The pelvis is greatly affected during pregnancy, and it is not uncommon for the expectant mom to experience aches and pains in this area. Many times women just accept these pains as annoyances that will go away after the baby is born, which is most likely true, but there are some things that can be done during pregnancy to deal with these discomforts.
I just received my latest copy of Midwifery Today (yes, it does happen to brighten my day when I fish it out of my mailbox!). This months issue features a short article about SPD (symphysis pubis disorder) and some wonderful suggestion about dealing with it. Heres a quick anatomy lesson: the pubic bone is not actually a single bone. It is the point at which the two halves of the pelvis join in the front via a piece of cartilage. This cartilaginous joint is the pubic symphysis. During pregnancy, because of the presence of relaxin in the body, all joints become more flexible, including this one. Sometimes the bony portion of the pubis (left or right pubic tubercle) separates slightly from the cartilaginous joint causing pain. Pain can range from slight, which indicates just minor overstretching of the joint, to extreme, due to full-on separation (diastasis) on one or both sides of the joint.
In your prenatal yoga practice, we would suggest avoiding deep pelvic opening poses that will be likely to exasperate the situation. We also encourage students to take shorter, wider stances in standing poses and to be gentler with their hip-opening poses. The article I mentioned above also suggests options that can be explored outside the yoga room, and especially during labor.
Author Barbara E Herrera, LM, CPM makes this suggestion: “I have found tight binding very helpful during pregnancy and labor. Use a long wrap or rebozo (and if you are large woman, tie two or three together) and have someone help you tie the wrap tightly around your hips. In labor, you might need two people to do the work. Wrap the cloth as if you are going to make a knot, having each person pull an end after that first step. Once the cloth is very tight around your hips, have them tie a knot. After this is in place, you will feel less pain and be able to try different positions. Standing, holding onto the squatting bar, allows you to do a supported squat without spreading your legs far.”
A very common birthing position is lying supine, drawing the knees to the armpit area. This is a huge pelvis opener, which is useful for making more space, and is among the easiest positions for a doctor or midwife to get a good view of what is going on. However, this may not be the idea position for a mother who is suffering from SPD. In fact, lying supine can cause more pain through the healing process. The mother may not notice the pain during labor since many other things are going on, but she is likely to feel the pubic pain afterwards if the pubis has spread even further. Other options for birthing positions include: coming onto an all-4 position, standing, kneeling, gentle squatting or side lying. It would be best to avoid any position or situation where someone is likely to pull the legs far back.
After the baby is out, the mother still has relaxin, the hormone responsible for softening the tendons and ligaments, in the body for up to six months. So it is not uncommon for the new mother to continue to feel pubic pain. Herrera suggests continuing to bind the hips until the new mother feels the pain subside and more stability in the pelvis. In postnatal yoga, we specifically address this common discomfort and work on poses that help create stability in the pelvis. Luckily, over time this issue usually corrects itself.
March 21st, 2009
Over the last week or so, many childbirth education blogs and articles have focused on Pamela Paul’s latest article in TIME magazine, The Trouble With Repeat Cesareans. It is so wonderful that this important subject is receiving some attention. Paul, who happens to be a third time student at the Prenatal Yoga Center, also expanded on the story in the Huffington Post in Childbirth Without Choice. In this lengthier version, Paul goes on to detail her own personal experience with a VBAC (Vaginal Birth After Cesarean) backlash.
The current trend in our country is that one third of pregnant women will give birth via cesarean section. Within that population, 9 out of 10 women will have c-sections for any subsequent births. For some women it is a choice, and the c-section will be scheduled; others who may want a VBAC will find themselves restricted by the lack of hospitals or doctors willing to provide the service.
Paul’s article focuses on the obstacles women who want to try a VBAC face. Many hospitals are moving away from offering VBACs to their patients altogether. A recent study from the International Cesarean Awareness Network shows 821 hospitals formally banning VBAC, and 612 with a “de facto” ban. There seem to be three main factors contributing to this decision: financing, scheduling and medical risk. Financially speaking, many doctors and hospitals are not willing to risk either the chance of litigation or higher insurance premiums. In a 2006 ACOG (American College of Obstetrics and Gynecology) survey of 10,659 ob-gyns nationwide, 26% said they had given up on VBACs because insurance was unaffordable or unavailable, while 33% said they had dropped VBACs out of fear of litigation. There is also the personnel cost to take into consideration. In order for a hospital to provide a VBAC, they are required to have an anesthesiologist and surgeon on call in case something goes awry and an emergency c-section is needed. This is both costly and time consuming. However, Ms. Paul highlights a comment from Dr. Mark Landon, a maternal-fetal-medicine specialist at the Ohio State University Medical Center and lead investigator of the NIH’s largest prospective VBAC study: “How can a hospital say it can handle an emergency C-section due to fetal distress yet not be able to do a VBAC?”
Hospital staff scheduling is also a factor. A cesarean takes an hour while a labor undertaken “the old fashion way” is unpredictable and can last many hours. I often joke with my students when they are scheduling their c-sections or inductions that they will never go in on a Friday, Saturday or Sunday night. Monday through Thursday is the prime time in the Labor and Delivery unit.
As Paul boldly points out, the medical risk of a VBAC is real. Once the uterus is cut, the strength of its muscle tissue is compromised. In the case of a uterine rupture, the results can be fatal to both mom and baby. Because there is a higher risk of uterine rupture for a VBAC candidate, there are stricter protocols about induction and monitoring to assure the safety of both mother and child. A rupture, however, occurs in just 0.7% of cases. That’s not an insignificant statistic, but the number of catastrophic cases is low - only 1 in 2,000 babies die or suffer brain damage as a result of oxygen deprivation. While that number may seem frightening, especially to a mother-to-be who wants nothing but a healthy baby, it is important to remember that there are also significant risks associated with cesarean births.
Neither a VBAC nor a planned cesarean can guarantee a complication-free experience. Both options offer benefits and serious risks that need to be taken into account. But doesnt an expectant mom who understands all the relevant factors deserve access to both? Dialogue on both sides of the VBAC argument is crucial, especially when were seeing the prevailing attitude toward VBACs robbing so many expectant moms of the choice of how to birth their babies.
March 10th, 2009
