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 One partner may become very withdrawn or feel the need to find control when feeling out of control within the situation.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.
July 21st, 2009
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!
July 14th, 2009
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.
July 8th, 2009
