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.
Before I became involved in the prenatal yoga and childbirth education world, I associated childbirth with a cute cuddly baby, happy parents and fuzzy teddy bears. Now, I think technology, defensive medicine and insurance issues. Hmm…I don’t really like that shift, but it does ring true to reality.
So here we have many medical and emotional downsides to receiving a c-section. But who would have thought there would a financial negative to this surgery? Recently, insurance companies have been charging a higher premium or even denying coverage to those that have given birth via c-section. The insurance companies know that many doctors are not delivering VBACs (vaginal births after cesarean) and as I mentioned earlier, higher costs, longer hospital stays and more medication are all associated with c-sections. All this equals a higher payout from the insurance company. Not only are women compromising their birth experience, their bodies and their baby’s well being, now they may have to actually pay more for health insurance!
What can a mother do to prevent an unnecessary surgery?
Talk to your care provider! If you are not a high-risk patient, don’t work with a doctor that is used to practicing more routine interventions that high-risk patients need. Ask the care provider for his/her c-section rates and induction rates. Who you choose to give birth with will have a big effect on how your birth unfolds.
Get good support! A growing body of research shows that the use of a doula has clear benefits for families during childbirth and postpartum periods, with no known risks. Whether it be a professional labor support doula, or just your partner, friend or mother, have people around you that trust the birth process and your ability to birth!
Stay at home as long as possible If you have chosen to have a doula present at your birth, most likely she will be laboring at home with you. Part of the advantage of that is that she has experience recognizing when you have moved into active labor or have transitioned into the first stage of labor. If you arrive at the hospital too early, you will likely be thrown onto their timetable and possibly given pitocen to speed up your labor. Many hospitals like to see the laboring mom progress 1 cm every one to two hours. This may not be how your labor unfolds, which doesn’t necessarily mean anything is wrong - your body and baby just may not be following Friedman’s curve (a common, still-used approach for determining how labor *should* progress).
Demand less routine interventions Again, if you are not a high-risk patient, you do not need to be treated like a high-risk patient. Ask about intermittent monitoring, freedom of movement, and eating and drinking during labor. Can you have a hep lock instead of a full time IV fluid drip? Instead of jumping right to pitocen to move labor along, can you try alternatives like nipple stimulation, castor oil or an enema?
Avoid unnecessary inductions Schedules (whether it be yours or the doctor’s) are never a good reason to induce. Neither is a presumed “big baby.” Ultrasound predictions have a fairly large margin of error.
Discover pain management techniques Start to explore ways in which you deal with pain, both physically or mentally. Look back on your past and think of times where you were physically challenged, maybe an athletic challenge or illness, and try to remember what helped you through those really tough moments. I am sure any marathoner will tell you that completing 26 miles is just as much of a mental challenge as it is a physical one. Think about relaxation techniques, deep breathing exercises and whether you might like heat, ice, massage or water therapy to aid you during contractions.
Trust your body and your baby! Remind yourself that birth is a natural and normal part of life. In The Business of Being Born, Dr. Jacques Moritz, OB/GYN at St. Luke’s/Roosevelt reminds us: “98% of obstetrics is boring, 2% is exciting.” Why should you jump to the conclusion that something will go wrong and you will be in the 2% he referred to? Trust that your body knows how to birth your baby and that your baby knows how to be born.
I am going to go out on a limb and say: “I strongly believe the best breathing for labor is deep-belly breathing!” There, I said it. This may upset some, or contradict what others believe and what some childbirth educators are teaching. However, from my experience as a labor support doula, this is what I have seen work best. The days of the Lamaze hee-hee-hoo breathing is (thankfully!) falling into the past. Now, I say this with great respect to Lamaze International, being a member and certified Lamaze teacher myself. When I took a certification course 3 years ago, my teacher explained that Lamaze no longer teaches that method.
The reason I like deep-belly breathing is because it helps move the body into the action of the parasympathetic nervous system. The autonomic nervous system (ANS) is divided into two parts: the sympathetic nervous system (the fight-or-flight response), and the parasympathetic nervous system (the rest-and-relax response). The body responds to the parasympathetic nervous system by slowing the heart rate and decreasing blood pressure while increasing the release of endorphins.
I admit that my experience can be considered biased, since my doula clients are also primarily my prenatal yoga students – these women already have a relationship to deep breathing. One reason prenatal vinyasa yoga is so conducive to teaching expectant moms how to connect to the breath is because it encourages them to link breath and movement. This helps to create a mindful connection to the breath; even if they are in a stationary position, they will have a memory of their own relationship to their breath. When the mother is dealing with the growing pain of a contraction, she has the imprinted memory of connecting to her breath and trying to relax her mind and body.
There may be times during labor - the transition period, resisting the urge to push, the pushing stage, or as the baby’s head is crowning - when deep breathing is challenging. The breath may end up short and shallow, blown out, or what I call “defused breath.” However, if the intention is still to try and take a deep breath, even though it may not come to fruition, the mother gains the benefits of it, as opposed to consciously taking shallow breaths that may not be as helpful, and may cause additional tension.
I have found that patterned or coached breathing, which can have a positive effect by creating a helpful distraction, can also cause short, shallow breathing, and potentially hyperventilation, muscle tension, and anxiety. I believe there are more beneficial ways to distract from the sensation of the contraction. Some women like to count their breaths: 4 counts to inhale, 4 counts to exhale, and so forth. This type of breathing is often used in yoga, called sama vritti pranayamaor even-fluctuation breathing . The individual still receives the helpful effects of deep breathing while finding a distraction or focal point within the breath.
Another benefit to the deep-breathing method is figuring out what part of the breath you need to facilitate. By this I mean that you can use the breath differently depending on the task at hand. When faced with a challenging situation where you may need a little more energy, focusing on the inhale can provide you with more energy or prana. This is called the inhalation, (puraka) which stimulates the body. The other side of the breath is the exhalation (rechak), which cools and relaxes the body and mind. Particularly in labor, this may be useful in reminding moms that instead of tightening their body when feeling a lot of sensation, they can use the exhalation to try and surrender to the discomfort. *Please remember that in traditional pranayama there would be a third part to the breathing, the breath retention (kumbhaka), which is not appropriate during pregnancy.
I also teach a variation of viloma breathing, or 3-part breathing, in class. One of the PYC teachers, Michelle, reported that she used this technique while in labor with her daughter. Here, the pranayama is executed by breathing into the belly, then drawing a little more breath into the ribcage, allowing the ribs to widen all the way up to the collarbone. Exhale from the top downward, let the air out from the ribcage, allow the ribs to slide closer together and the belly to deflate, gently drawing the navel towards the spine. The benefits are similar to those of other deep-breathing techniques which, while calming the mind and relaxing the body, slow the heart rate and have a calming effect on the central nervous system. They also oxygenate the blood and purge the lungs of residual carbon dioxide.
Another technique to explore is exhaling with vocalization. hmmm…ahhh…oooh…shhhh Again, this encourages a commitment to a long, deep inhale and long, slow exhale. The benefit of adding a vocalized sound is that the listener can hear the quality of the voice and notice if the throat is constricted or open. (This goes back to my favorite saying: “Open throat, open vagina”!)
However much I believe in the benefits of deep breathing, it is really up to the individual to discover what breathing techniques are most effective at a given moment. You may find yourself jumping between several techniques and discovering usefulness for each at different times of your labor. The most important thing is to commit to your breath and trust that it will help you.
My friend and future midwife, Jocelyn, passed this article on to me. I thought it was a great piece to post on the blog since I often hear women say, “Thank goodness I had a cesarean! The cord was wrapped around the baby’s neck and was choking the baby!” I completely understand why one would think that, however about 1/3 of babies are born with the cord either around the neck or entangled around the baby’s torso. The majority of the time this is completely harmless, the doctor will clamp the cord and cut it as the baby is emerging. Other times, the care provider can actually somersault the baby out and disentangle the baby.
The umbilical cord around the fetus’ neck cannot strangle your baby! There, I said it. Now, let’s discuss the logic behind this truth. Nature has devised a system to nourish the developing baby inside the womb of all mammals. The placenta and umbilical cord are an amazing creation of both form and function. The placenta acts as a factory for hormones to support the pregnancy, a filter that among a myriad of tasks acts to bring in good things and remove waste and provides a reserve of blood and oxygen to support the baby through labor. The umbilical cord is the conduit by which nutrients such as sugar and oxygen help feed the baby via its two veins while through its one artery passes the waste by-products of growth.
Understanding how a baby gets its oxygen allows us to understand why a baby cannot strangle or “choke” on its cord. In order to choke, one must be using its trachea to breath air. Clearly, there is no air in the uterus, the baby does not breathe through its throat and, therefore, cannot choke. When an ultrasound reveals the cord around the neck it is a normal human response to anthropormorphasize the intrauterine baby to our extrauterine experience. But this is not the case and there is no reason to have fear. So, let’s dispel once and for all the rumor that a cord around the neck (nuchal cord) is more dangerous than any other situation. About 35-40% of normal term babies are born with the cord around the neck at least once. It can also be wrapped around the body or legs or even at times have a true knot. None of which are usually significant as the cord is designed to deal with this.
Cord compression can occur anytime during pregnancy. The cord is well equipped to handle temporary squeezing as the 3 vessels are cushioned by a matrix called Wharton’s jelly and the surrounding amniotic fluid. In labor, sometimes after the bag of waters breaks and fluid leaks out, the cord can be repeatedly compressed with contractions. This is not uncommon and is not, by itself, a sign of distress. Your practitioner or nurse can listen to or interpret the fetal heart rate pattern to know whether any intervention is necessary. And the compression of the cord almost never is an emergency or a cause for the tragic death of a baby inside the womb. When that tragedy occurs we all want to know why and often, mistakenly, we are told it was a “cord accident”. Compared to the number of times I have heard this mentioned by patients or news stories the real truth is that this is a very rare event.
Please be reassured that your baby will not strangle on its cord because it is not breathing through its neck like you and I. If you hear someone repeat this rumor you would be doing a great service to pregnant women everywhere by logically explaining to them the reasons why.
I often encourage my students and doula clients to take some time to figure out how they foresee their birth. This is, of course, with the understanding that nothing - especially birth - can ever truly follow a plan; however, at least one might hash out some preferences and desires toward the manner in which she wishes to birth.
The clients that usually hire me as their labor support doula often have similar requests, requests that are definitely not out of the ordinary when desiring a natural birth: hep lock instead of full-time IV hook up, intermittent monitoring, staying home for as long as possible, having the freedom to move during labor and the freedom to choose the position to birth. Expectant moms should also run these ideas by their care provider to make sure they will be supported with their requests. For the most part, moms come home from this appointment with the care provider feeling assured that their wishes will be heard. These expectant moms enter labor feeling confident and ready to move forward with the birth plan. Until…..they get to the hospital.
OK. I am not knocking hospitals; they definitely play a role in helping people. However, during the last several births I have attended, it has become very clear to me that the hospital’s main purpose may not always be to serve the best interest and comfort of the laboring mom, but to protect itself.
Last Friday night: my client is in labor and, taking into consideration the 4-hour window needed to administer two doses of antibiotics she needs because she is group B strep positive, we decide it is time to head to the hospital. Once admitted, my client was immediately hooked up to the EFM (External Fetal Monitoring) machine. After being on the monitor for over an hour, we asked if she could take the straps off. My client’s doctor had agreed beforehand to allow intermittent monitoring as long as all looked good with baby. However, the hospital’s protocol was full-time EFM. This was a point of frustration for my client since she went in believing she would not be attached to a machine during her whole labor and that she would have some freedom of movement. The nurse explained to us that the doctor was needed to give the order to allow intermittent monitoring. (This being the middle of the night, the doctor is not there.) The nurse was very honest, and pointed out that because everyone works with individual licenses, she had to consider that if something were to happen, she’s the one whose license would be revoked. At one point, she actually said it was illegal not to full to have full-time monitoring. (IT IS NOT ILLEGAL- but a good scare tactic!) After more than an hour and a half on the monitor, the resident briefly agreed to intermittent monitoring. This infuriated the nurse who went to get the charge nurse and the resident who had agreed to it. They came in and told us we had every right to refuse their medical advice, but would need to sign a release form. Not wanting to do this, the husband offered to hold the fetal monitor in place as to avoid his wife being strapped up again.
Along with the plan for intermittent monitoring, the client’s previously approved request to use a hep lock instead of full time IV drip also went by the wayside. As for the antibiotics - the whole reason for arriving a little on the earlier side - we waited almost 2 hours to receive the first dose of antibiotics until the doctor gave the order. The mother had only received one by the time the baby was born.
The point is: what your doctor agrees to will not necessarily be honored unless your doctor is there to sign off on it. Many doctors do not show up until the end to catch the baby. Please note, I recently did a birth with Dr. Bradley (love her!) at St. Lukes/Roosevelt and she was there ALL night - from 5am, when we first arrived, to the following morning. Anyway, I digress. I am now encouraging my students and clients to walk in with a prescription from their care provider supporting their birth plan as long as mom and baby are medically sound.
Doctors and midwives are free agents. They are associated with a particular hospital but do not work for the hospital. Nurses work for the hospital. Their allegiance is to the hospital and (most of them) will strictly follow the hospital protocol. At another birth I attended about a month ago, my client was told that as long as she was going naturally- meaning no pain meds - she could lightly eat during labor. The nurse was VERY unhappy when she saw the laboring woman nibbling on some fruit. We needed to have the doctor tell the nurse she would allow this. Again, the doctor can override some hospital policies.
If you have specific wishes as to how your birth will unfold, you need to get your care provider on board and your partner and/or doula behind your choices so that they can be your advocate. Labor is not the time to be negotiating with the hospital staff. You also need to talk to your care provider and find out when he/she usually arrives at the hospital once you have called them and told them you are on your way. The sad truth is, we are a litigate society. The needs and desires of the laboring mother do not always come first in our medical system. Plan ahead and have open conversations with your care provider about what you can honestly expect at your birth.
In the movies and on TV the onset of labor is often depicted with the expectant mother experiencing a big gush of water and immediately thrust into active labor. As exciting as it may be, that scenario very rarely happens. For 90% of women, the onset of contractions will happen first, and then at some point during labor the bag of water will spontaneously rupture or the care provider will manually break the membranes. The other 10% of mothers will have what is called PROM or Premature Rupture of the Membranes. Their bag of water will break BEFORE the onset of labor.
What does that then mean for the pregnant mother? Most patients (90%) enter spontaneous labor within 24 hours when they experience PROM at term. (At term being 37 weeks or beyond.) Once PROM has occurred, there are two avenues to choose from. One is managed care - meaning inducing labor – and the other is expectant management, which means waiting for labor to start on its own. (Please note: I am not including situations in which meconium is present in the water or instances of premature labor in which the woman is less then 37 weeks pregnant in this discussion.) There are pros and cons to both options. The major risk with PROM is intrauterine infection, indicated by a maternal fever. This risk is small (10 %) during the first 24 hours but increases by 40% after that point. It is because of this increased chance of infection that care providers like to see the mother in active labor within that window of time. Since the amniotic sacs acts a barrier to infection, one of the best ways to protect the open bag and avoid infection is to limit vaginal exams which introduce bacteria into the uterus. Another concern is an increased risk of cord prolapse. Since the amniotic fluid is lessened, there is a risk of the cord following between the baby’s head and the cervix which would cause fetal distress. However, the body does continue to produce more amniotic fluid which is why, once the water does break, the mother continues to leak.
There can also be a false positive in diagnosing PROM because of leakage from the outer bag. False positive may be from blood, semen, alkaline antiseptics and sometimes, alkaline urine. Vaginal infections may also raise the vaginal pH, causing a false positive. To test for a leakage of amniotic fluid, Nitrazine paper is placed at the entrance of the cervix. This test is used to indicate the ph balance of the fluid. If it turns dark blue, there is a ph balance of 7- 7.5 or above indicating that there could be an amniotic leak. There are two more conclusive way to diagnose PROM. One very reliable way is to have the care provider (do NOT do this yourself) do a digital examination. The care provider should be able to feel the bag bulging at the presenting part, which indicates that the bag is still full and intact. Another way is to test the fluid from the vaginal pool and do a fern test for detecting amniotic fluid in the secretions. This test is based on a fernlike crystallization of sodium chloride in the amniotic fluid, which can be observed microscopically when the specimen is dried. It is important to remember the possibility of a false positive result from the Nitrizine paper - that way you could request further analysis of the situation to better help you decide on the direction of your care.
Again, this comes back to your care provider’s preference of action and your choice for how to handle PROM. Some care providers are open to and supportive of the ‘watch and wait method’, although usually requiring the mother to be in active labor by the 24th hour after rupture. They will keep an eye on the mother and baby, checking for maternal fever and fetal wellness. Others will want to start induction sooner. For those wishing to go the all-natural route, there are ways to help move labor along: nipple stimulation, castor oil, enema, and acupressure or acupuncture (these last two should only be done by a trained professional.) I also recommend having a conversation with your care provider before the onset of labor about how he/she handles PROM so that you are not negotiating options after the fact.
While the timing of your membrane rupture is largely out of your control, at least now you have an understanding of how it is truly determined whether you are experiencing a rupture, as well as how you may wish to proceed should PROM be at hand.
My very good friend, Liz, recently told me she is pregnant with her third child. I had the thrill and privilege to be her doula for the first two births and was so excited when she invited me back for the third (and final!) one. Liz’s story is really quite interesting. We met when Liz was taking prenatal yoga classes while pregnant with her first child, Liem. At the time, her mind was set on a hospital birth and she was planning on going the epidural route. In fact, if I remember correctly, while having the “meet and greet” with her and her husband, Steve, she asked if she could get the epidural right then and there. (She was somewhere around 30 weeks). As it turns out, she had a completely natural birth. One of the first things she said once the baby was out was: “That wasn’t bad. I want do it again.” For her second baby, Owen, Liz switched doctors and gave birth at St. Luke’s/Roosevelt Birthing Center. Fast forward a year, Liz is completing her Lamaze Childbirth Educator Certification and is researching home birth midwives for baby number three.
Liz’s husband is a bit nervous about this decision. Please don’t misunderstand me; Steve is a wonderfully supportive husband and a great dad. It does not surprise me at all that he is concerned about this choice in childbirth. After all, our culture has not embrace home birth for nearly a century and many people automatically jump to the “what if” place. “WHAT IF something goes wrong…” Liz told me she answered Steve with “What if I walk out the door and get hit by a car?…”
For those that have gotten to know me, you can just image my excitement when I found an article titled “Study: Home Birth With Midwife As Safe As Hospital Birth” in USA Today. I LOVE studies and facts! (Probably a result of having a lawyer for a father.) I invite you to take a moment and read the article. It might help those that are considering this birth option talk to their partners and families about the safety of home birth.
Study: Home birth with midwife as safe as hospital birth
By Amanda Gardner, HealthDay
Having your baby at home with a registered midwife is just as safe as a conventional hospital birth, a new study says.
In fact, planned home births of this kind may have a lower rate of complications, according to the study published in the Sept. 15 issue of CMAJ. [Canadian Medical Association Journal]
Even though the study was conducted in Canada, where attitudes toward midwifery are more accepting than in some other countries, the findings may help to calm an ongoing controversy in the United States and elsewhere.
The American College of Obstetricians and Gynecologists is opposed to home births, as are certain organizations in Australia and New Zealand. More organizations in Great Britain are supportive and Canadian provinces are currently transitioning to midwifery, said study lead author Patricia Janssen, director of the Master of Public Health Program at the University of British Columbia.
Janssen, a registered nurse who has midwife training though not certification, said: “People who function as independent midwives are not necessarily tightly regulated [in the U.S.] depending on which state you’re in, so there may not be a guarantee that they have had an adequate level of training or a certified diploma or anything like that. And they may not be monitored and regulated by a particular professional college.”
The controversy has resulted in a lack of clear regulation and licensing requirements in the United States, said Dr. Marjorie Greenfield, associate professor of obstetrics and gynecology at University Hospitals Case Medical Center in Cleveland.
According to Greenfield, the National Association of Certified Professional Midwives does have a certification process but many states don’t recognize it. “If you’re a woman who wants to have a home birth, how do you determine if this person has appropriate qualifications?” she said.
The authors of the new study compared three different groups of planned births in British Columbia from the beginning of 2000 to the end of 2004: home births attended by registered midwives (midwives are registered in Canada), hospital births attended by the same group of registered midwives, and hospital births attended by physicians. In all, the study included almost 13,000 births.
The mortality rate per 1,000 births was 0.35 in the home birth group, 0.57 in hospital births attended by midwives, and 0.64 among those attended by physicians, according to the study.
Women who gave birth at home were less likely to need interventions or to have problems such as vaginal tearing or hemorrhaging. These babies were also less likely to need oxygen therapy or resuscitation, the study found.
The authors acknowledge that “self-selection” could have skewed the study results, in that women who prefer home deliveries tend to be healthier and otherwise more fit to have a home birth.
Janssen said she hoped “this article will have a major impact in the U.S.” But there is a definite “establishment” bias against home births. And the issue is an emotionally charged one, she said.
“There is a political and economic issue about controlling where birth happens, but also a deep belief by physicians that it’s not safe to have your baby at home,” Greenfield said. “Doctors see every home-birth patient who had a complication, but we don’t see the ones that have these beautiful, fabulous babies at home who may breast-feed better or have less hospital-acquired infections. There may be medical benefits,” she added.
“Midwifery needs to be regulated. It can’t be under the radar because then it’s dangerous,” Greenfield said. “There has to be a regulatory process and a licensure process [to protect] women who are going to choose home birth anyway.”
I am often asked about the usefulness of perineal massage for expectant mothers. To be completely honest, I haven’t heard much feedback about it either way. I decided to investigate the question a bit more and see if there was any hard data on it.
Let’s start at the very beginning to get everyone on the same page. The true perineum is called the Central Tendon. It is the center point at which almost all the muscles of the superficial layer of the pelvic floor converge. However, most people broaden this area and refer to the skin and muscles between the vaginal opening and the anus as the perineum. Perineal massage is a massage of these muscles for the purpose of creating more “stretchiness” and flexibility to the area. It can cause some stinging sensation which is believed to help the mother become familiar and comfortable with the intense stinging that occurs as the baby’s head is crowning. Perineal massage can also be a good opportunity for the mother to learn how to relax the pelvic floor muscles.
I think most women would agree that keeping their perineum intact is a pretty high priority during childbirth. Beyond perineal massage, it is recommended to do kegel exercises regularly. Kegels help strengthen the pelvic floor muscles, improve circulation to the perineum, and create an awareness of how to relax the pelvic floor muscles. One other recommendation for helping your perineum stretch is to either labor or birth in water (the water softens the muscle tissue) or ask your care provider to apply warm, wet compresses to the perineum as the baby’s head starts to crown.
For those interested in trying perineal massage, here are some easy to follow instructions:
INSTRUCTIONS FOR PERINEAL MASSAGE DURING PREGNANCY (Courtesy of Midwife.org)
*It is recommended to start 6 prior to your due date
*It is recommended to use a water soluble lubricant for this massage such as KY jelly, olive oil, almond oil, vitamin E oil or pure vegetable oil. Do not use baby oil, mineral oil, or petroleum jelly.
*Place your thumbs about 1 to 1.5 inches inside your vagina (see figure). Press down (toward the anus) and to the sides until you feel a slight burning, stretching sensation.
*Hold that position for 1 or 2 minutes.
*With your thumbs, slowly massage the lower half of the vagina using a “U” shaped movement. *Concentrate on relaxing your muscles. This is a good time to practice slow, deep breathing techniques.
*Massage your perineal area slowly for 10 minutes each day. After 1 to 2 weeks, you should notice more stretchiness and less burning in your perineum.
*Partners: If your partner is doing the perineal massage, follow the same basic instructions, above. However, your partner should use his or her index fingers to do the massage (instead of thumbs). The same side-to-side, U-shaped, downward pressure method should be used. Good communication is important be sure to tell your partner if you have too much pain or burning!
Published in International Doula, Volume 17, Issue 4 2009
Recently I was at a couple’s apartment doing a private childbirth education class. We went through quite a bit of information that covered everything from pain management techniques to understanding the different stages of labor to how the mom’s partner can support her through the variations and complications that might arise during labor and delivery. Near the end of our session, I asked the couple, “How do you work as a couple in highly emotional or uncontrolled situations?” The father-to-be looked at me oddly and said “I think we work well together, but why are you asking?” I think this is one area that is not given much attention, but is really important. I am not trying to say that labor is innately stressful, but it is a departure from normal everyday occurrences, a situation where one part of the couple is going through an intense physical experience.
From my experience as a labor support doula, the un-laboring partner tends to get very uncomfortable seeing the other person in pain. One dad told me it was hard to see his wife become so primal and animalistic as she moaned and swayed her body around. Because of his discomfort, he was unsure of how to respond his wife’s needs. Another couple I worked with argued and bickered through most of labor. They had explained to me prior to the labor that when they get stressed as a couple, the wife gets snippy and the husband gets defensive. So even though I was a bit taken aback by their behavior, this was how they functioned as a couple. My favorite moment was a father-to-be telling me that he yells when he is nervous and stressed and would it be ok if he yelled at me? I answered very quickly: “No.”
I strongly advise that expectant couples take some time to discuss the emotional side of labor. One partner may become very withdrawn or feel the need to find control when feeling out of control within the situation. Does seeing your partner in pain make you vulnerable or even angry at that vulnerability? To be the best support person for a laboring woman, there needs to be an understanding of the emotional dynamic and the natural give and take of the relationship. One dad-to-be admitted that he was used to having his wife be the calm, grounded, organized one in their relationship; the reason they hired me as their doula was because he wasn’t sure he would be able to support her fully.
Here are some questions to get the conversation started:
1. Ask each other, when you are stressed or under pressure, how do you react? Do you feel the need to try to control the situation? Do you shut down or get talkative and anxious? Do you look for distractions? Are you a “people pleaser”, taking care of everyone else except yourself?
2. Tell your partner what helps ground and calm you. Is it looking at one another? Can the partner tell the laboring mom a story, or maybe just hold her?
3. Discuss what does NOT help. (Partners, put away the blackberry - that is NEVER helpful!)
4. What fears and concerns do each of you have surrounding the labor and delivery? Fear can slow labor down or even bring it to a halt. Several years ago I worked with a woman who realized after her birth that she was so overwhelmed by the reality of becoming a mother that she held her baby in and stopped dilating. It was a very tough labor for her both emotionally and physically.
5. Who might you want in the room with you? It is often helpful to have more then one person there. This way, the support system can tag-team and do food runs, bathroom breaks or just get a breath of fresh air. This should NOT include the nurse, doctor or midwife. They have other people to attend to and can not give the laboring mom undivided attention.
Knowing that the two parties have already discussed the emotional side of labor can bring great ease and comfort to the mother-to-be. She will be reassured that her partner understands the best way to support her through this incredible challenge. A talk like this can bring the couple closer and help them deal with issues before they occur.
Many women think that the abdominal region is off limits during pregnancy, when in fact it is even more important to maintain strength and stability in the core to help support the exaggerated curves of the spine and the weight of the growing fetus. Also, proper abdominal strengthening will decrease the chances for the rectus abdominus (the “6 pack muscles”) from separating, which is called diastasis. Keep in mind that there is always a balance between strength and flexibility. While we encourage the moms-to-be to keep up on their abdominal toning exercises, we need to allow space for the abdominal muscles to stretch and release as the baby grows inside. Any muscle that is too toned, may loose its ability to stretch properly.
Another advantageous outcome from proper abdominal toning is teaching the expectant mother a beneficial way to push her baby out. By engaging her abdominal muscles, especially her upper region of her abdominal muscles she will more effectively push her baby out rather than relying on pressure and tension from her face, jaw and shoulders. We have all seen images in movies or on TV of a woman pushing her baby by holding her breath, puffing her cheeks and squishing up her face. Yes, this manner can work, but it is not nearly as effective (and timely!) as using the abs to facilitate the birth of the baby.
The abdominal muscles can be classified in two groups the posterior which includes the psoas and the quadratus lumborum and the anterior which include the flat muscles, the transverse abdominus, the rectus abdominus and the internal and external obliques. For the sake of not going into a whole anatomy lesson, I am just going to refer to the anterior abdominal muscle group, specifically the transverse abdominus .
The transverse abdominus is the inner most muscle, arises from the lower 6 costal cartilages, the lumbar fascia and the iliac crest. The fibers of the transverse muscles run inward towards the midline. You can think of this group of muscles as a natural corset, helping to stabilize the torso and maintain internal abdominal pressure. Unlike the other three abdominal muscles, the transverse abdominus doesn’t move your spine. You flex this muscle to pull in your belly.
Transverse abdominus muscles can be toned using an exercise involving deep slow exhalations of the breath. The pregnant mom comes on to her hands and knees. While trying to maintain a flat back, she inhales and releases the muscle tone of the belly and then exhales contracting the transverse and rectus abdominus. Many women want to “cat/cow” in the exercise, and it is more effective to try not to undulate the spine. Another way to think about this exercise is to image that with each exhalation they are tightening a corset around their middle and drawing their baby closer to their spine.
Another option for toning the rectus abdominus and transverse abdominus muscles is to do a similar action as described above, but upright against a wall. Some women feel that with the feedback of the wall against their back, they can better understand how to engage their muscles. It is suggested when doing this exercise at that wall, that you image that you have a ruler next to you. The ruler goes from 1-12 with the one furtherest away from the wall. As you contract the abdominal wall, try to bring the belly into the 8 mark on the ruler and as you release the belly, only allow it to move to the 4 mark. Each time the belly is drawn in, count out loud. 1-2-and so forth. This is a good way to make sure that the mother is breathing. You can start by just counting up to 20 and throughout time maybe move up to 75 or 100.
Beyond understanding how to strengthen the abdominal region, it is important to understand how not to exasperate the diastasis. While it is normal to have some separation of the rectus abdominus muscles during pregnancy, more extreme diastasis can be prevented from just a few mindful movements.
Be mindful about movements like:
o The way a woman gets in and out of bed or a chair, and how she lifts things can often increase separation.
o “Kicking up” to seated from a reclined position or pushing up to standing when seated.
o Moving from an upright position to a supine position without either using their arms to lower herself. Ideally they should be rolling to their side and then onto their back
o Lifting heavy objects (or small children) incorrectly
o Navasana which tends to “bulge the belly.”
All of these movements can be detrimental, as these actions usually cause a woman to push her belly out. That pushing out of the belly can in fact push the rectus abdominus apart can also cause extreme separation, as it can force the uterine wall to push between the rectus abdominus, increasing the separation between them.
I hope these helpful hints allows the mom-to-be more comfortable during her pregnancy and have a quick delivery. Happy pushing!
Take a moment to read this article about External Fetal Monitoring from yesterday’s New York Times. It has become a real issue and a routine practice in so many hospitals.
July 7, 2009
New York Times
By JANE E. BRODY
Electronic fetal monitoring during labor and delivery was introduced into obstetrical practice in the early 1970s in hopes that it would reduce the risk of cerebral palsy and death resulting from inadequate oxygen to the fetal brain.
The monitors continually measure the fetal heart rate and produce tracings on a screen and paper that can alert a doctor to a baby who is doing poorly under the stress of labor. It is up to the doctor to try to alleviate the problem and, if those measures do not help, to decide whether to deliver the baby vaginally with forceps or surgically by Caesarean.
Today, more than 85 percent of the four million babies born alive in this country each year are assessed by electronic fetal monitoring, amid continuing controversy over whether it does more harm than good. New guidelines on fetal monitoring, published this month, aim to bring more consistency to how doctors interpret the results and act on them.
“Honestly, the technology got rolled out before we knew if it worked or not,” Dr. George A. Macones, an obstetrician at Washington University in St. Louis, said in an interview.
Continuous monitoring became a standard obstetrical procedure before studies could show if the benefits outweighed the risks, and without clear-cut guidelines on how doctors should interpret the findings.
But experts report that the use of fetal monitoring has produced both negative and positive results, including these:
¶Electronic monitoring has led to a significant increase in both Caesarean deliveries and forceps vaginal deliveries.
¶Monitoring results are widely used by lawyers to bolster malpractice cases of spurious merit, which has led to soaring costs for malpractice insurance and, in turn, prompted many obstetricians to stop delivering babies.
¶Electronic monitoring has not reduced the risk of either cerebral palsy or fetal deaths.
Revised Guidelines
Last year a workshop held by the Eunice Kennedy Shriver National Institute of Child Health and Human Development produced new recommendations that have now been incorporated into revised practice guidelines by the American College of Obstetricians and Gynecologists and published in the July issue of the journal Obstetrics & Gynecology. Dr. Macones supervised the development of the new guidelines.
The college hopes the revised guidelines will reduce misinterpretations and inconsistencies in the understanding and use of readings on fetal monitors, although experts are not optimistic that the rate of Caesareans will drop.
In cities like New York, Philadelphia and Chicago, as many as 40 percent of babies are delivered by Caesarean. Although it is one of the safest operations, it is not without risk to either mother or baby, and it is far more costly than a natural vaginal delivery.
Nor is it likely that any change in the use of monitors will result in a decrease in babies with cerebral palsy.
As the new practice bulletin explains, monitoring the fetus during labor does not affect the risk of cerebral palsy, because 70 percent of cases occur before labor begins and only 4 percent result solely from a mishap during labor and delivery. The remaining 26 percent of cases can be attributed to a combination of factors that occur before and during labor or after delivery, according to Dr. Macones and other experts who helped develop the guidelines.
Inconsistent Interpretations
How the new guidelines might affect the rate of malpractice cases is unknown. “Lawyers pick through every finding on the tracings and say the doctor should have done a Caesarean here and saved the baby,” Dr. Macones said, “even though that’s seldom the case since most cases of cerebral palsy don’t happen during labor.”
Doctors differ greatly in how they interpret tracings. In a study in which four obstetricians examined 50 fetal heart rate tracings, they agreed in 22 percent of the cases. Two months later, the same four doctors re-evaluated the same 50 tracings and changed their interpretations on nearly one of every five. Furthermore, when the baby’s outcome is already known, interpretation of the tracings is especially unreliable, the guideline report says.
And in more than 99 percent of cases, predictions based on the tracings that the baby would have cerebral palsy have proved wrong.
3 Categories of Tracings
The new guidelines refine the meaning of different readings from the monitors, in the hopes of helping doctors make better decisions during labor about when to intervene and when to let nature take its course.
Previous guidelines divided readings into two categories — reassuring and nonreassuring — and it was up to the doctor to decide whether a nonreassuring reading meant the fetus was at serious risk of oxygen deprivation.
With fear of liability hanging over doctors’ heads, many babies with “nonreassuring” readings who might have done just fine with a natural vaginal delivery are being delivered surgically or with forceps, Dr. Macones said.
The new guidelines divide monitor readings into three categories and help to make “the gray zone of nonreassuring clearer,” Dr. Catherine Y. Spong, chief of the Pregnancy and Perinatology Branch at the child health institute, said in an interview.
In Category I, tracings of the fetal heart rate are normal and no specific action is required.
In Category II, indeterminate tracings require evaluation and continuous surveillance and re-evaluation, the guidelines say. Dr. Spong said that in deciding how serious the tracings are, doctors “need to look at the entire clinical picture, not just the tracing,” and consider factors like the mother’s blood pressure, heart rate and temperature, what medicines she might have been given, the frequency of contractions and how fast labor is progressing.
Depending on what makes the reading Category II, the doctor can take steps to see if the reading will go back to Category I, Dr. Spong said. For example, the doctor might try to stimulate the baby by scratching its scalp or making a loud noise, to see if the heart rate will accelerate naturally and bring the baby back to Category I.
Babies with Category II readings are not considered in danger, she said, “but they have to be watched very closely because they could become compromised.”
In Category III, tracings are clearly abnormal, requiring prompt evaluation and efforts to reverse the abnormal heart rate. That could involve giving the mother oxygen, changing her position, treating her low blood pressure and stopping stimulation of labor if that is being done. If the tracing does not improve with such measures, the new guidelines say that “delivery should be undertaken.”
Further refinements of the guidelines are expected to be released next year.
