CHICAGO (EGMN) – The modification of the oxytocin infusion protocol at a
large university-affiliated community hospital nearly halved the number of
emergency cesarean deliveries over a 3-year period, reported Dr. Gary
Ventolini.
As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean
deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual
meeting of the American College of Obstetricians and Gynecologists.
Other birth outcomes improved as well at an 848-bed community hospital that
serves as the primary teaching hospital of the Boonshoft School of Medicine
at Wright State University in Dayton, Ohio.
These included significant declines in emergency vacuum and forceps
deliveries and a sharp reduction in neonatal ICU team mobilization for signs
of fetal distress (P = .0001 in year 3 compared with year 1).
“More and more data are showing us that we are using too much oxytocin too
often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at
the university, said in an interview.
“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units
every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,”
he said.
Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively
analyzed to determine any impact of the change in an oxytocin protocol
implemented in 2005. Patient characteristics were similar in all three
calendar years.
The most profound changes were in emergency deliveries, including caesarean
deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps
deliveries (which fell from 4% to 2.3%).
The overall cesarean section rate remained unchanged, as did the rates of
cord prolapse, preeclampsia, and abruption.
Dr. Ventolini cited a recent article in the American Journal of Obstetrics
and Gynecology that suggests guidelines for oxytocin use, including
avoidance of dose increases at intervals shorter than 30 minutes in most
situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-.e6).
Dr. Ventolini and his associates reported no financial conflicts of interest
relevant to the study.
I just received my copy of New York Magazine yesterday and noticed that it was the “Best Doctors” issue. I eagerly opened it to see if I knew any of the featured doctors, since I have worked with quite a few over the past 6 years as a labor support doula. I found that I knew one, Dr. Joan Kent OB/GYN from NY Pres-Weill Cornell. I would like to note that out of the 18 OB/GYNs listed, she - along with only one other – was not described as a “high risk, fertility specialist,” or by having any other surgical specialty.
The magazine explains that the list is compiled from peer recommendations, not from client/patient recommendations. They say: “The idea is that medical professionals are best qualified to judge other medical professionals.” I believe there is some truth to that, but it emphasizes that the medical profession (in this case, obstetrics) follows a pathological model of care. Meaning that doctors are trained to look for what is abnormal or pathological as opposed to accepting a wide range of what is normal. So does that mean, then, that there is a higher regard for doctors who know how to do the “fancy” procedures instead of those that are comfortable sitting back, observing and caring for the low-risk mother? If I was teaching a yoga class with my peers watching or judging me, would they be more impressed that I taught a challenging, difficult series of poses as opposed to a simpler, but perhaps more appropriate, basic class? I would like to stress that we do need specialists for abnormal conditions or situations, but it was shocking that out of the list of 18 OB/GYNs, only two were “average, low-risk doctors”. (I won’t even go into my distress that there was no mention of a midwife in this article.) As a low-risk woman, I would so much rather go to a doctor that has a low cesarean rate then one who has a high one. Yes, the doctor who has a high rate may be more proficient at performing that procedure since that doctor performs them more often. However, I would think that there may be a problem based on the mere fact that the doctor does perform this surgery so often.
Are we valuing technology and complicated procedures more than we value instinct and personal touch? Two years ago I went down to Summertown, Tennessee to take a week long midwifery assistant program at The Farm with Ina May Gaskin and the renowned Farm Midwives. While there, I learned how to feel for fetal position. The technique that made the most sense to me is called Leopold’s Maneuver. It consists of four distinct hands-on actions, each helping to determine the position of the fetus. I worked with some actual pregnant mamas along with teaching dolls. This technique is primarily what the Midwives use to determine fetal positions. After learning this technique relatively easily and seeing it function with good accuracy, I noticed that it is never used in hospitals!! Upon admittance to the Labor and Delivery floor, an ultrasound machine is wheeled into triage to determine whether the baby’s head is down. Why go straight for the costly technology, especially since the overuse of ultrasound is in question relative to its safety to the fetus? Why not just have the residents place their hands on the laboring mother’s abdomen? Along these same lines, why are unmedicated, laboring mothers strapped to an external fetal monitor designed to tell everyone when that mother is having a contraction. If she is indeed unmedicated, she will likely be able to tell you when she is having a contraction. If the mother does not perceive the contractions, the nurse or doctor can feel the uterus hardening since the whole belly tightens during the contractions. Another great example of toned-down technology is the fetal scope. It is an instrument used to listen to the fetus’s heart rate without exposing the baby to ultrasound waves like the doppler or ultrasound machines. The fetal scope is definitely “old school”, but that doesn’t mean it doesn’t work! Look below for a picture of it. The care provider listens like they would through a stethoscope. The horn-shaped part is at the mother’s belly and the flat part against midwife’s or doctor’s forehead. I wonder if a high risk OB/GYN walking into an “average” risk doctor’s or midwife’s office and seeing them use the fetal scope or the Leopold maneuver instead of more modern machinery would look down upon these less advanced devices.
The New York magazine article also features stories about several of the “Best Doctor” candidates talking about their first time performing procedures that were scary for them. The author explains that: “In relating the stories of their inaugural attempts to remove a brain tumor or deliver sextuplets, among other harrowing scenarios, the doctors in question display an almost superhuman ability to cure what ails us-and an altogether mortal mix of self-doubt, fallibility and compassion.” Maybe we, as a society, have put the doctor and his/her modern technology into the “superhuman” category to such an extent that we no longer look to or value the simplicity of human touch and instincts.
Take a look at the hospital sketch from Monte Python Meaning of Life. It illustrates quite humorously how impressed we are with the machine that goes PING!
FACT: The United States ranks 42nd in the WORLD for maternal mortality rates
FACT: The Centers for Disease Control (CDC) report that there has been no improvement in the maternal death rate in the United States since 1982.
FACT: The CDC estimates that more than half of the reported maternal deaths in the United States could have been prevented by early diagnosis and treatment. (1)
The difficult part of this information to digest is that the US is also one of the highest cost-per-birth countries in the world. I am dumbfounded and saddened by the statistics I continue to uncover while researching for this blog. My original idea was to focus on Ina May Gaskin’s “The Safe Motherhood Quilt Project”. Ina May’s quilt is a reaction to a growing problem in this country, a traveling and virtual quilt representing mothers that have died from pregnancy-related causes since 1982. Each square in the quilt represents the story of the mother that has died. It is similar to the AIDS Memorial Quilt. Currently the quilt has over 125 pieces.
What is maternal mortality rate? According to the World Health Organization: “A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental cause.”
Why is this happening? Well, the answer is complicated; there are several ideas about what might play a role in this issue. Many arrows continue to point back to the growing number of cesarean births as a cause of our embarrassing ranking. If we begin by considering medically unnecessary inductions, we follow a cascade effecting leading to a greater chance of a c-section. With each cesarean a woman has, her chance of complication grows. It is also important to look at the defensive practice of medicine. In the movie, “The Business of Being Born” Dr Eden Fromberg says “There was a doctor who trained me that says “They can never fault you if you just section ‘em.” Several doctors in the movie concur that it is a growing problem and litigation plays a role into the decision to perform a cesarean. The maternal mortality rate for cesarean section is 4 times higher than for vaginal birth and is still twice as high when it is a routine repeat cesarean section without any emergency.
While many of the complications listed above are rare, the chance of a cesarean birth is not. Please do not interpret my strong stance against cesareans to mean that they should never be done, or that you will have problems should you need one. The cesarean is a valuable intervention when used appropriately. However, much research supports that our misuse of this surgical procedure leads to complications and, in some rare cases, maternal death.
If you are interested in learning more this subject, there is a very intriguing, detailed 20 minute video called Birth by the Numbers. Eugene R. Declercq, PhD, Professor of Maternal and Child Health, Boston University School of Public Health, presents the sobering statistics of birth in the United States today. Click here for a direct link.
***Please note, that this blog entry is not meant to scare pregnant moms. I am just shedding some light on a growing problem in our society when it comes to wellness of moms and babies.
Last night I was teaching a refresher childbirth education class to a couple. The father is a physician and the mother is an occupational therapist - so when I started talking about non-pharmacological methods of pain relief, specifically those related to the Gate Control Theory, they knew exactly what I was referring to. They added to the conversation by sharing that this method of pain relief can really help a mother during her first labor. This particular mom labored submerged in a warm birth tub up to the time she was ready to push. She explained that the water really helped relieve a lot of the pain she was experiencing.
I find it interesting that the Gate Control Theory and these nonpharmcological methods produce an outcome similar to the relief of an epidural. Ok, granted, an epidural takes much less effort to sustain pain relief, offers a chance for the laboring mother to sleep and has a very high rate of success. (Although it is important to note that the epidural does not offer total pain relief. For some women, it offers none at all.) Here is a very simplified explanation of how the epidural works: a hollow needle is inserted into the epidural space below the spinal cord, and the epidural anaesthesia passes through a catheter that remains in the back for the remainder of labor. The anaesthesia blocks the A-delta and C-fibers from transmitting pain to the brain, offering relief and numbness from the waist down.
It is comforting to know that there are several options for pain relief during childbirth. Even for those choosing to have an unmedicated birth, there are still plenty of ways to relieve the innate pains of labor. Prepare in advance, arranging for a birth tub if you are birthing at home or investigating whether your birth center or hospital has a tub/shower. Purchase a hot water bottle, get an ice pack, and have a rice sock or massage tools available.
I love when childbirth related articles fall into mainstream media. The Sunday, LA Times published an article, “Childbirth: Can the U.S. improve?”. It highlights some of the biggest issues facing expectant parents now a days; high cesarean and induction rates, the growing strain on health care, and the refusal to allow for VBACs (Vaginal Births After Cesareans). I highly recommend spending a moment to read this eye opening article.
Childbirth: Can the U.S. improve?
By Lisa Girion
May 17, 2009
Ruby Wales holds her newborn, Carson. Her first doctor worried more about the risks of vaginal delivery than of cesarean, so she found a different one. C-sections are expensive. Doctors ask if we are doing too many.
After an emergency cesarean with her first baby, Ruby Wales was holding out for a vaginal birth with her second one.
With a toddler underfoot, the 33-year-old Mission Viejo woman wanted a faster recovery. But finding a physician to deliver her second child wasn’t easy. Her first obstetrician turned her down flat. “She said, ‘No — no way,’ ” Wales recalled.
Once reserved for cases in which the life of the baby or mother was in danger, the cesarean is now routine. The most common operation in the U.S., it is performed in 31% of births, up from 4.5% in 1965.
With that surge has come an explosion in medical bills, an increase in complications — and a reconsideration of the cesarean as a sometimes unnecessary risk.
It is a big reason childbirth often is held up in healthcare reform debates as an example of how the intensive and expensive U.S. brand of medicine has failed to deliver better results and may, in fact, be doing more harm than good.
“We’re going in the wrong direction,” said Dr. Roger A. Rosenblatt, a University of Washington professor of family medicine who has written about what he calls the “perinatal paradox,” in which more intervention, such as cesareans, is linked with declining outcomes, such as neonatal intensive care admissions. Maternity care, he said, “is a microcosm of the entire medical enterprise.”
As the No. 1 cause of hospital admissions, childbirth is a huge part of the nation’s $2.4-trillion annual healthcare expenditure, accounting in hospital charges alone for more than $79 billion.
Because spending on the average uncomplicated cesarean for all patients runs about $4,500, nearly twice as much as a comparable vaginal birth, cesareans account for a disproportionate amount (45%) of delivery costs. (Among privately insured patients, uncomplicated cesareans run about $13,000.)
Pregnancy is the most expensive condition for both private insurers and Medicaid, according to a 2008 report by the Childbirth Connection, a New York think tank.
“The financial toll of maternity care on private [insurers]/employers and Medicaid/taxpayers is especially large,” the report said. “Maternity care thus plays a considerable role in escalating healthcare costs, which increasingly threaten the financial stability of families, employers, and federal and state budgets.”
The cesarean rate in the U.S. is higher than in most other developed nations. And in spite of a standing government goal of reducing such deliveries, the U.S. has set a new record every year for more than a decade.
Click here to continue to read this article
I was really struck by a quote from Diana Korte and Roberta Scaer, authors of A Good Birth, A Safe Birth, who said: “If you don’t know your options, you don’t have any.” From what I have encountered in my years of teaching, many women really do not know how many choices they have with respect to their own childbirth. For example, I was quite dismayed to hear from a student that her former OB/GYN said to her “You don’t need to take childbirth education classes or buy the books; I will tell you what you need to know.” (She had the good sense to switch away from that doctor!)
Here are a few areas I review with my doula clients to help them better understand their choices and preferences for the upcoming birth.
Once you have a clear idea of your choices and options, it will help you communicate your wishes with your care provider to assure you are both on the same page.
Labor and Delivery Labor at home as long a possible- Most of the time the doctor does not want you coming to the hospital too early. In general, go by the 4-1-1 or 3-1-1 rule. This means that the contractions should be 4 or 3 minutes apart, lasting one minute for one hour. Especially if the mother is intending to do a no or minimal intervention birth, it is best to labor at home as long as possible.
Food/ Drinking- While many hospitals have a no food or “clear liquids” only rule, you can decide if you want to continue to eat and drink at home or eat and drink in your labor room. Small meals with plenty of complex carbs are recommended. In fact, the Lamaze Organization, in their Care Practice Paper, “No Routine Interventions,” stresses the importance of continuing to eat lightly through out labor.
Hep lock and IV- The hep lock is a portal for a continuous IV drip. Some doctors and hospitals require the full-time IV while others are ok with just the hep lock. Unless you are in a birth center, you will most likely have the hep lock, but can perhaps negotiate the IV. According to the Cochrane Pregnancy and Childbirth Group, a respected worldwide source of information about evidence-based care, routine use of IVs is not likely to be beneficial. No studies demonstrate that routinely placing an IV in low-risk laboring women prevents poor outcomes.
Vaginal exams- Some women really want to hear regular updates of how they are doing. This can be very encouraging. However, if the water has been broken it is important not to do too many vaginal examines, in order to prevent infection. It is also recommended to have the same person check you so you do not hear too many opinions. The mother also has the right to request minimal vaginal exams. As one midwife explained to me, she does not have to do an internal to see what is happening with the mom. She can watch and listen. If the mother is unmedicated, the mother will let the midwife know when she is ready to push.
Labor augmentation- There are many ways to naturally move labor along: nipple stimulation, sex, acupuncture, and castor oil, just to name a few. If you are facing an induction date, check with your care provider to see if these ideas are an option. Once you’re in labor, and if things are not moving along as the care provider wants, consider castor oil as an option before moving on to pitocin.
Epidural and other pain medications- The most common anesthesia during childbirth is the epidural. However, other options are demerol and stadol. These narcotics promote relaxation and reduce the sensation of pain. Many women report that IV medication makes you feel sleepy or as if you’ve had a drink of an alcoholic beverage.
Many students have asked me about the “walking epidural”. They say they like the idea of the pain relief but want to stay active and move around. This epidural is different then the traditional type because it is a combination of spinal and epidural analgesia. However, there is no walking around. This is mainly for legal reasons, but with the epidural the mother is also hooked up to a fetal monitor (external or internal), contraction monitor, IV, epidural catheter, blood pressure cuff and urinary catheter.
Episiotomy- While the use of routine episiotomy has decreased, there are still many doctors that strongly believe it is better to cut than tear. Again, the Lamaze Organization has commented on this subject: “There is no evidence that an episiotomy reduces the risk of perineal injury, improves perineal healing, prevents birth injury in babies, or reduces the risk of future incontinence (involuntary loss of urine or feces).” You can ask your care provider to apply warm compresses to the perineum to encourage the muscle tissue to become more malleable.
Laboring positions/ Freedom of movement- Excerpt from “Care Practice Papers” from the Lamaze Institute for Normal Birth: When you walk or move around in labor, your uterus, a muscle, works more efficiently. Changing position frequently moves the bones of the pelvis to help the baby find the best fit through your birth canal, while upright positions use gravity to help bring the baby down. When labor slows, a change in position often will help you “find your rhythm” again. If your baby is in a posterior position (with the back of the baby’s head toward your spine), getting on your hands and knees helps the baby rotate and decreases back pain. If your baby is posterior, labor may be very long and difficult until the baby rotates to an anterior position, with the back of the head toward your front.
Pushing positions- There are so many options for second stage of labor, the pushing stage. The laboring mom could be on all 4’s, side lying, standing, squatting, sitting on a birthing stool, and of course, the most traditional and common, in a reclined or semi- reclined position. This is a really important subject to discus with your care provider! It is not that they may be against alternative positions; they just may not know how to guide the baby out in any other positions besides a supine position.
Students- Here is one that many people don’t think about. You have every right to ask that there be a minimum of people interacting with you and/or in the room while you birth. You or your partner can request not to have students present during your birth experience.
Pushing- Directed or spontaneous pushing? Directed is when the nurse, partner, doctor or doula instructs the mother when to push and for how long. This is what is often portrayed in the movies with the whole counting while pushing scenario. Spontaneous pushing is the mother pushing when she feels the urge to and pushing on her own.
After delivery Cord blood collection- There are private companies that offer cord blood collection as well as public banking.
Skin to skin- You can request to have your baby placed directly on your stomach or chest immediately after delivery before they are weighed, foot-printed or given the vitamin K shot and eye ointment if all is medically sound with your baby. The Cochrane Review, an authority on evidence-based maternity care, concluded in a study that involved 1,925 mothers, that “Skin-to-skin contact between mother and baby at birth reduces crying, improves mother-baby interaction, keeps the baby warmer, and helps women breastfeed successfully.”
Cutting of the cord- You do not need to have the cord cut immediately. This excerpt from an article on cord clamping explains why. “Late vs. Early Clamping of the Umbilical Cord in Full-Term Neonates: Systematic Review and Meta-Analysis of Controlled Trials” by Eileen K. Hutton, PhD, Eman S. Hassan, MBBCh:
“Earlier physiological studies have shown that, of the total blood volume in the combined fetal-placental circulation at full gestation, approximately 25% to 60% (54-160 mL) is found in the placental circulation and that as many as 60% of the fetal red blood cells are found therein. This blood is also known to be rich in hematopoietic stem cells.
Previous research has suggested that early clamping of the cord (within the first 5 to 10 seconds of birth), compared with later clamping, results in a decrease to the neonate of 20 to 40 mL of blood per kilogram of bodyweight, which would provide the equivalent of 30 to 35 mg of iron. It has been argued that early cord clamping puts the newborn at increased risk of hypovolemic damage and iron loss, as well as of several blood disorders and type 2 diabetes, as a consequence of loss of hematopoietic stem cells.”
Newborn procedures- Unless it is medically necessary, you can request to postpone newborn procedures for up to one hour or until after initial breastfeeding.
Placenta delivery- When to deliver the placenta. This is called the third stage of labor and it could take anywhere from 5 minutes to an hour. The uterus will continue to contract, which helps expel the placenta from the uterine wall. Often, the doctor may add a little pressure to help bring it out. Some care providers allow the placenta to detach and birth on its own.
I found this great antidote by Roberta Gehrke, CNM from Midwifery Today E-News (Vol 2 Issue 2, Jan 14, 2000) about placenta delivery. “Placenta delivery techniques were taught to me when I was studying basic midwifery in London many years ago. I recall the demonstration with a smile every time my hand goes to a uterus after the birth of a babe and before the placenta comes out. The Sister asked one of my classmates to stand up and put her arms out; she threw a sheet over her and said, ‘This is the uterus, tubes and ovaries.’ She then jabbed the student moderately firmly in the sides, making her jump and quickly bring down her arms. Sister then said, ‘When you are getting impatient waiting for the placenta to let loose, the first rule is to never fiddle with the fundus! It makes the uterus jumpy, and it clamps down, keeping the placenta trapped for longer than it needs to be. It can lead to hidden hemorrhage between the placenta and uterine wall. So it may be a wise idea to ask your care provider to allow the placenta to release naturally instead of helping it along.
Breastfeeding - If you are planning on breastfeeding exclusively, you should make it clear to the hospital staff not to give your newborn a bottle or pacifier.
Now you may have a clearer idea of the choices that are in front of you. Education is empowerment. You will certainly make clear choices with how you wish to raise your child, shouldn’t you do the same with how you choice to birth your child?
A recent article from BBC News, Home Births “as safe as Hospital”, highlights the largest study of its kind, with over a half million participants. It indicates that for low-risk women, giving birth at home is as safe as doing so in hospital with a midwife.
The American College of Obstetricians and Gynecologists (ACOG) stated in 2008 that they do not support births out side of a hospital setting. They maintain that “there is not enough research to substantiate its safety.” But there is now!
“Research from the Netherlands - which has a high rate of home births - found no difference in death rates of either mothers or babies in 530,000 births.” Professor Simone Buitendijk of the TNO Institute for Applied Scientific Research said, “We found that for low-risk mothers at the start of their labour it is just as safe to deliver at home with a midwife as it is in hospital with a midwife.” In the UK, The Royal College of Obstetricians and Gynaecologists (RCOG), recently said it supported home births “in cases of low-risk pregnancies provided the appropriate infrastructures and resources are present to support such a system. In fact the British government has pledged to give all women the option of a home birth by the end of this year.
While it still is far from the norm to give birth outside the hospital in many places, it is exciting to see that research is supporting a shift in our current paradigm. American culture has embraced diversity and choice in so many areas of society; it seems unfortunate that birth, one of the most basic parts of our existence, is being so stifled and controlled by one ideology. There is no one right way or place to give birth.
Part of my job as a doula is to hold a prenatal meeting with the couple I’m working with, then type up notes from that meeting and return them to the couple for review. Over the years I have established a format for the questions I ask, although I do change them each time according to the couple’s intentions for their birth. One question that remains unchanged, though, is this: “Would you like immediate skin-to-skin contact (SSC)?” Rarely do I hear a parent say no to this question. After my notes are typed up, I encourage the parents to share these birth preferences with their care provider – this ensures everyone is on the same page. The feedback about SSC is generally the same and unless there is a medical reason, new mothers always get skin-to-skin contact with their babies. It’s no surprise that new parents would want the mother to hold her delicious new bundle, allow the oxytocin to flow, look deeply into her baby’s innocent eyes and fall in love with her child immediately after giving birth. Additionally, if her baby is interested in breastfeeding right away, the mother will continue to produce oxytocin, which allows her to have the contractions that will help expel the placenta and shrink the uterus.
Despite these benefits, I usually witness the mother holding baby for mere moments before that baby is whisked away and placed under the heater, administered the vitamin K shot and eye drops, weighed, foot-printed, swaddled and then returned to the mother. Though parents have the option to postpone these hospital procedures for up to an hour, they often (unfortunately) take precedence over prolonged and immediate SSC, delaying the mother receiving her baby by about 30 minutes. During this time, the mother is delivering the placenta, which can take anywhere from 5 to 30 minutes, and being stitched up in the event of tearing or an episotomy. It is possible, as long as everything looks normal and there is no hemorrhaging, for the mother to keep the baby on her chest during these procedures and spend time with her baby.
The separation of mother and newborn is unique to humans, something other mammals do not experience. It is also newer to our culture, and results from the fact that more births are taking place in hospitals where immediate separation is more commonly seen. “In order for a mammalian species to survive, newborns must learn to nurse, and their mothers must learn to protect and care for them. Researchers have described a ‘sensitive period’ in the first hour after birth, during which hormonal changes and innate behaviors coincide to produce optimal outcomes. They have also identified care practices that disrupt these processes with detrimental effects. Even apparently benign practices can disrupt their innate behaviors if they occur in the first 1-2 hours after birth.” (Journal of Perinatal Education, Volume 16, Number 4, pg 71)
I have yet to find a study that demonstrates negative side effects or outcomes from SSC between mother and newborn. In most cases, since the majority of births these days take place in a hospital, it will likely take some orchestrating and persistence to have prolonged, immediate skin-to-skin contact, but it is unarguably extremely beneficial for the newest member of your family, your baby.
The pelvis is greatly affected during pregnancy, and it is not uncommon for the expectant mom to experience aches and pains in this area. Many times women just accept these pains as annoyances that will go away after the baby is born, which is most likely true, but there are some things that can be done during pregnancy to deal with these discomforts.
I just received my latest copy of Midwifery Today (yes, it does happen to brighten my day when I fish it out of my mailbox!). This month’s issue features a short article about SPD (symphysis pubis disorder) and some wonderful suggestion about dealing with it. Here’s a quick anatomy lesson: the pubic bone is not actually a single bone. It is the point at which the two halves of the pelvis join in the front via a piece of cartilage. This cartilaginous joint is the pubic symphysis. During pregnancy, because of the presence of relaxin in the body, all joints become more flexible, including this one. Sometimes the bony portion of the pubis (left or right pubic tubercle) separates slightly from the cartilaginous joint causing pain. Pain can range from slight, which indicates just minor overstretching of the joint, to extreme, due to full-on separation (diastasis) on one or both sides of the joint.
In your prenatal yoga practice, we would suggest avoiding deep pelvic opening poses that will be likely to exasperate the situation. We also encourage students to take shorter, wider stances in standing poses and to be gentler with their hip-opening poses. The article I mentioned above also suggests options that can be explored outside the yoga room, and especially during labor.
Author Barbara E Herrera, LM, CPM makes this suggestion: “I have found tight binding very helpful during pregnancy and labor. Use a long wrap or rebozo (and if you are large woman, tie two or three together) and have someone help you tie the wrap tightly around your hips. In labor, you might need two people to do the work. Wrap the cloth as if you are going to make a knot, having each person pull an end after that first step. Once the cloth is very tight around your hips, have them tie a knot. After this is in place, you will feel less pain and be able to try different positions. Standing, holding onto the squatting bar, allows you to do a supported squat without spreading your legs far.”
A very common birthing position is lying supine, drawing the knees to the armpit area. This is a huge pelvis opener, which is useful for making more space, and is among the easiest positions for a doctor or midwife to get a good view of what is going on. However, this may not be the idea position for a mother who is suffering from SPD. In fact, lying supine can cause more pain through the healing process. The mother may not notice the pain during labor since many other things are going on, but she is likely to feel the pubic pain afterwards if the pubis has spread even further. Other options for birthing positions include: coming onto an all-4 position, standing, kneeling, gentle squatting or side lying. It would be best to avoid any position or situation where someone is likely to pull the legs far back.
After the baby is out, the mother still has relaxin, the hormone responsible for softening the tendons and ligaments, in the body for up to six months. So it is not uncommon for the new mother to continue to feel pubic pain. Herrera suggests continuing to bind the hips until the new mother feels the pain subside and more stability in the pelvis. In postnatal yoga, we specifically address this common discomfort and work on poses that help create stability in the pelvis. Luckily, over time this issue usually corrects itself.
Over the last week or so, many childbirth education blogs and articles have focused on Pamela Paul’s latest article in TIME magazine, The Trouble With Repeat Cesareans. It is so wonderful that this important subject is receiving some attention. Paul, who happens to be a third time student at the Prenatal Yoga Center, also expanded on the story in the Huffington Post in Childbirth Without Choice. In this lengthier version, Paul goes on to detail her own personal experience with a VBAC (Vaginal Birth After Cesarean) backlash.
The current trend in our country is that one third of pregnant women will give birth via cesarean section. Within that population, 9 out of 10 women will have c-sections for any subsequent births. For some women it is a choice, and the c-section will be scheduled; others who may want a VBAC will find themselves restricted by the lack of hospitals or doctors willing to provide the service.
Hospital staff scheduling is also a factor. A cesarean takes an hour while a labor undertaken “the old fashion way” is unpredictable and can last many hours. I often joke with my students when they are scheduling their c-sections or inductions that they will never go in on a Friday, Saturday or Sunday night. Monday through Thursday is the prime time in the Labor and Delivery unit.
Neither a VBAC nor a planned cesarean can guarantee a complication-free experience. Both options offer benefits and serious risks that need to be taken into account. But doesn’t an expectant mom who understands all the relevant factors deserve access to both? Dialogue on both sides of the VBAC argument is crucial, especially when we’re seeing the prevailing attitude toward VBACs robbing so many expectant moms of the choice of how to birth their babies.
I wanted to share some questions with you that I am asked on a regular basis: “What is the difference between a midwife and a doula? “; “Does my doctor work with my midwife?”; “Why would I choose a midwife over a doctor?”; “Isn’t the nurse like a doula?” I figured the best way to answer all of these questions would be to finally sit down and map it out.
First, let’s understand the definitions of those terms and the job of each of the people mentioned.
You will see your OB/GYN or members of his/her practice throughout your pregnancy, although who your care provider will be at delivery depends on who is on call during your labor. During the labor, the doctor will come in and out to check on your progress and, as the definition above states, “manage” your labor. Obstetrics is also a surgical field, so in the case of a cesarean, it would be your OB that would perform the procedure.
A midwife works with each woman and her family to identify their unique physical, social and emotional needs. When the care required is outside the midwife’s scope of practice or expertise, the woman is referred to other health care providers for additional consultation or care.
Midwives operate from The Midwives Model of Care which emphasizes the fact that pregnancy and birth are normal life processes. Midwives statistically have lower rates of interventions and provide the mother with individualized education, counseling, prenatal care and postpartum support as well as continuous hands-on assistance during labor and delivery.
Midwives, like doctors, may work in a group that rotates who is on call and who will see you for your prenatal visits. Some midwives work alongside doctors in their practices, while some work individually or outside the hospital setting. There are different types of midwives: Direct Entry Midwifes, Certified Professional Midwives, and Certified Nurse Midwives. Depending on their credentials and training, some midwives work in hospitals while others solely attend home births.
Labor Support Doula: A trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period.
Unless the doula has additional training, she is NOT a medical professional and will not perform medical procedures on the laboring mothering or deliver the baby. However, she most likely will be one of the most consistent elements of the labor experience. She does not change shifts and only deals with one client at a time. The doula will also labor with you at home and come with you to the hospital or birth center.
Now that there is an understanding of what each professions offers, it may be clearer how they might or might not work together. So, back to the original questions:
What is the difference between a doula and a midwife?
As described above, the doula acts as an emotional, physical and informational support for the mother. While the midwife may offer many of those same qualities, it is the midwife that will deliver the baby and perform the necessary medical examinations throughout pregnancy, labor, delivery and postpartum. Midwives are also available to do “well woman” yearly exams throughout a woman’s life, not just working with her while pregnant.
Does my doctor work with my midwife?
Yes, sometimes a practice has both doctors and midwives. But if your current doctor does not work with midwives you cannot have both as care providers. If a midwifery practice does not have a doctor as part of the group, there will be a doctor that backs up that group. However, if you choose a home birth, you will have just a midwife; should you need further medical assistance, you would be transferred to a hospital. Some midwives have privileges at a hospital, while others just have a relationship with a doctor and will no longer be your care provider should you be admitted.
Why would I choose a midwife over a doctor?
Choosing your care provider is a very personal choice. It requires a long, hard look at the model of care you would like for your pregnancy and delivery. While both professions try to offer the best care they can to women, the path in which that support is offered differs. The Model of Care that midwives subscribe to reflects the idea that pregnancy and birth is a natural physiological process that should be inherently trusted, while the medical model focuses on the pathologic potential of pregnancy and birth. They both have the same desired outcome, but use different routes to get there.
You should also consider the style of care you personally prefer. Midwives will tend to be more present during labor; moreover, they will be more holistically based and allow more space for the labor to unfold naturally before moving to medical interventions. Doctors are not as likely to give you as much personal care and time and may move to medical interventions more quickly.
Isn’t the nurse like a doula?
Many of the Labor and Delivery nurses (L & D nurses) I have worked with are wonderful and can offer a lot of helpful advice for the laboring mom. However, I would not advise depending on your L & D nurse to provide the same comfort and assistance as a labor support doula. The L & D nurse often has several women they are monitoring at the same time and cannot offer consistent support since they work in shifts and breaks. You may also find it appealing to choose your labor support doula and have the opportunity to previously discuss you birthing preferences with this person.
Now that the cast of characters has been laid out, I hope this makes it easier to make decisions about the model of support you will receive and who you would like at your birth.
Just the other day at the end of class several students were discussing their doctors’ recommendations for weight gain during pregnancy - a very hot topic among the pregnant mamas! Some women were saying that their doctors are very lenient while others have stricter guidelines, suggesting no more than 25 pounds. One woman commented that she remembers her mother telling stories about walking out of the hospital in her pre-pregnancy clothes, that “back in her day” the doctors didn’t want women gaining more than 20 pounds.
So what is a healthy guideline for weight gain during pregnancy? I went straight to a trusted source, a doctor with whom I have worked a number of times and greatly respect, Dr. Gae Rodke. Rodke says, “There seems to be an ideal range of weight gain in pregnancy–in normal weight women, 25-28 pounds gives a nice 7 pound baby and all the necessary accessories–breast tissue, amniotic fluid, placenta, extra blood volume, etc. Less than 20 lbs can be associated with poor fetal growth (and possible developmental delays); more than 40 lbs statistically increases the risk of Cesarean Delivery–not only are the babies bigger, but the fat upholstering the inside of the pelvis reduces the space available.”
For a lot of women, hearing that they will be gaining 25-30 pounds may be overwhelming, but consider the overall weight gain distribution to better understand where it all goes. Here is a sample breakdown provided by the Mayo Clinic:
Healthy eating is definitely part of the equation for healthy weight gain. The idea of “eating for two” is more of a myth than a reality, since you are not trying to feed another grown adult. Nutritionist Stephanie Clarke MS, RD from C & J Nutrition says, “If you are normal weight pre-pregnancy you’ll need about 300 extra calories per day during the second and third trimester; if you are overweight you may need as little as 150-250 extra calories per day. Keep in mind that tracking your weight gain is the best way to determine whether or not you’re eating too much or too little. If you have concerns about your weight gain, make sure to talk to your obstetrician as soon as possible”.
Remember that it is important to be careful not to make those extra calories empty calories. The food you take in should be of high nutritious value that will benefit you and your baby. Rodke goes on to explain that it is important to remember that what you eat while pregnant can directly effect your baby: “I find that refined carbs (white flour, white sugar, white bread, cakes, cookies, candy, white rice, white potatoes and other high glycemic index foods) are prone to increase the size of the baby beyond what one would expect from the amount of weight gained. Changes in the mother’s hormonal pattern keep these rapidly absorbed sugar molecules in her bloodstream longer, and babies are very efficient in taking sugars and making big bodies (just like in gestational diabetes).”
Clarke offers some tips for quick and easy ways to make the most of your calories:
* Add canned beans, dried fruit, whole grains like quinoa, and nuts/seeds to salads
* Choose whole grains and whole grain products (cereals, crackers, bread, wraps, etc.)
* Make oatmeal with fat free milk, rather than water (to add more calcium and protein)
* Top cold cereal with fruit and nuts
* Add veggies (spinach, mushrooms, salsa, etc.) to scrambled eggs or egg sandwiches
* Make snacks = calcium + fiber (lowfat whipped cottage cheese with strawberries, low
fat plain yogurt with fruit and cereal, part skim string cheese with a piece of fruit or 100% juice)
* Use avocado on sandwiches instead of mayo
* Stir frozen veggies into canned/boxed soups
It is crucial to stress that pregnancy is not the time to try to lose weight or greatly restrict yourself. It can and should be a time of bringing greater consciousness to your eating habits and food choices. After all, that all old saying “you are what you eat” means that much more to your little bun in the oven!
I just recently came across a wonderfully informative article, Early C-Section Carries Risks, Study Finds by Keith Winstein in the Wall Street Journal about a study recently conducted and published in The New England Journal of Medicine about the risks of early elective cesarean births. This struck me as an important, immediate topic, as I regularly hear my students discussing elective cesarean births: postpartum women saying that they had a c-section and would likely do so for their subsequent child, and currently pregnant women talking about their scheduled c-section appointments.
Side note: I know this is a delicate topic for many expectant moms who are choosing to have an elective cesarean birth. Time and time again, when a student tells me that she has scheduled an elective c-section, that information is very quickly followed by her reassurance that the procedure is being done strictly on the basis of medical necessity. This hasty follow-up statement often carries a fair degree of defensiveness. So I want to be clear, I am not making a judgment for or against c-sections. In fact, I particularly like the article because it does not criticize women for electing to have a cesarean birth, but rather discusses the importance of when in the pregnancy it is appropriate to schedule the surgery.
Generally speaking, the medical community believes that full gestation is established at 37-40 weeks, making it acceptable to deliver a baby anytime after 37 weeks - though many health professionals believe it inadvisable to deliver a baby before the 39 week mark. This particular study is based on the latter supposition, defining “early” delivery as anytime before 39 weeks gestation. The study, which is based on 13,258 elective cesareans, found that more than 35% were delivered before 38 weeks, which can result in higher frequency of infection, need for cardiac resuscitation and lengthier hospitalizations for the newborns. And, there appears to be a significant differentiation between 37, 38, and 39 weeks with regard to the complications that may result: Among babies born at 39 weeks, 3.4% had certain breathing problems, including one called respiratory distress syndrome. The frequency of such problems rose to 5.5% for babies delivered at 38 weeks, and to 8.2% at 37 weeks.
The difference between 37 and 39 weeks may not seem significant to you and me, but for baby these extra few weeks allow that bun in the oven to cook a little longer! Seriously, the last three weeks of pregnancy are very important for the baby’s lung development. In short, the difference between a few weeks is meaningful for the developing fetus, and so the decision to deliver a baby on either side of these three weeks can have very real implications for the baby’s health.
Ultimately the decision as to when to schedule an elective cesarean warrants a frank discussion between a patient and her care provider. My teacher Colette Crawford drilled into my head during my prenatal training that it’s important to remember to weigh the risks versus the benefits. What is the basis of your decision to have a c-section, and when to have it? What are the risks for you and baby? What are the benefits for you and baby? I am proud to pass on her wise words, especially where it concerns such an important decision - the health of your baby.
Inspired by what I saw on my bike trip through Vietnam, since returning I have been obsessed with incorporating more squatting poses into my prenatal yoga classes. I have long been fascinated by the incredible ease with which many people from other cultures (particularly in Asian countries I have visited) can assume a squatting position, compared to the struggle I often see in the yoga community I typically teach. So many of the Vietnamese people I saw just folded right up and sat down into self-made collapsible seats. Our bodies are designed to do just that: Fold at the ankles, knees and hips. If you watch little kids play, they take this shape effortlessly. So why is it so hard for us adults?
I think that we Americans have difficulty with this pose because of the daily routines and physical habits many of us have adopted: We sit for long periods of time, which shortens the hip flexor muscles and creates general stiffness in the body. Women tend to wear high-heeled shoes, which shortens the Achilles tendons and keeps the calves in a state of contraction, which makes it difficult to lengthen the muscles.
You’re probably wondering why it matters whether or not one can squat and what purpose it serves in a prenatal yoga class. In a previous blog entry, Birthing Positions: Don’t Just Take It Lying Down, I wrote about the importance of exploring a number of positions for laboring and pushing and not just limiting oneself to the traditional supine position. Many women find that birthing in a squatting position is ideal. Now we can delve deeper into the benefits of this particular choice.
For one, squatting tips the pelvis and uterus forward, placing the baby in an anterior position, which is good alignment for birthing. And, there is great benefit to using gravity to your advantage as the baby is making its way down. Additionally, you are widening the space for the baby to pass through. Squatting actually opens the pelvic outlet on average 15-20% wider than reclining back and shortens the birth canal. If the diameter of the pelvis is increased and the birth canal is shortened, the second stage of labor is likely to be shorter. (Read: Less pushing!) As I jokingly say in class a lot, “Nobody I have ever worked with requests more hours of pushing.” If you can shorten this stage, by all means do so! One final “shout out” for the benefits of this fantastic position: Squatting can also lessen the necessity for the use of forceps and vacuum extraction.
As great as squatting is, I would be irresponsible if I neglected to mention the one downside of this pose, perineal tearing. Because births tend to happen more quickly while squatting, there may not be time for the muscle tissue to stretch, and the attending care provider may not be able to offer the perineal support needed to prevent tearing. It is nevertheless a pose worthwhile exploring for the reasons listed above.
So what can one do to better prepare the body for taking this position? Here are a few tips: As I mentioned before, our bodies are not too accustomed to squatting. I would recommend doing calf and hamstring stretches to help open and release the backs of the legs. In yoga we do Downward-Facing Dog and Janu Sirsasana for this purpose. It is also important to build some leg strength, and you can cultivate this strength by practicing some standing yoga poses. I would also recommend wall squats; leaning your back against the wall and sliding down while trying to keep your heels on the floor. Allowing for the wall to bear your weight, just get your joints used to folding. You can also practice squats with a partner. If you are practicing away from the wall and without a partner and your heels pop up, simply place a rolled blanket or towel under them. You want to feel supported, and you should not have to hold yourself up with your leg muscles. While the legs are engaged, you want to relax into the pose. Finally, you can practice a wide-knee child’s pose to give your body a feeling of folding at the hips and knees.
What can you do if you have tried squatting and it is really difficult for you, but you’d like to explore squatting as you’re birthing? Well, you can labor on a toilet or bedpan. This allows for similar opening of the pelvis but offers support under the legs. You can do a partner squat or hold onto a railing or squatting bar (many hospitals now have these available to use), both which will help support your weight. Or you can use a birth ball (more for laboring than pushing). If your hospital or birthing center has a large tub or if you are doing a home birth and you have a rented tub, you can squat in the water. This has the additional benefit of buoyancy, making your body feel lighter and thereby making it easier to stay in this position for a length of time.
If you are intrigued by the idea of squatting during birth, there is a beautiful 10-minute Brazilian video called “Birthing In the Squatting Position”. It is truly remarkable. It shows several women calmly birthing in a squat, many of them reaching down and scooping up their own babies. I have seen it a number of times, and it still takes my breath away how at ease these mothers look while birthing.
Four years ago I was traveling through India when I came face to face (as it were) with the reality of the ‘Sphincter Law’. First allow me to describe my experience, as I think that it will illustrate why Ina May Gaskin has so termed this ‘law’.
When I arrived at Amma’s ashram, I had hitherto avoided the foot-tread toilets for the necessity of pooping. (I tried to think of a better way to say it - but couldn’t - so there it is!) So here I was, my very first experience relieving myself on anything but an English toilet, and my sphincters locked up. The area was somewhat private, but I knew there was a line waiting for my stall and just a short wall between me and everyone else. With the pressure of people waiting, my body not knowing how to handle this new experience and not wanting to spend too much time in my stall, I literally had to ‘doula’ myself through the experience. So I shut my eyes, pretended I was by myself and kept repeating a mantra, “Open! Let go!” I consciously softened my mouth and my jaw, knowing that there is a direct correlation between a tight throat and a tight bottom. Eventually, my body relaxed and I was able to go.
So what does this very personal toilet experience have to do with birthing??? Everything! Take my experience and translate that into birth. Imagine you are in a hospital, with unfamiliar people and bright lights, exposed in a revealing hospital gown, a clock ticking and people continuously checking to see if you have progressed. Does this sound like the ideal situation to allow your body to open up? Could you possibly poop in this situation? At least pooping you do on a regular basis so there is familiarity with it and very little pressure. How can we expect the laboring mother to feel comfortable enough to open her body and birth her baby in these circumstances?
Ina May Gaskin describes the Sphincter Law in the following way: o Sphincter muscles of both anus and vagina do not respond on command.
o Sphincter muscles open more easily in a comfortable intimate atmosphere where a woman feels safe.
o The muscles are more likely to open if the woman feels positive about herself; where she feels inspired and enjoys the birth process.
o Sphincter muscles may suddenly close even if they have already dilated, if the woman feels threatened in any way.
One way we can help a mother adhere to the rules of the Sphincter Law is to allow her to have a sense of privacy with as little distraction as possible. Keep the lights low, the traffic in and out of the room to a minimum, and try not to stimulate the neocortex (the ‘thinking mind’) with unnecessary questions. Even if there is a schedule within which she needs to fit in accordance with the hospital’s protocol, do not let her know that. When the mother is feeling safe and cared for, her body will respond. The sphincters will open, and her baby will come out more easily, with less stress for all involved.
Open! Let go! And always, always obey the law!
Below is a clip of Ina May Gaskin at a lecture at The Farm talking about the Sphincter Law:
I love when a study comes out that supports normal, healthy birth. This fall’s edition of The Journal of Perinatal Education features the article “Doula Care For Middle-Class Women With Male Partners Substantially Lowers Cesarean Rates”. The article describes a recent study that demonstrates some of the benefits of having a doula present.
Of course, being a labor support doula, I am a little biased towards the rewards of having continuous labor support from someone in addition to one’s partner. But more importantly, this study is relevant because of the negative press doulas are getting lately in mainstream America. Last year in the New York Times, Pamela Paul wrote a not-so-supportive piece, And Doula Makes Four, about problems with doulas in the labor and delivery room. Just a few weeks ago, The Today Show aired a segment about doulas in which a doctor discussed how bothersome doulas were at her hospital and in fact, that particular hospital has banned doulas from coming into the labor and delivery room. I would be curious to see that hospital’s cesarean rate! The segment, especially the written transcript, did try to create some balance by highlighting some of the positive aspects of having a doula present. However, the piece did not provide hard facts about the upside of adding a doula to the support team. That is why I am thrilled to share some of this new study:
Authors: McGrath, Susan K.; Kennell, John H.1
Source: Birth, Volume 35, Number 2, June 2008 , pp. 92-97(6)
Publisher: Blackwell Publishing
Background: Previous randomized controlled studies in several different settings demonstrated the positive effects of continuous labor support by an experienced woman (doula) for low-income women laboring without the support of family members. The objective of this randomized controlled trial was to examine the perinatal effects of doula support for nulliparous middle-income women accompanied by a male partner during labor and delivery. Methods: Nulliparous (First time mothers) women in the third trimester of an uncomplicated pregnancy were enrolled at childbirth education classes in Cleveland, Ohio, from 1988 through 1992. Of the 686 prenatal women recruited, 420 met enrollment criteria and completed the intervention. For the 224 women randomly assigned to the experimental group, a doula arrived shortly after hospital admission and remained throughout labor and delivery. Doula support included close physical proximity, touch, and eye contact with the laboring woman, and teaching, reassurance, and encouragement of the woman and her male partner.
Results: The doula group had a significantly lower cesarean delivery rate than the control group (13.4% vs 25.0%, p = 0.002), and fewer women in the doula group received epidural analgesia (64.7% vs 76.0%, p = 0.008). Among women with induced labor, those supported by a doula had a lower rate of cesarean delivery than those in the control group (12.5% vs 58.8%, p = 0.007). On questionnaires the day after delivery, 100 percent of couples with doula support rated their experience with the doula positively.
Conclusions: For middle-class women laboring with the support of their male partner, the continuous presence of a doula during labor significantly decreased the likelihood of cesarean delivery and reduced the need for epidural analgesia. Women and their male partners were unequivocal in their positive opinions about laboring with the support of a doula. (BIRTH 35:2 June 2008)
I like facts and studies. I know it makes me slightly geeky and maybe it is the result of having a lawyer for a father, or being part of the Lamaze Association (I am also a certified Lamaze teacher), which is always impressing on me the importance of substantiating the work with evidence-based research. Whatever the reason, it feels very empowering to have current research supporting a topic that is near and dear to my heart and that lately has garnered some negative attention in our society.
I often find myself teaching postnatal yoga while sitting on a birth ball, balancing two babies on my knees. I joke that the ball was the best piece of equipment I bought for the studio. Although I say this in jest, there is great truth to this statement!
The birth ball, a basic 65 cm physio ball for a woman of average height (the knee should be at a 90 degree angle), can be a wonderful asset in creating comfort during pregnancy, labor and postpartum. During pregnancy, especially throughout the last trimester when back pain seems to be the worst and fetal position is of most importance, sitting on the birth ball can help align the pelvis, creating an anterior tilt. This subtle forward tipping of the pelvis will encourage the baby towards the mother’s belly, as opposed to leaning back against her spine in a posterior position. Also, when the pelvis assumes this gentle sway, the position forces the architecture of the body into good posture and engages the abdominal and lower back muscles, which can alleviate back pain.
Some women also find the rocking movement that naturally occurs when sitting on the ball very calming and comfortable, and it can relieve pelvic floor pain and discomfort from hemorrhoids. This rocking or bouncing idea leads me to my favorite postpartum use: Helping to quiet your baby! I don’t know what it is that they respond to, but they seem so happy and content with a little bouncing and rocking. For the past 6 years, I have found this to be my favorite baby-quieting technique. And again, it is good for posture, which during the postpartum period tends to slump due to fatigue and weak back and abdominal muscles.
So let’s move on to the namesake of the birth ball - using the ball during birth! I find the birth ball invaluable during labor. There are so many uses for it! Let’s start with the basic: The all-fours position is a popular and favorite position to assume during labor. It takes the pressure off the mother’s back and helps to encourage the baby to stay in a good position. Since labor may last awhile, it is a lot more comfortable to spend the time draped over the birth ball than it is to have the palms completely pressed into the floor with pressure on the wrists. This position also slightly angles the torso upwards and uses gravity to press the baby’s head downwards against the cervix, which will encourage dilation. A similar usage is to put the ball on a bed or couch and have the mother hang over it. While the mother is at rest on the ball, the birth partner may be massaging her back or applying counter pressure, heat or ice. You can also place the ball in the shower or bathtub and have have the mother sit on the ball while allowing the water to run along her body. This way she can enjoy the sensations of the warm water while staying passive and at ease. The laboring mom may also just simply enjoy sitting and rocking or circling her hips in a figure eight motion. The rocking can be comforting and relaxes the back muscles. I usually find that at some point, usually near or in transition, the pressure of the ball against the pelvic floor gets to be too much and it may just be used to lean against.
I have also found that hospital staff are very open to the use of a birth ball, since it does not inhibit the usage of the EFM (External Fetal Monitors). Some hospitals even provide them. However, if you borrow one from the hospital or birth center, I would recommend that you clean it - and DEFINITELY put a chuck pad over it. You don’t want to put your bottom where so many have sat before.
So there you have it! Three very useful purposes for one very small investment! Yes, I know New York City apartments are not particularly spacious and the ball may be rather in the way. Do what I did: I color-coordinated the ball with the decor of the yoga studio!
There was a flurry of e-mails in my inbox earlier this week as the teacher trainees were very excitedly passing on an article from the NY Times on home birth. The article, Baby, You’re Home, discusses the upward trend of home births, the practicality of it, the safety precautions, and the opposition.
I find it very exciting that people are being made aware of the different options there are for birthing. Just earlier today, a friend of mine asked me to recommend a care provider for his wife. They are starting to plan for a family and the wife’s doctor is up in Westchester. So, I asked him about their birth preferences: Do they want a particular hospital or birth center, or a home birth? Are they interested in natural birth? Are they opposed to routine intervention? My friend - who asked to remain anonymous - admitted he had no idea there were so many choices to be made. He thought you just chose a doctor and did as you were told. But isn’t it great that we can make choices about how we bring our children into this world?
My friend and co-teacher, Nikita, just gave birth to her second child last week at home with a home birth midwife. She was very open with her students about her plans for a home birth. Her first child was also born at home, as were she and her husband. What I found surprising were the misconceptions about home birth. Many people thought she and Noah, her husband, just stayed at home and did this by themselves. Ok- that is a choice some people make, but it is rather uncommon and is not what home birth necessarily means.
Also, many people didn’t realize that when a home birth midwife arrives she comes prepared with a great deal of equipment and various safety precautions. Since I have only attended a handful of home births I asked my friend Nancy, a Midwife Assistant, to provide me with a list of the equipment, instruments and materials that she brings to a home birth. The list is quite extensive!
When we arrive at a mom’s house, the first thing we do is take vital signs on mom and listen to the baby with a doppler. In active labor we listen to the baby every 15 minutes, when she’s pushing it’s every 5 minutes or after each push. Mom’s vitals are re-checked every 4 hours in labor. We bring 3 big bags of supplies with us to the birth, as well as a birth stool and birth ball.
In the first bag we have:
*doppler and gel for listening to baby’s heart rate
*sterile medical delivery instruments
*sterile suturing instruments
*lab vials for collecting cord blood to test for baby’s blood type and antibodies
*a medication bag - vitamin K, medications to stop hemorrhaging, antibiotics, Pitocin, etc.
*bag full of different size syringes
*betadine
*different size needles for stitching up tears
*lidocaine gel to numb areas before stitching
*lidocaine for injecting into spots that need more than the gel can help
*stethoscope for mom
*stethoscope for baby
*blood pressure cuff
*baby scale
*heating pad and cutting board to have a warm, firm place if resuscitation of baby is needed
*IV equipment and fluids
*Delee suction tube for baby
*amnio-hooks for breaking water
In the second bag:
*homeopathic remedies, about 50 of them
*homeopathic reference book
*aromatherapy
*herbal tinctures
*music CD’s
*rebozo
*lab forms
*newborn care info
*postpartum care info
*sharps container
*extra gauze pads
*extra gloves
*extra everything!
In the third bag:
*oxygen tank
*different oxygen masks for mom and baby
*ambu-bag for giving positive pressure ventilation
For the birth, the mom is responsible for buying a birth kit which includes the following:
*10 23×24 underpads (chux)
*10 30×36 underpads (chux)
*1 tape measure
*1 cotton hat
*1 peri bottle
*12 Topper 4×4 gauze pads
*15 alcohol prep pads
*1 digital thermometer
*1 pt of alcohol
*1 pt of witch hazel
*1 postpartum pad system
*1 bulb syringe, 2 oz
*8 oz lube jelly
*1 4 oz Betadine
*10 pairs of latex small sterile gloves
*10 single latex small sterile gloves
*1 cord clamp, plastic
*1 betadine scrub brush
*2 peri cold pad
*1 box of exam gloves latex small (100)
*2 straws
*1 kleenprint footprinter and Home Birth Certificate
There is also another list of home supplies the family has to have ready for the birth which includes things like towels, baby blankets, baby diapers, a mirror, garbage bags, a laundry bag, olive oil, etc.
Nancy also reminded me It’s important for couples to know that the prenatal care is completely different than what they are used to. The midwife I work for schedules an hour for each visit. Most doctors’ offices schedule one patient every 10 minutes. The prenatal visits include the usual hands on - check blood pressure, weight, urine, position of baby (with hands, not an ultrasound machine!!), heart rate of baby. The visit also includes nutrition counseling, emotional preparation for pregnancy, birth and motherhood, suggestions and handouts for pregnancy issues, and care during the postpartum period. We also lend out DVD’s for mom and family to prepare by watching other birthing moms. Families can also rent a birthing tub if they would like to have a water birth, or even just to labor in.
How one chooses to birth is a very personal choice, but one that should be made with great consciousness. Where and with whom you give birth will greatly impact the experience and the outcome. Sometimes I feel people spend more time picking out a new flat screen TV than they do their OB/GYN or midwife. It is important to discuss with your partner what style of birth is right for your family and what is within your comfort zone. The choice is yours.
Last weekend I was walking home from the gym when I ran into one of my students. She told me that she was in early labor - 4 cm - and was sent to go walk around to try to get things moving. She also told me that her doctor had informed her that since her fluid levels were low, if she didn’t get things started on her own soon they would “help move her along” - meaning start Pitocin to increase the contractions and push her or “Pit her” into active labor.
Just the week before I had run across the article “Low Level of Amniotic Fluid - No Risk to Normal Birth” in Midwifery Today. Of course, I knew this was not the time to start contradicting my student’s doctor, but it made me realize how common it is for doctors to start the cascade of intervention on the basis of low fluid levels.
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 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?”
This new information may create an opening for you to discuss your options with your care provider. If diagnosed with a low amount of fluid, will your doctor give you some time to go home and hydrate (in the latter part of pregnancy, amniotic fluid is primarily baby pee) and then come back the next day for another fluid check? Or, does your provider prefer to act immediately? My experience is that most doctors allow for some time to pass. But, now is a good time to make sure you and your care provider are on the same page.
Please enjoy this list of 10 healthful hints for pregnancy, labor and postpartum. Much of this information is gathered from friends, students, hands-on experience, mentors and teachers. I strongly believe in learning from others, so please feel free to pass this along to all your friends!
1. Olive Oil on Baby’s Bottom to Prevent the Meconium From Sticking
Vanessa, one of my recent doula clients, enlightened me to this brilliant idea. Right after your baby is born, take a few drops of olive oil and rub it onto the baby’s bottom. When your baby passes the meconium (your baby’s first poop), this dark, tar-like substance will be easy to wash off.
2. Arnica Helps Heal Tears of the Perineum After Labor
Most use the pellets rather than the cream for this type of wound. The cream is not supposed to be used on broken skin - though I have known women who have used the cream and found it to work without problems.
With the pellets, the you can put 2-3 in your peri bottle before you fill it with water, and use that solution when you pee. You can also take it orally (2 pellets) whenever you remember to. Try to avoid taking it around meals or touching the pellets with your hands. As you start to feel better you will naturally start taking it less often. Any dosage you can get will be helpful, but I think the stronger the better for this.
3. “The Midwive’s Pitocin”
Make a bowl of oatmeal, honey and nuts during labor and graze on it as you desire. If you break down the ingredients, you will find the perfect balance of complex carbohydrates, protein and natural sugar.
4. Hard Candy to Help Boost You During Labor
Because so many hospitals restrict eating during labor, it is possible for mom to get a little low in the energy department. I always bring hard honey candies with me to labors. This can give the laboring mom a bit of energy, and it dissolves in the mouth so it does not count as eating food, should any one ask.
5 Apple Cider Vinegar for Acid Reflux
Drink one tablespoon of apple cider vinegar in the morning, before eating. Theoretically, it works because the stomach is fooled into producing less acid. (Midwifery Today Winter 2007)
6. Cold Maxi-Pads with Witchhazel, Lavender and Vaseline
Before you head to the hospital, take several maxi pads and pour witch hazel and several drops of lavender on them, and then place them in the freezer. Not only will this small science experiment feel good on your sore bottom, it also promotes healing.
One of my students recently passed on the idea of smearing some Vaseline on the pad to prevent any stitches you might have needed from sticking to the pad.
7. Breastmilk for Cracked Nipples
It is not uncommon for women to experience sore or cracked nipples while breastfeeding. It is usually a sign that your baby is not latching correctly. One treatment for helping heal your nipples is to express a small amount of breast milk or colostrum onto the nipple and allow it to air-dry.
8. EAT YOUR GREENS!!!
Dark leafy greens, such as kale, collard greens, spinach, arugula, beet greens and dandelion are packed full of vitamins and minerals, and they can alleviate many pregnancy-related discomforts. Studies have shown increasing your iron intake can help relieve restless leg syndrome. A lack of calcium and magnesium (both found in dark leafy greens) can help rid you of middle-of-the-night calf cramps. For those that suffer from constipation, the fiber in these vegetables will help get things moving along!
These dark greens are also rich in vitamin K. Insufficient Vitamin K can contribute to postpartum hemorrhaging.
Coconut water is also a natural diuretic, which will help prevent urinary tract infections as well as relieve constipation.
10. Check Out the Wonders of Nettles: A Safe, Wonderful Herb for Pregnancy and After
The use of herbs may be a very new concept for some, but I would like to introduce you to the nettle leaf. There are no contraindications to the use of this leaf during or after pregnancy. (Holistic Midwifery, Anne Frye) And the benefits are bountiful!
*Vitamins A, C, D and K, calcium, potassium, phosphorous, iron and sulphur are particularly abundant in nettles.
*Increasing fertility in women and men.
* Nourishing mother and fetus.
* Easing leg cramps and other spasms.
* Diminishing pain during and after birth. The high calcium content, which is readily assimilated, helps diminish muscle pains in the uterus, in the legs and elsewhere.
* Preventing hemorrhage after birth. Nettle is a superb source of vitamin K, and increases available hemoglobin, both of which decrease the likelihood of postpartum hemorrhage. Fresh Nettle Juice, in teaspoon doses, slows postpartum bleeding.
* Reducing hemorrhoids. Nettle’s mild astringency and general nourishing action tightens and strengthens blood vessels, helps maintain arterial elasticity and improves venous resilience.
* Increasing the richness and amount of breast milk.
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The benefits of nettles listed above are an excerpt from Wise Woman Herbal for the Childbearing Year by Susun Weed
