I just recently came across a wonderfully informative article, Early C-Section Carries Risks, Study Finds by Keith Winstein in the Wall Street Journal about a study recently conducted and published in The New England Journal of Medicine about the risks of early elective cesarean births. This struck me as an important, immediate topic, as I regularly hear my students discussing elective cesarean births: postpartum women saying that they had a c-section and would likely do so for their subsequent child, and currently pregnant women talking about their scheduled c-section appointments.
Side note: I know this is a delicate topic for many expectant moms who are choosing to have an elective cesarean birth. Time and time again, when a student tells me that she has scheduled an elective c-section, that information is very quickly followed by her reassurance that the procedure is being done strictly on the basis of medical necessity. This hasty follow-up statement often carries a fair degree of defensiveness. So I want to be clear, I am not making a judgment for or against c-sections. In fact, I particularly like the article because it does not criticize women for electing to have a cesarean birth, but rather discusses the importance of when in the pregnancy it is appropriate to schedule the surgery.
Generally speaking, the medical community believes that full gestation is established at 37-40 weeks, making it acceptable to deliver a baby anytime after 37 weeks - though many health professionals believe it inadvisable to deliver a baby before the 39 week mark. This particular study is based on the latter supposition, defining “early” delivery as anytime before 39 weeks gestation. The study, which is based on 13,258 elective cesareans, found that more than 35% were delivered before 38 weeks, which can result in higher frequency of infection, need for cardiac resuscitation and lengthier hospitalizations for the newborns. And, there appears to be a significant differentiation between 37, 38, and 39 weeks with regard to the complications that may result: Among babies born at 39 weeks, 3.4% had certain breathing problems, including one called respiratory distress syndrome. The frequency of such problems rose to 5.5% for babies delivered at 38 weeks, and to 8.2% at 37 weeks.
The difference between 37 and 39 weeks may not seem significant to you and me, but for baby these extra few weeks allow that bun in the oven to cook a little longer! Seriously, the last three weeks of pregnancy are very important for the baby’s lung development. In short, the difference between a few weeks is meaningful for the developing fetus, and so the decision to deliver a baby on either side of these three weeks can have very real implications for the baby’s health.
Ultimately the decision as to when to schedule an elective cesarean warrants a frank discussion between a patient and her care provider. My teacher Colette Crawford drilled into my head during my prenatal training that it’s important to remember to weigh the risks versus the benefits. What is the basis of your decision to have a c-section, and when to have it? What are the risks for you and baby? What are the benefits for you and baby? I am proud to pass on her wise words, especially where it concerns such an important decision - the health of your baby.
January 29th, 2009
Inspired by what I saw on my bike trip through Vietnam, since returning I have been obsessed with incorporating more squatting poses into my prenatal yoga classes. I have long been fascinated by the incredible ease with which many people from other cultures (particularly in Asian countries I have visited) can assume a squatting position, compared to the struggle I often see in the yoga community I typically teach. So many of the Vietnamese people I saw just folded right up and sat down into self-made collapsible seats. Our bodies are designed to do just that: Fold at the ankles, knees and hips. If you watch little kids play, they take this shape effortlessly. So why is it so hard for us adults?
I think that we Americans have difficulty with this pose because of the daily routines and physical habits many of us have adopted: We sit for long periods of time, which shortens the hip flexor muscles and creates general stiffness in the body. Women tend to wear high-heeled shoes, which shortens the Achilles tendons and keeps the calves in a state of contraction, which makes it difficult to lengthen the muscles.
You’re probably wondering why it matters whether or not one can squat and what purpose it serves in a prenatal yoga class. In a previous blog entry, Birthing Positions: Don’t Just Take It Lying Down, I wrote about the importance of exploring a number of positions for laboring and pushing and not just limiting oneself to the traditional supine position. Many women find that birthing in a squatting position is ideal. Now we can delve deeper into the benefits of this particular choice.
For one, squatting tips the pelvis and uterus forward, placing the baby in an anterior position, which is good alignment for birthing. And, there is great benefit to using gravity to your advantage as the baby is making its way down. Additionally, you are widening the space for the baby to pass through. Squatting actually opens the pelvic outlet on average 15-20% wider than reclining back and shortens the birth canal. If the diameter of the pelvis is increased and the birth canal is shortened, the second stage of labor is likely to be shorter. (Read: Less pushing!) As I jokingly say in class a lot, “Nobody I have ever worked with requests more hours of pushing.” If you can shorten this stage, by all means do so! One final “shout out” for the benefits of this fantastic position: Squatting can also lessen the necessity for the use of forceps and vacuum extraction.
As great as squatting is, I would be irresponsible if I neglected to mention the one downside of this pose, perineal tearing. Because births tend to happen more quickly while squatting, there may not be time for the muscle tissue to stretch, and the attending care provider may not be able to offer the perineal support needed to prevent tearing. It is nevertheless a pose worthwhile exploring for the reasons listed above.
So what can one do to better prepare the body for taking this position? Here are a few tips: As I mentioned before, our bodies are not too accustomed to squatting. I would recommend doing calf and hamstring stretches to help open and release the backs of the legs. In yoga we do Downward-Facing Dog and Janu Sirsasana for this purpose. It is also important to build some leg strength, and you can cultivate this strength by practicing some standing yoga poses. I would also recommend wall squats; leaning your back against the wall and sliding down while trying to keep your heels on the floor. Allowing for the wall to bear your weight, just get your joints used to folding. You can also practice squats with a partner. If you are practicing away from the wall and without a partner and your heels pop up, simply place a rolled blanket or towel under them. You want to feel supported, and you should not have to hold yourself up with your leg muscles. While the legs are engaged, you want to relax into the pose. Finally, you can practice a wide-knee child’s pose to give your body a feeling of folding at the hips and knees.
What can you do if you have tried squatting and it is really difficult for you, but you’d like to explore squatting as you’re birthing? Well, you can labor on a toilet or bedpan. This allows for similar opening of the pelvis but offers support under the legs. You can do a partner squat or hold onto a railing or squatting bar (many hospitals now have these available to use), both which will help support your weight. Or you can use a birth ball (more for laboring than pushing). If your hospital or birthing center has a large tub or if you are doing a home birth and you have a rented tub, you can squat in the water. This has the additional benefit of buoyancy, making your body feel lighter and thereby making it easier to stay in this position for a length of time.
If you are intrigued by the idea of squatting during birth, there is a beautiful 10-minute Brazilian video called “Birthing In the Squatting Position”. It is truly remarkable. It shows several women calmly birthing in a squat, many of them reaching down and scooping up their own babies. I have seen it a number of times, and it still takes my breath away how at ease these mothers look while birthing.
January 16th, 2009
