks, is rarely used.
*Child/Mother bonding time and skin to skin time eliminated - While the mother can view her baby or have her baby brought to her face, skin to skin contact is limited in the operating room. However, it is a good idea for the father to initiate skin to skin contact with the baby as soon as possible. (For more information about the benefits of skin to skin contact, please read Study Finds Benefits For Skin to Skin contact with Newborn)
*Breastfeeding difficulty - Women can successfully breastfeed after a cesarean birth. However, there are a few obstacles they may encounter on the way, the first being prolonged separation from their baby. (I would advise checking into the hospital’s protocol to see whether the baby goes to the nursery after delivery or the recovery room with mom.) The second issue that arises is finding a comfortable position to nurse in. Placing the baby on the mother’s abdomen may result in painful pressure on the mother’s incision. The “football hold” may be a better option immediately following surgery. Third, due to the increased pain and risk of infection, the mother is given painkillers and antibiotics. These medications may have an effect on the milk, leaving the baby a bit lethargic. Finally, there is an increased chance of developing a yeast infection due to the antibiotics. This could lead to thrush in the baby’s mouth or diaper area, as well as on the nipples.
*Longer recovery time - Due to the nature of any sort of surgical procedure, there is a recovery time that needs to be honored. With vaginal births, most women are mobile and recovering from birth within one or two days. With a cesarean birth, it can take up to 6 weeks to feel fully recovered.
*Extended hospital stay - Women that have cesareans will stay in the hospital for an average of 2 days longer than a vaginal birth. During these days the mother will receive post-operative care and observation.
*Avoid Fecal Incontinence - This situation is much less common than urinary incontinence as a result of a vaginal birth, with only 4% of women encountering this issue.
*Avoid the risk of an unplanned cesarean - This category is different then the emergency c-section, which indicates that the mother or child’s life is endangered. An “unplanned cesarean” can be advised for reasons such as “failure to progress”, CPD (Cephalic Pelvic Disproportion, aka “the baby is too big”), or time restraints for either labor or pushing.
*Timing - For those that feel it is important to plan when their baby is born, an elective cesarean gives the parents the opportunity to choice the baby’s birth day.
*Fear - If the mother cannot get past the fear of labor, a cesarean might eliminate this stress factor.
Hopefully, these facts will offer the mother deciding between a vaginal birth and elective cesarean some clarity when weighing risks verses benefits.
The answer is NO, and I am actually quite surprised by this conclusion! I thought that the upward trend in adult weight gain, type 2 diabetes, and processed food consumption in this country would be accompanied by an average increase in fetal weight. However, research from Harvard Pilgrim Health Care Institute’s Department of Population Medicine (an affiliate of Harvard Medical School) states in a study from the February 2010 issue of Obstetrics & Gynecology that birth weights have actually decreased an average of 52 grams (1.83 ounces) leaving the average birth weight of a newborn at 7 lbs 7 ounces.
This study analyzed data collected during the past 15 years and included 36,827,828 American babies born at full-term. Keep in mind that full term is considered to be anything past 37 weeks. In addition to the decrease in birth weight, the study also found that babies are being born an average of 2.4 days earlier than term (ie the “estimated due date” of 40 weeks). This is relevant because babies born earlier tend to weigh less, since they had less time to grow.
Bigger babies tend to correlate with older mothers and nonsmokers. So with a national increase in maternal age and a decrease in tobacco use, one would expect fetal birth weight to have increased amongst this population. In fact, the study showed that low-risk women (defined, in this case, as educated, married, white, nonsmokers, with early prenatal care and uncomplicated vaginal deliveries) were having babies weighing on average, 2.79 ounces less in 2005 than 1999.
For the past 20 years, many care providers have adopted the guidelines of the Institute of Medicine (IOM) which advises proper maternal weight gain based on pre-pregnancy Body Mass Index (BMI). Just recently, the IOM has revised their guidelines, putting a cap on weight gain for obese women. These guidelines offer a range of healthy weight gain based on expectant mother being underweight, normal, overweight or obese pre-conception. When determining where one fits into these 4 categories, factors are not measured purely by pounds, but by a ratio of height and weight.
Shifting the focus from weight gain to maintaining a safe BMI seems like a move in the right direction. It’s very clear to me that healthy weight gain during pregnancy is not a “one size fits all” issue. There are definite risks associated with both too little maternal weight gain and too much. Taking into consideration the sensitivity many women have with respect to weight gain and body image, it may be helpful consult with your care provider on the individual guidelines and nutritional support that might be best for you. So while the researchers sort out the data on this connection between maternal weight gain and fetal weight, the best advice seems to be paying more attention to a healthy diet and proper exercise than the number on the scale.
For more on estimated fetal birth weight and the risks involved with a larger baby, take a look at this blog entry.
My last two doula clients were both induced due to a diagnosis of Oligohydramnios - low amniotic fluid. I have heard many of my students report that they were induced for the same reason, or that it was a very big concern for their care provider. I decided it was time to really understand the ins and outs of this condition.
What is amniotic fluid?
By the 12th day after conception, the amniotic sac will start to form. Within this protective barrier lives the baby, the placenta, the umbilical cord and the baby’s amniotic fluid. The amniotic fluid is a clear, slightly yellowish, odorless substance. At the onset of pregnancy, as the amniotic fluid starts to build in the amniotic sac, it comes from the mother. Over time, the fetus adds to the supply of amniotic fluid through a shedding of skin cells, along with floating stem cells and the baby’s own urine. As the baby breathes in and ingests the fluids, it urinates them out, and this is the basic cycle that continues until the baby is born.
What is the importance of the amniotic fluid?
The amniotic fluid has many roles. For one, it acts as a buffer or cushion should the mother slip or experience jerky, jarring movements. The baby is basically floating around in this big sac of fluid, so should the mother stumble, the baby will not likely feel the impact. This “floating” idea also helps protect the baby from compressing its umbilical cord, which would deprive the baby of oxygen and put the baby in distress. This pool of fluid also gives the baby room to move, which helps the baby build muscle tone and a strong skeleton, protecting it against infection.
Low fluids can be an indication of other problems, such as:
*Kidney or urinary tract issues for the baby
*Pre-eclampsia, diabetes, or high blood pressure for the mother
*Partial abruption of the placenta
*PROM - Premature Rupture of the Membranes
*Intrauterine Growth Restriction (IUGR)
How is it measured?
Amniotic fluid is measured with an ultrasound. The technician measures the fluids in 4 quadrants of the uterus and adds the measurements together to see how many centimeters of fluid are in the uterus. The AFI or Amniotic Fluid Index rates the fluids, with 5 cm being too little fluid and 25 cm being too much.
Also, since dehydration may be a cause for the low fluid levels, you might ask your care practitioner if you can hydrate and return the next day to be retested.
Another option is an amnio-infusion, which reintroduces fluids into the amniotic sac. During labor, the doctor can pass a catheter through the cervix and add a warm saline solution. This is helpful if the concern is cord compression.
The final solution for oligohydramnios is to induce labor.
Final food for thought: a study from The Johns Hopkins Hospital which discusses the outcome of births with suspected low fluids.
Low Levels of Amniotic Fluid No Risk To Normal Birth
Doctors may not have to deliver a baby early if it has low levels of amniotic fluid surrounding it, Johns Hopkins obstetricians report.
In a study to be presented Feb. 7 [2003] at the annual meeting of the Society for Maternal-Fetal Medicine in San Francisco, researchers show that babies born under such conditions fared similarly to those born to women whose wombs held normal amounts of amniotic fluid. No significant differences were found in the babies’ birth weights, levels of acid in the umbilical cord blood, or lengths of stay in the hospital.
Typically, doctors have been concerned about women with low levels of amniotic fluid during the third trimester – a condition called oligohydramnios – because too little fluid can be associated with incomplete development of the lungs, poor fetal growth and complications with delivery. Amniotic fluid is measured by depth in centimeters. Normal amounts range from 5 to 25 centimeters; any amount less than 5 centimeters is considered low.
“These study results are very surprising – they go against the conventional wisdom,” says Ernest M. Graham, M.D., senior author of the study and assistant professor of gynecology and obstetrics. “Amniotic fluid stems from the baby’s urine, and the urine results from good blood flow, so if we see low fluid we assume there probably is not good blood flow and the fetus is compromised. This study shows the fluid test is not as good as we thought, and there is most likely no reason to deliver the baby early if other tests are normal.”
The researchers studied 262 women (131 with oligohydramnios and 131 with normal amounts of amniotic fluid) who gave birth at The Johns Hopkins Hospital between November 1999 and July 2002, comparing the babies’ health at birth. Patients with oligohydramnios were delivered sooner, but were less likely to need Cesarean sections. Babies born to moms with isolated low amniotic fluid were normal size and were at no increased risk of respiratory problems, immature intestines or brain disorders.
Study co-authors were Rita Driggers, Karin Blakemore and Cynthia Holcroft.
Abstract # 318: Driggers, R. et al, “Are Neonatal Outcomes Worse in Deliveries Prompted by Oligohydramnios?”
Statistics show that 70% of birthing women will take an epidural during the labor and delivery process. That being the case, it is important to discuss how to be pro-active and assure a good chance at a successful vaginal delivery with an epidural.
In a recent blog entry, I outlined the pros and cons of taking an epidural, with one of the main drawbacks being the lack of movement available to a laboring mother. When the mother is moving, it allows her pelvic bones to shift and better accommodate the baby, a baby that is hopefully gently moving into an optimal fetal position. Because of the lack of movement an epidural brings, it is easy for the baby to get stuck in one position in the pelvis. One way to combat the baby getting too relaxed in an unfavorable position is to make sure that the mother is frequently shifting from one side to the other. If possible, she should alternate between truly side-lying (with the hips stacked and a pillow between the knees, supporting the upper knee and ankle) and semi-prone (lying more toward the belly, with the top leg supported and the bottom leg straight). Since the heaviest part of the baby is its back and the back of its head, gravity will naturally pull the baby toward the mother’s belly, guiding the baby to an anterior position.
If the mother is resting on her back for a long period of time, it is more likely that the baby will shift toward the mother’s back, which is the posterior position. In this position, it is harder for the baby’s head to effectively apply pressure to the cervix and encourage it to dilate. “There is evidence to suggest that if the mother lies flat on her back then vena caval compression is increased, resulting in hypotension. This can lead to reduced placental perfusion and diminished fetal oxygenation. The efficiency of uterine contractions may also be reduced”ť. (Humphrey et al. 1974, Kurz et al. 1982) If the contractions are inadequate, then pitocin will be introduced into the labor scenario to strengthen the contractions and the frequency of the contraction. Without going into an explanation of the “cascade of interventions”, let’s just say it would be better not to rely on pitocin too much to drive the labor forward. Point being: stay off your back.
Another helpful idea to keep in mind is that once the epidural is in place, the mother is going to continue to receive IV fluids. For some women, this creates a lot of swelling in the lower body. It can be nice to have someone massage and rub the mother’s legs and feet to help prevent the edema from pooling in the lower extremities.
As research has shown, the second stage of labor, the pushing stage, is often longer with an epidural than without. That can be because the mother does not feel the urge to push or can feel a bit clumsy when it is time to push since she has less awareness and coordination of the lower part of her body. Also the epidural often slows second stage by reducing or eliminating the normal surge of oxytocin, and by reducing pelvic floor muscle tone, which may lead to more deep transverse arrests or persistent occiput posteriors. I usually suggest two things, first: ask to have the epidural turned down (or at least resist the urge to self-administer more). Secondly, since the pain is greatly diminished, why not take the time to “labor down,” meaning that the contractions are going to continue to move the baby further down the birth canal; the mother may as well let the baby continue to descend. When it is time to push - which requires a lot of effort and energy - the baby has less distance to travel to be born.
In the ideal birthing position, the pelvic outlet is as spacious as possible. An “all 4″ position is great since there is not any pressure on the back, pressure which might push the sacrum into the birth canal and require the baby to maneuver around the tailbone. Also, the rectum, which is elasticized, has somewhere to go when it is pushed out of the way as the baby passes by. I have also seen variations on the “all 4″, like standing and leaning over the bed, or a half-squat. All these positions allow for maximum space.
I also believe that forcefully pulling the knees back to the arm pits, while it may spread the sit bones, compresses the pubis, making it more difficult for the baby to come under the pubis and uphill towards the vaginal opening. On a side note: if the mother is doing this forceful movement for a very long period of time, she may create a diastasis (separation) of the pubis symphysis which can become painful.
How can a mother birth effectively with an epidural? One of the best options is side-lying. In this position, the mother is on her side while holding her top leg up. This gives the sacrum, rectum and tailbone space and mobility, and creates a nice amount of room for the baby to pass through. This position is really ideal if the baby is posterior. If the mother tries to push her posterior baby out on her back, the baby’s occiput can get caught on the mother’s sacrum. Another option is to think of slightly pointing the tailbone up. Many years ago, I heard a nurse give this advice to a mother who had been pushing for nearly 5 hours. We tried EVERYTHING and that really helped! Just last week, I attended a birth and gave that advice to a mother who was on the verge of needing vacuum assistance to birth her baby. The tailbone trick worked. (Let me backtrack and say that the baby was very close to getting under the pubis and this trick just allowed a little bit more space for the tailbone to move out of the way. This maneuver also pushed the top of the sacrum down towards the bed and out of the birth canal.) I don’t think I would advise this from the get-go of pushing, but it certainly helped for those last few pushes.
It is such a fine dance of the mechanics of the female pelvis to birth a baby. Small adjustments can make a huge difference for both you and your baby. The best thing you can do for you and your baby is to know your options and be educated about your choices. No matter whether you are medicated or un-medicated, there are ways to birth your baby in a healthy, supportive manner.
Whether to opt for pain medication during labor and delivery is a personal choice. In making these choices, it may be helpful to understand the pros and cons of epidural anesthesia. It is not my job as a teacher to lead you in one direction or another, but to simply present factual information and give you the opportunity to decide what is best for you.
The epidural is, for the most part, very successful in eliminating the pain of labor contractions while allowing the mother to stay alert. It will not compromise her state of mind the way other medications like stadol or demoral do.
In my experience, the women who tend to hire me as a doula usually request that I help them avoid the use of drugs or help them get to a certain point before taking the epidural. However, there have been times when I have suggested, for the sake of the mother, that she consider taking the epidural.
For example:
*If the mother has been laboring for a very long time and is completely exhausted, this will give her the opportunity to sleep and get re-energized so that she can push her baby out.
*If the mother’s labor has been long and difficult, her body can become very tight and tense which can prevent the baby from descending. The epidural can allow her pelvic muscles to relax, the baby to descend, and cervix to dilate.
*Along these lines, if the mother is paralyzed by the fear of pain, the epidural will help her relax.
*An epidural is a good choice for those opting for a cesarean birth, since it will allow the mother to remain awake and alert during her surgery and for the birth of her baby.
Difficulty Pushing With an epidural or without, I recommend “laboring down” which means: even once the cervix if fully dilated to 10cm, wait until you have the urge to push before starting the second stage of labor - the pushing stage. The contractions will continue to help move your baby further down the birth canal and lessen the time you are actually pushing. Because of the lack of sensation with an epidural, it may be difficult for the laboring woman to access and utilize the muscles needed to push her baby out. If you have the epidural, you may want to consider letting it wear down so that there is some sensation and muscle recognition that will help in pushing. Also - why not take advantage of not having a lot of pain (although there still will be pressure) and let the baby continue to descend on its own?
Attachments and Lack of Mobility One of the main reasons I am writing this particular post is because I overheard some students talking about their plans for the “walking epidural”. What most people don’t know is that once you receive the epidural, you are not leaving that bed! Once the epidural is placed, the mother is restricted from getting out of bed. This lack of mobility does not allow the mother’s pelvic bones to move, which would help the baby to find the best fit. I would recommend shifting frequently from one side to the other. Do not give the baby too much of an opportunity to snuggle into place for too long.
The birthing mother is often hooked up to numerous machines:
*The epidural catheter is taped to her back for the remainder of labor and that catheter is attached to the machine dispensing the medication.
*External Fetal Monitor (EFM) or sometimes Internal Fetal Monitor if the EFM is not adequately picking up the baby’s heart beat.
*External contraction monitor, measuring the timing the contractions. If the care provider is not sure the contractions are adequate, an intrauterine-pressure catheter (IUPC) may be inserted to measure the strength of the contractions.
*Urine catheter
*Continuous IV drip
*Blood pressure cuff
*Pulse oximeter
Maternal and Fetal Side Effects There are several possible side effects to consider when taking the epidural.
For those considering the epidural, here is a short, animated video demonstrating how the epidural is placed in the body. Please note: the last 45 seconds can be ignored (it is an ad for Episure AutoDetect Loss of Resistance Syringe). But I do think the beginning portion is worth watching!
This blog entry was recently given to me from a New York City Midwife. The topic of Group B Strep is often confusing to people and not usually explained very well. I invite you to read about what Group B Strep is and how you can prevent it.
I hope you enjoy!
What is GBS?
Group B Streptococci (GBS, Group B strep, Beta Strep) can be present asymptomatically in the vagina. It can cause inflammation of the amniotic sac, the uterine lining or lead to a urinary tract infection in the mother. Occasionally a newborn will have a local infection, septicemia or meningitis as a result of Group B strep. There are five serotypes of Group B strep, with type III as the most associated with meningitis. However, all types may cause disease.
What is the risk?
Between 15-40% of all women have GBS present in the vagina. As many as 75% of their babies contract strep, but only 3 to 4 percent per 1000 get sick as a result. Of these sick babies, 7% of them are under 1000 gm (around 2 lbs). Babies born before 37 weeks gestation are at much higher risk of infection than full term babies. There is an increased risk for the baby with premature rupture of membranes (PROM) or surgical delivery. In other words: Of the 15-40% of mom’s who test + only 2-3 babies will actually become ill (15-40% is between 150 - 400 babies and out of those 75% or 142 -300 will contract GBS but only 3-4% will get ill or somewhere around 4-12 babies.)
If recurrent prematurity has been a problem for the mother or a urinary tract infection (UTI) is present, a culture may be done to determine if strep B is present. In a hospital setting, when premature rupture of membranes is being checked, a culture can be done at that time. In clinical practice, vaginal strep culture is usually offered to women at 34-36 weeks.
If the client has a past medical history with a baby who was ill from Group B strep, or had a UTI with Group B strep, membranes ruptured more than 18 hours, this baby is less than 37 weeks gestation, then the risk to this baby is higher.
If the result is positive, the midwife should discuss management options.
Babies and Infection
Risk Factors that increase the likelihood of infection for the baby:
1. Labor is premature (less than 37 weeks)
2. A prolonged rupture of membranes, greater than 12 to 19 hours.
3. Maternal fever before or during labor.
4. There are signs or symptoms of maternal or fetal infection.
5. Group B strep in the urine of the Mom
6. Multiple vaginal exams in labor
In a hospital, if strep is present, the baby is cultured immediately after birth. If strep is found, antibiotics are begun. In a well-nourished mother the baby will be more resistant to infection. Remember, problems only manifest in a small number of cases.
How is it treated?
My preferred methods for treating GBS before labor are below. Begin treatment as soon as you know that you are GBS positive.
1) First to treat the vaginal area, there are two options. Both involve a vaginal suppository combined with an anti- bacterial wash. One is with tree oil suppositories & the other is with an antibiotic suppository. If you prefer to use tea tree oil suppositories, go to a health food store or Vitamin Shoppe to purchase it. At night, before you go to sleep, insert one tea tree oil suppository for 7 nights.
2) At the same time we must treat the source of the bacterial contamination. This is where the anti-microbial wash comes in. Go to a pharmacy with a good medical supply section and buy Hibiclens anti-bacterial soap. The generic name of the soap is chlorhexadine. It will be with first aid and medical supplies, not with bath soap. If you can’t find it, ask the pharmacist. To use the Hibiclens, you will also need an 8 ounce squeeze bottle or peri-bottle. Your birth kit comes with one, but if you have not received it you may be able to buy one at the pharmacy, or we can give you one. To use, pour one ounce of Hibiclens into the peri-bottle and fill the rest with clean water. After all bowel movements, squirt the soapy water from front to back, in the way that you wipe. Don’t rinse, just wipe gently (front to back). Do this until the baby is born. I also recommend the wash before sex.
Cultures will be repeated each week until the birth. If the first one is still positive, and tea tree oil suppositories were used, I recommend going right to the antibiotic suppository, Cleocin, and continuing the wash.
If the first culture is negative, continue the wash until the birth. But we will continue to culture at each visit to be sure we are still clear of the bacteria. I am usually comfortable with not using IV antibiotics if I have a negative cultures
What if the above treatment does not work?
If we do not have a negative culture for GBS before your labor begins, we will discuss the mainstream treatment, IV antibiotics during labor. If we get a negative culture and it returns to positive then I think this is an indication of a higher colony count of the bacteria and that alone increases the risk of illness for the baby. IV antibiotic treatment does not preclude homebirth. It does not mean you must walk around with an IV.
Nutritional and Lifestyle Recommendations for GBS
1. Boost Vitamin C in your diet, such as eating 2 grapefruit per day. Other good sources of Vit C: red peppers, oranges, kiwi fruit.
2. Drink a cup of Echinacea tea or take Grapefruit Seed daily.
3. Get extra sleep before midnight. Slow down your schedule. Take it easy and eat well. Follow a nutritious Pregnancy Diet.
3. As a precautionary measure, oral sex should be avoided whenever a strep infection is present in the throat of a partner (this is usually strep A).
4. Plan ahead for extra warmth after the birth for both you and baby. Hot water bottles, heating pads, hot packs, big towels dried in a hot dryer during the pushing phase–will all help you and baby keep extra toasty after birth and reduce stress. Have a friend or family member assigned to be in charge of the “Mother/baby warmth team”.
5. The colostrum from your breasts is the best antibiotic treatment your baby could ever get. The colostrum is very important for your baby. Breastfeeding your baby is the best thing you can do to keep your baby healthy since you pass on your immunities to your baby through the breastmilk.
6. Do not allow children of other families to visit the new baby for the first 3 weeks. Keep your older kids healthy so they are not sneezing and coughing on new baby.
The rest of this packet contains other techniques of treating GBS that I do not have personal experience with. The information is collected from other midwives.
HERBS
Propolus can be taken daily, either in capsules or tincture, 3 to 4 times daily.
Echinacea root (Augustofloria) can be taken either as a tea or tincture, 3 times daily. To make the tea, use 1 oz of the root to 1 pint of boiling water and steep for 6 to 8 hours. Echinacea root is specific to staph and strep infections. It stimulates the body’s defense mechanisms as well. A strong tea may also be diluted and used as a douche. When douching in pregnancy, extra care must be taken to avoid forcing water up into the uterus, causing infection and other problems.
Safe Douching During Pregnancy:
Fill douche bag with cooled tea, attach cleaned vaginal tip. Hang bag 10 inches or less from the floor. Lay in the bathtub and gently insert the nozzle into the vagina no more than half way in.
Very gently release the hose clamp and allow tea to run in and out of the vagina, do NOT attempt to retain water in the vagina in pregnancy.
When finished, clean the equipment thoroughly.
Douching should never be attempted if there is any question that cervical dilation, placenta previa or prematurely ruptured membranes are present.
At home, Echinacea tincture can be given prophylactically if desired. The infant dose is 1 drop tincture every 3 hours. Symptoms of neonatal infection often begin with respiratory distress which gradually worsens. Evaluate other signs of infection, e.g., alertness, nursing, etc., and if the midwife suspects trouble, the client’s pediatrician should be consulted by the client immediately.
ESSENTIAL OILS
Essential Oil Protocol to get rid of GBS (From: www.thebirthsource.homestead.com/gbs.html )
It’s imperative that the oils are of highest quality. Young Living oils from Essential Oils R Us are one source that has been recommended.
Put the following in a Double “O” gelatin or vegetable capsule:
Take one capsule 3 times daily.
Additionally do the following:
Soak an ORGANIC tampon in…
15 drops Lemon Essential oil
9 drops Oregeno Essential oil
15 drops Mountain Savory Essential oil
1 tsp carrier (V-6) oil
Leave soaked tampon in overnight. Insist on being retested. Do this daily for the last six weeks of pregnancy.
Insert a small ORGANIC tampon or a cotton ball, whichever is more comfortable, soaked in a combination of 10 drops of tea tree essential oil and Olive oil. Leave the tampon in for 4 hours each day for 6 days. There are Tea Tree Oil suppositories in most health food stores.
MISCELLANEOUS
V-6 Mixing Oil combines food-grade vegetable oils for mixing with essential oils to create blends, formulas and massage oils. Grape seed oil, wheat germ oil and vitamin E are nurturing to the skin as natural antioxidants. V-6 is also excellent for cooking and making salad dressings. Blendi 15-30 drops of an essential oil to 1 oz. mixing oil. V-6 is good for mixing massage oils, creating your own blends and formulas, for cooking and making salad dressings, etc. The ingredients of V-6 Mixing Oil are sesame seed oil, grape seed oil, almond oil, wheat germ oil, sunflower seed oil and vitamin E.
Another GBS Remedy (From the archives at http://www.gentlebirth.org/archives/gbs.html :
3 capsules of Congaplex by Standard Brands 3 times a day for a week, then reculture. If negative, no more Congaplex. If positive, 1 cap a day until the end of pregnancy.
Congaplex Ingredients: Bovine thymus Cytosol™ extract, carrot root, ribonucleic acid, bovine bone, nutritional yeast, defatted wheat, bovine adrenal, dried alfalfa juice, oat flour, alfalfa flour, bovine kidney, veal bone PMG™ extract, mushroom, dried buckwheat juice, buckwheat, peanut, soy bean lecithin, mixed tocopherols and carrot oil.
Do not take if you have food allergies to any of these ingredients.
Congaplex is available at:
http://www.humandiamond.com/hdpub3/store/store0100.html (1-800-366-5992) Congaplex Supplier
Take 500 mg Vitamin C every 4 waking hours.
1 acidophilus (4 billion micro-organisms or higher) capsule every 4 waking hours.
Acidophilus is available as:
Probiotics High Potency Acidophilus
Friendly Colonizer Acidophilus Powder
Take Congaplex, vitamin C and acidophilus daily for the last six weeks.
:
EHB by NF Formulas given over a 10 day period (6 caps per day) (E.H.B. by NF Formulas, Inc.), and Tea tree oil vaginal suppositories 3 to 4 x daily for that time (see above). This mom was re-tested at two weeks after positive culture (3 to 4 days after last EHB taken), two weeks after that (2 1/2 weeks after first positive culture), and on one occasion was tested again 2 1/2 weeks later (5 weeks after positive culture) because of a prolonged ROM with no labor.
Then insist on retesting to see if the GBS has gone away. Midwives have seen heavy colonization completely cleared with these treatments, although there is no scientific study to support it.
Last Sunday I took a workshop with Jessie Levey, Certified Childbirth Educator (CCE) through the Childbirth Education Association of Metropolitan New York (CEA/MNY) on Cesarean Birth and Prevention. Workshops likes these always get me driven to share what I learn. I figure if some of these statistics are new and shocking to me, a gal very much in the childbirth education world, they are probably unfamiliar to the average pregnant mother and must be shared!
Currently, cesarean sections are accounting for the highest number of surgeries in hospitals in the US. The US is hovering around a 33% c-section rate, twice that recommended by the WHO (World Health Organization). This rate has gone up dramatically from 1970 when there was a 5.5% CS rate, and 205,000 surgeries performed that year. Twenty years later – in 1990 - there were 914,096 CS and a national rate of 22.7%. In 2006, 1,321,054 CS surgeries with a national rate of 31.1%. (Statistics from ACOG) In all fairness, I also want to present the infant mortality rates from the compared periods: in 1970, the US experienced 20.0 infant deaths per 1,000 live births; in 1990, 9.2 per 1,000 live births; and in 2006, 6.9 per 1,000 live births. (Stats from OECD- Organization for Economic Co-operation and Development) So from the data you can see that the US is up 400% in c-sections with a drop of infant mortality rate of 50%. However, to support the 400% of c-sections, we really should be seeing a 75% drop of infant mortality. The Office on Women’s Health at the U.S. Department of Health and Human Services has stated “Many experts think as many as half of all C-sections are unnecessary.” The good news is that cesarean sections are now much safer, and if there truly is a life threatening risk to mother and baby, we have the resources to save them.
If experts believe that half the C-sections performed are unnecessary, what medical indications are valid to justify this major abdominal surgery? The following list may be helpful in eliminating factors that may not be applicable to you, and may help you and your care provider decide if a cesarean birth is a medical necessity. If you feel pressured to accept a c-section by a care provider, take this list and review it with them. This way, you will feel more confident and empowered as you decide how to birth your baby.
Indications for Cesarean Sections, Fact vs. Myth
1. Fetal Distress. Fetal distress is the #1 stated reason for c-sections. This means that the fetus is in distress during labor, usually referring to a lack of oxygen and a compromised fetal heart rate. There is no hard, solid definition of what “fetal distress” really means. I came across a very interesting article, “What Constitutes Fetal Distress?” by Jeffrey P. Phelan, MD, JD in which a seasoned group of OB/GYNs discuss their interpretation on fetal distress. Here are some of their thoughts:
David B. Owens, MD, Overland Park, Kan–A FHR (Fetal Heart Rate) with persistent, true, late decelerations accompanied by loss of beat-to-beat variability and no reactivity-unresponsive to O2, a change in maternal position, or correction of low blood pressure; or persistent severe variables with loss of beat-to-beat variability. Severe variables and loss of beat-to-beat variability should prompt a call from the L&D nurse.
Donald P. Ward, MD, Austin, Tex–Fetal distress is continually confused with fetal intolerance to labor. The former exists when the obstetrician has concluded with reasonable certainty that some degree of fetal hypoxia is present and that sustained exposure to this condition is likely to result in irreversible tissue damage. Thus, it may be more appropriately termed obstetrician’s distress over severely abnormal indicators.
Joseph H. Cutchin, Jr, MD, Salisbury, Md–To me, fetal distress is a term used by the legal profession after an obstetrician has a bad outcome. I have been practicing obstetrics for 30 years and I still do not know what fetal distress is, nor have I seen any studies that define it.
Ways to avoid fetal distress
*Avoid pitocin. (Pitocin is the synthetic form of oxytocin used to stimulate uterine contractions).
*Ask your care provider if you can do intermittent EFM (External Fetal Monitoring) instead of full-time monitoring.
*Change positions if the baby is not responding favorably to one position. Try multiple positions. While it is common to put a mom on her left side if the baby’s heart rate is decelerating, the cord may be on that side and laying on it will cause compression.
2. CPD (Cephalic Pelvic Disproportion)
Basically, this is the determination that the baby’s head is too big for the mother’s pelvis. True CPD is rare and often seen in cases where there is a maternal birth defect involving the pelvis, where the mother has experienced a major accident in which the pelvic was severely damaged, or when it is a teenage mother whose pelvis has not fully developed. Should your care provider mention that this is the case or a concern, make sure you are not birthing on your back. When reclining flat on the back, the sacrum is being pushed into the birth canal and the elasticized rectal space is being squished. Birthing on hands and knees or squatting allows maximum pelvic space.
3. Failure To Progress
This means that cervical dilation has reached a plateau. This could be the result of fetal position. If the baby is OP (occiput posterior) or in an asynclitic position - meaning that the baby’s head is tilted to the side - the speed and progress of dilation will be effected. Often this can be solved by changing position. I have used a “butt-up child’s pose” for 30-40 minutes to disengage the baby from the pelvis, allowing it to re-rotate into a more favorable, effective position.
Other reasons for “failure to progress” could be psychological: if the mother is feeling pressured, exposed or uncomfortable, for example. If there is someone in the room that is making the mother nervous or if she is fearful of what is going to happen once she progresses. Ina May Gaskin calls this the Sphincter Law. Our sphincters - including the cervix- can not open unless we feel comfortable and relaxed. It could be as simple as keeping the lights low and the door shut to help ensure privacy and create a cozy environment. Should this be the case, I recommend that the mother and partner (or whoever the mother choices to confide in) take a few minutes alone to talk about what might be the trouble.
4. Time Issue
The hospital or care provider may have a rule about how long you can spend in labor before a c-section is considered. Should this situation arise, consider the same factors as with a “failure to progress:” change position, look at the environment in the room, consider the language that the staff is using with you, and discuss potential fears. If the clock is ticking and the care provider has brought it to your attention that you only have a certain amount of time, ask: “if mother is ok, and baby is ok, can we have more time?” You can also ask, “what would happen if we did nothing and waited?”
5. Previous C-section.
Many doctors and hospitals are not performing VBACs (vaginal birth after cesarean), and some insurance companies will not cover VBACs. The main concern about the VBAC is uterine rupture. There is a .5-1% chance of uterine rupture (stat from ACOG). In the past few years, the protocol for those attempting a VBAC has changed. In the late 1990’s, women with one previous c-section were being induced with a prostaglandin called cytotec which resulted in a high rate of uterine rupture. Currently, those that do pursue a VBAC do so without the aid of prostaglandin induction. It’s important to note that there is still a greater risk to mother and baby with elective cesarean section then there is from a vaginal birth. The maternal death rate is twice as high for elective cesarean as it is for vaginal birth.
6. Placenta Previa
There is no getting around a cesarean birth if the mother has placenta previa. This is a situation where the placenta is completely covering the cervix. It would be life-threatening to both mother and baby to deliver this way.
7. Placenta Abruptio
Placenta apbruptio is a condition where the placenta has detached from the uterine wall. This is a serious situation and the results range from an automatic c-section to bedrest, depending on how far along the fetus is and if it is fully separated or partially separated. With a mild abruption, the care provider may opt for the woman to deliver vaginally if the baby is mature and there is little distress.
8. Umbilical Cord Prolapse
This is a condition in which the umbilical cord slips out the vagina after the amniotic sac has been broken. The compression of the cord cuts off the baby’s oxygen supply. This is a very rare occurrence and is seen in 0.6% of deliveries. Because of the high risk to the baby, this is resolved with a cesarean section.
9. Breech or Transverse Presentation
A breech baby has the buttocks, feet or knees presenting at the cervical opening instead of the head. Some doctors and midwives are still safely delivering breech babies. If your baby happens to be breech and you are still hoping for a vaginal birth, go to a doctor that is experienced with delivering a breech. Many doctors are uncomfortable with this and are no longer taught how to handle this fetal presentation.
If the baby is transverse, that means the baby is lying across mom’s belly and there is no presenting part. A transverse baby has to be born via cesarean section.
10. Twin Babies
The twin situation is much like the breech situation. There are care providers well-skilled at handling a twin birth, but since it is rarely taught to newer doctors, it may be difficult to find a care provider comfortable delivering twins vaginally. However, several seasoned doctors in NYC area are open to delivering twins vaginally if both babies, or at least baby A, is head-down. If both babies are head-up, the likelihood of a vaginal birth is low.
11. Previous Infant Death or Major Birth Injury
Remember that part of birthing is being able to let go and trust the body’s ability to give birth safely. If a mother has already experienced a previous infant death or major birth injury to a previous child, she may have lost that confidence and may feel safer with undergoing a scheduled c-section.
12. Sexual Abuse
In cases where the mother has been sexually abused, a vaginal birth may be too traumatizing, in which case, a cesarean birth may be the healthier option.
13. Active Herpes
If the mother is experiencing an active herpes breakout, it would be much safer for the baby to be born via cesarean section. A vaginal birth while the mother is has a lesion or prodromal symptoms can be extremely harmful to the baby. I have heard that women can suppress the herpes outbreak with medication, but as always, check with a care provider before taking any prescription drug during pregnancy.
14 Past Uterine Rupture or Scar Tissue
If the mother has already experienced a uterine rupture or has significant scar tissue on her uterus, a cesarean section is a safer method of birth.
15. Pre-eclampsia
Pre-eclampsia is a condition where there is protein in the urine and hypertension (high blood pressure). This is a serious situation that is best remedied by the birth of the baby. Depending on the severity of the case and gestation of the baby, some women are induced to deliver the baby while other women may require a cesarean birth.
16. Estimated Fetal Weight
I recently wrote a whole blog entry covering the issue of estimated fetal weight. Please read it for more information, especially if this is being presented to you as a reason to have a c-section.
The other day I was reading through some blogs and came across a story about the correlation between Vitamin D deficiency and an increased risk of C-sections. The article, Vitamin D deficiency ups risk of C-section deliveries, study says, is featured in Scientific America. Funnily enough, that same day, one of my students came up to me before class informing me that her general care practitioner notified her that she is deficient in vitamin D and asked if I knew the correct amount a pregnant mom should take? Well, I didn’t know that information off the top of my head, but told her I would look into it especially since I had just read about the relationship between vitamin D and cesareans.
Sunlight exposure is a good way to get Vitamin D, since exposure causes our bodies to produce it. However, with winter coming on, I would suggest exploring other options to get vitamin D. I typically try to get my nutrients from whole foods (meaning not processed foods, not from the supermarket). With that in mind, here is a list of foods rich in Vitamin D
Cod liver oil 1 tablespoon 1,360 IU (International Units)
Salmon, chinook, baked/broiled, 4 ounces 411.00 IU
Sardines, canned in oil, drained 1ľ ounces 250 IU
Shrimp, steamed/boiled 4 ounces 162.39 IU
Orange juice, fortified with vitamin D 8 ounces 100 IU
Cow’s milk, 2% 1 cup 97.60 IU
Cod, baked/broiled 4 ounces 63.50 IU
Egg, whole, boiled 1 each 22.88 IU
Along with Vitamin D, there are some other nutrients that will help prepare your body for labor and postnatal healing. Here are some suggestions:
FOR LAST MONTH OF PREGNANCY
BY: Sandra Fields, CNM, NYC Home Birth Midwife
Food suggestions contributed by Luisa Gui
TEA COMBINATION DRINKS:
Raspberry Leaf Alfalfa Leaf Comfrey Leaf
(all of these teas help to tone and strengthen the uterus) 2-3 cups a day
YOGURT AND ACIDOLPHILUS : daily, 8 oz . prevents yeast infections
COOKED GREEN LEAFY VEGATABLES DAILY : Good for Vitamin K source to stop hemorrhaging
INCREASED POTASSIUM FOODS: fish, soybeans, fruits and veggies to help in the muscle strengthening
DECREASE SALT INTAKE: only in the last month
VITAMIN C 3-5 grms./day, calcium ascorbate powder in juice prevents perennial tears. ½ tsp. 4x/day in juice. Food options: Citrus fruits, bell peppers, green beans, strawberries, papaya, potatoes, broccoli and tomatoes
VITAMIN E: 600 IU’s daily, prevents jaundice in baby and promotes tissue elasticity and muscle strength. Food options: Vegetable oil, wheat germ, nuts, spinach, fortified cereals
ZINC: 10-15 mgs./daily, 1-2 weeks before due date. (This could already be in prenatal vitamin, please check) promotes more rapid and efficient labor and tissue elasticity. Food options: Red meats, poultry, beans, nuts, whole grains, fortified cereals, dairy products
VITAMIN B COMPLEX : 50 mgs of this 2x/day and only 1x if in prenatal vitamin. This protects you from stress during labor and birth. Food options: Whole grains, fortified cereals, wheat germ, organ meats, eggs, rice, berries, legumes, meat, poultry, fish, liver, chicken, spinach, bananas, kale, broccoli, brown rice and oats
PROTEIN: maintain 80-100 grams a day. Food options: Red meats, poultry, beans, nuts, whole grains, fortified cereals, oysters, dairy products
PERENNIAL MASSAGE NIGHTLY
Here is a recipe from Luisa Gui called “Green Extravaganza Pesto Farfalle”:
Start with a bunch of dark leafy green vegetables to boil or steam. For example, broccoli, kale and spinach. (A very powerful team of Vitamin A, E, C B6, Carotene, Folic Acid, Iron and Calcium)
After boiling the three ingredients, strain and put in a blender.
Add a small handful of walnuts (rich is B1, B3, B6, Folic Acid, protein and zinc)
Enhance the mixture with a bit Parmesan cheese (high in Calcium, B2, B3 and protein)
Add a few drops of lemon juice (good source of Vitamin C)
Add a few drops of olive oil (good source of Vitamin E) and a few drops of low sodium soy sauce or tamari.
Blend all together until the texture is creamy
After preparing your al dente pasta of choice, it could be whole wheat pasta, kamut, spelt, get creative! Save a little of the pasta water to add to the combination of the pesto mixture and pasta to maintain a smooth consistency.
Top your pesto pasta with raw butternut squash flakes by grating the squash with a cheese grater. (Adding a pinch more Vitamin A, B,C and Carotene)
Before putting the fork in your mouth, take a moment to feel the warmth of the food and smell the ingredients. While you eat, look at the food, as recommended in Ayurveda. You and your baby will be happy and feel all the love of nature.
“Cervical dilation” and “effacement” are terms that you will hear your care provider talk about toward the end of your pregnancy and throughout your labor. These terms refer to the opening and thinning of the cervix. Dilation is measured in centimeters, from 0-10cm, and being at 10 cm means that you are fully dilated and can start push when you feel the urge to do so. Effacement is the thinning and shorting of the cervix measured in percentages, from 0-100%, and being at 100% means your cervix is paper-thin.
It is not uncommon for me to hear students come in and proclaim that they are 1cm dilated and expect labor to start any moment. Realistically, that is probably not going to happen. You can walk around dilated for several weeks before the onset of labor. As a labor support doula, I am more interested in how effaced a client is than how dilated. If the cervix is not shortening and thinning it doesn’t really matter much that it is has opened a bit. The cervix will not open significantly if it is not effaced very much. Once the cervix is on its way to fully becoming effaced, change in dilation will often happen.
What can you do to help effacement? The cervix becomes soft or effaced by the secretion or application of prostaglandins. “Prostaglandins are produced by the mother’s body as well as by the fetus and placenta.” (Holistic Midwifery pg 190) However, there are some other nonpharmaceutical ways to help ripen the cervix. Since semen contains prostaglandins, sexual intercouse is one of the best, natural ways to apply prostaglandins directly to the cervix. I know that toward the end of pregnancy, that may not seem all that appealing, so you can also insert evening primrose oil directly into the vagina. Please note: THIS IS NOT TO BE DONE IF YOUR MEMBRANES HAVE BROKEN! The recommended dosage is 2,500mg capsules a day. This can also be done by taking the oil capsules orally if you are not comfortable with inserting it vaginally.
Another natural method is called “stripping the membranes,” but again, note: THIS PROCEDURE NEEDS TO BE PERFORMED BY A MIDWIFE OR DOCTOR! It is done by the doctor or midwife inserting two fingers inside the cervix and separating the amniotic sac from the cervix. This may stimulate the body’s natural production of prostaglandin. “In two studies, sweeping the membranes successfully induced labor in half the cases attempted.” (Ina May’s Guide to Childbirth. Pg 216.)
If your cervix is not ripening on its own and, for a medically sound reason, your care provider is advising you to be induced, you will receive a vaginal suppository of either cervidil or cytotec. These both contain prostaglandins to help soften the cervix and make it favorable for dilation.
Take a look at the picture below to get an idea of how the cervix shortens and thins out.
Before moving on to discussing dilation, I also want to take a moment to mention the mucus plug. This is just an accumulation of secretions that forms a seal in the cervical canal. Its main function is to create a barrier for infection. As the cervix starts to change, the mother will notice the passing of the mucus plug. Some women describe it as clumpy mucus others experience the release as more of a stringy mucus discharge. The color can be anywhere from pinkish to slightly brownish. The passing of the mucus plug does not guarantee the rapid onset of labor, just an indication that some change is starting to happen.
Cervical dilation can best be described as the baby’s head pushing through a turtleneck sweater. It is the downward pressure applied directly to the cervix that causes the cervix to open. A well-applied head is regarded as being more efficient at dilating the cervix during labor. This pressure is made possible by the uterus contracting around the baby and pushing it downward. Gravity also helps apply pressure to the cervix, which is why squatting can be so beneficial and productive. If you are either stalled in labor or hit a plateau in dilation, it could be a result of poor fetal positioning. Read “Explanation of Fetal Of Position” for more details.
Although this is not to scale, you can get an idea of how the cervix widens and thins until there is no cervix left, at which point full dilation (10 cm) has been reached.
Also keep in mind that second or third time, mothers tend to dilate more, up to 3 or 4 cm before labor even starts. Some mothers may experience this kind of dilation for several weeks before the onset of labor.
The whole reason I was prompted to write this blog was the many questions and concerns that have come up in class. One mother was particularly concerned about doing yoga at 37 weeks pregnant, being 1cm dilated. I always refer to the care provider should there be a medical reason I am unaware of, but for most women, it is fine to continue your yoga practice right up until labor, dilated or not. I wish I could say yoga will help further efface or dilate the mother’s cervix and start labor. The best I can offer is that the yoga practitioner walks (or waddles) out of class more relaxed which is good for the hormonal cocktail that supports labor. But as far as I know, it can not jump start your labor.
In the past week I have heard two rather disturbing stories from my students. One student came back and told me the unlikely unfolding of her birth story: the mother hit her due date, and the doctor predicted she was going to have a baby weighing nearly 10 pounds. Because of this “guestimation” on the baby’s size, the doctor strongly urged the mother to have a cesarean birth due to concerns about shoulder dystocia. The mother reluctantly agreed to have the surgery and gave birth to a beautiful baby girl weighing in at 8 pounds, two ounces. The second story involves a second-time mother, approaching her due date. She had a very quick delivery with her first child, giving birth to a 7-pound baby two weeks early. Her doctor, like in the first case, is concerned that this baby will be too big for the mother to birth, so she wants to induce on her due date.
What’s the moral of the story? There can be a significant margin of error in estimating fetal birth weight and these doctors may be practicing out of fear, or what I call “defensive medicine.” They are assuming there is a problem before a problem presents itself. I do have empathy for the position the doctors are in since obstetrics can a tricky field. The care provider is responsible for the well being of the mother and the child, but there needs to be some trust that the human race would not have survived if our bodies were inherently broken.
This brings us to the question: what are the risks of delivering a “big baby?” I would like to interject that I have seen perfectly healthy large babies - over 9 pounds - born vaginally. My own doctor agreed that most of the time big babies can be born vaginally if the baby is in a good fetal position. The main risks are: undetected gestational diabetes (which means the baby could be at risk of having a low blood glucose level), third- or fourth-degree vaginal lacerations, and an increased risk of cesarean. The most disconcerting risk, which is very rare, is shoulder dystocia. Shoulder dystocia occurs when the baby’s head is delivered but the anterior shoulder is caught on the mother’s pubic bone or, even more rarely, when the posterior shoulder is caught on the mother’s sacrum.
This information is so important take into account when you may be considering an induction or cesarean birth due to estimated fetal weight. It is upsetting how many times expectant mothers come to me and tell me their doctor wants to induce them for suspected big babies. Some of these mothers are even encouraged to be induced before their due dates! The birth of your child is something that you will carry with you for the rest of your life. It is the first introduction for your baby into the world and the first of many experiences you will share with your child. If it is not a medical necessity to be induced, allow yourself and your baby the opportunity to see how your story together starts on its own.
