Get On the Ball!

A birth ball, that is!

I often find myself teaching postnatal yoga while sitting on a birth ball, balancing two babies on my knees. I joke that the ball was the best piece of equipment I bought for the studio. Although I say this in jest, there is great truth to this statement!

The birth ball, a basic 65 cm physio ball for a woman of average height (the knee should be at a 90 degree angle), can be a wonderful asset in creating comfort during pregnancy, labor and postpartum. During pregnancy, especially throughout the last trimester when back pain seems to be the worst and fetal position is of most importance, sitting on the birth ball can help align the pelvis, creating an anterior tilt. This subtle forward tipping of the pelvis will encourage the baby towards the mother’s belly, as opposed to leaning back against her spine in a posterior position. Also, when the pelvis assumes this gentle sway, the position forces the architecture of the body into good posture and engages the abdominal and lower back muscles, which can alleviate back pain.

Some women also find the rocking movement that naturally occurs when sitting on the ball very calming and comfortable, and it can relieve pelvic floor pain and discomfort from hemorrhoids. This rocking or bouncing idea leads me to my favorite postpartum use: Helping to quiet your baby! I don’t know what it is that they respond to, but they seem so happy and content with a little bouncing and rocking. For the past 6 years, I have found this to be my favorite baby-quieting technique. And again, it is good for posture, which during the postpartum period tends to slump due to fatigue and weak back and abdominal muscles.

So let’s move on to the namesake of the birth ball - using the ball during birth! I find the birth ball invaluable during labor. There are so many uses for it! Let’s start with the basic: The all-fours position is a popular and favorite position to assume during labor. It takes the pressure off the mother’s back and helps to encourage the baby to stay in a good position. Since labor may last awhile, it is a lot more comfortable to spend the time draped over the birth ball than it is to have the palms completely pressed into the floor with pressure on the wrists. This position also slightly angles the torso upwards and uses gravity to press the baby’s head downwards against the cervix, which will encourage dilation. A similar usage is to put the ball on a bed or couch and have the mother hang over it. While the mother is at rest on the ball, the birth partner may be massaging her back or applying counter pressure, heat or ice. You can also place the ball in the shower or bathtub and have have the mother sit on the ball while allowing the water to run along her body. This way she can enjoy the sensations of the warm water while staying passive and at ease. The laboring mom may also just simply enjoy sitting and rocking or circling her hips in a figure eight motion. The rocking can be comforting and relaxes the back muscles. I usually find that at some point, usually near or in transition, the pressure of the ball against the pelvic floor gets to be too much and it may just be used to lean against.

I have also found that hospital staff are very open to the use of a birth ball, since it does not inhibit the usage of the EFM (External Fetal Monitors). Some hospitals even provide them. However, if you borrow one from the hospital or birth center, I would recommend that you clean it - and DEFINITELY put a chuck pad over it. You don’t want to put your bottom where so many have sat before.

So there you have it! Three very useful purposes for one very small investment! Yes, I know New York City apartments are not particularly spacious and the ball may be rather in the way. Do what I did: I color-coordinated the ball with the decor of the yoga studio!

Happy bouncing!

2 comments November 21st, 2008

Hormonal Blueprint of Labor

I finally sat down to go through the many books that are stockpiled on my bookcase to give away to Housing Works. As I was tossing several of my chick lit books into a paper bag, I came across a book I forgot I was given, Enjoy your labor: A new approach to pain relief for childbirth, by Dr. Gilbert Grant, Director of Obstetric Anesthesia at New York University Medical Center. Dr. Grant signed and gave me the book himself. Of course, he did this while I was acting as somebody’s doula during her final stages of pushing. Appropriate timing and interaction? I think not. Anyway, before throwing it into my rather large pile of recyclable books, I thought I would take a look at it. See what the good doctor had to say.

First of all, as an obstetric anesthesiologist, he is very pro-drugs. Fine, everyone is entitled to their opinion. But “Grant asserts that natural birthing is misogynistic in practice. In essence, it is hateful to women. In a Times Online article he asks why women are made to undergo labor without pain relief, when no man would be asked to undergo an appendectomy, which lasts about 24 minutes, without pain relief, yet the pain of labour, which can last for more than 24 hours, is viewed as something women have to endure.”

This is the kind of attitude that really upsets me. I don’t see how one can compare childbirth to surgery without pain medication. When someone undergoes surgery, it is because there is a dis-ease in the body. Something has gone awry which requires medical attention to correct it and restore the person to good health. And essentially he is saying that the female body is ill-equipped to birth babies - yet the female body is designed to birth offspring. I am not a particularly religious person, and I seldom use the word “God”, but somehow we were created to function and have been doing so for thousands of years. Our bodies are brilliantly designed to fight off many diseases, replenish itself from illness, repair broken bones, and certainly to procreate. Women are equipped with an amazing hormonal blueprint that allows them to manage the pain of childbirth. Pregnancy and labor are not illnesses.

Let’s take a closer look at the role hormones play in helping women through labor. The three main hormones that are involved in the labor and delivery process are oxytocin, endorphins and adrenaline.

Oxytocin

Oxytocin is made in the hypothalamus, deep in our brains, and stored in the posterior pituitary, the master gland, from where it is released in pulses. Oxytocin, also referred to as “the hormone of love” is the hormone released during pregnancy, labor, orgasm and breastfeeding and is responsible for triggering feelings of love and nurturing.

During labor, oxytocin levels are peaked, and the secretion of this hormone helps regulate the rhythmic contractions of the uterus. It is the contractions of the uterus that help move the baby down, putting pressure on the cervix and allowing it to dilate. After the baby is born, the oxytocin levels continue to surge, helping birth the placenta. It is important to get the baby to the mother’s breast to start suckling to continue the flow of oxytocin. The mother will still experience some strong contractions at this point which will protect her against postpartum hemorrhage.

Endorphins

Like oxytocin, beta-endorphin is secreted from the pituitary gland, and high levels are present during sex, pregnancy, birth, and breastfeeding. Beta-endorphin is also a stress hormone, released under conditions of duress and pain, when it acts as an analgesic and, like other stress hormones, suppresses the immune system. High levels of endorphins during labor and birth act a lot like morphine or similar drug, allowing a woman in labor to enter an altered state of consciousness that will help her cope with the birth process, provided she is undisturbed.

Several months ago, I attended my friend Liz’s birth of her second son, Owen. She chose to do a natural birth in the Birthing Center at St. Lukes/Roosevelt. The atmosphere was quiet with very little disturbance. Towards the end of the labor, Liz laid in bed, very quiet and still between contractions, with moans and movement during the contractions. Her eyes were soft and somewhat glazed over, and words were scarce. Here is how she described her birth experience:

“I got in the tub, and immediately my back pain went away. The warmth of the water slowed the contractions a bit too, and I was able to relax. After a while, though, I started to feel like a raisin, and the bed looked so inviting, so I got out of the tub and laid down. I was actually able to doze a bit between my contractions. A little before 7pm my doctor checked me and said I was about 9.5 centimeters. She asked if I wanted her to break my water and I decided to wait a bit. I don’t know why. I wasn’t thinking specifics. I was in such a bizarre zone of pain and power and determination and anticipation, that I just said no. From that point on I was on a level that I can only compare to a psychedelic drug experience *I feel funny using that analogy, and I apologize if it’s not appropriate, but I have been searching for a way to describe how i felt, and that is truly the only thing that compares.*”

Liz’s words describe the brilliant hormonal design of the female body. Her body produced the endorphins needed to allow her to move away from the pain, let go of her rational mind and follow her instinctual desires. Unfortunately, most studies have found a sharp drop in endorphin levels with use of epidural or opioid pain medication.

Adrenaline

Adrenaline, also known as the “fight or flight” hormone is secreted from the adrenal gland above the kidney in response to stresses such as fright, anxiety, hunger or cold, as well as excitement, when they activate the sympathetic nervous system for fight or flight.

I often explain the “fight or flight” hormonal reaction by viewing how animals birth. When an animal feels threatened, adrenaline is produced, slowing down the production of oxytocin and allowing the mama-animal to stop contracting, regather and find a safe, quiet place to birth her baby. As much as we may not want to admit it, we are animals and our bodies react the same way. It is not surprising that when a mother is at home, feeling safe and comfortable with her surroundings and birth attendants, her labor can often progress nicely. But the same woman that presents a strong laboring pattern at home may, upon entering the busy, noisy, bright hospital suddenly find that her contractions have spaced out or even stopped. This is because of the presence of adrenaline.

Now not everyone can birth like a dog and go hide under the porch. So what can you do if you choose to birth in the hospital? Try to keep interruptions to a minimum. Invite only those you want in the room to join you. Turn the lights down. Bring music that will help relax you. All of these things will help reduce the stress hormone and allow the oxytocin to flow.

And adrenaline is not all bad when it comes to birth. At the final stages of labor, high levels of adrenaline activate the fetal ejection reflex. It makes the laboring mom very strong, alert and determined, ready for the final pushes to birth her child.

So after taking a closer look at the design of the female body, it seems absurd to compare natural childbirth to a surgical procedure, like an appendectomy, without anesthesia. It is absolutely an individual choice whether or not to take pain medications. But remember, for many, pain medication is not a necessity. If you choose to forgo it, your body will kick in with its own special cocktail of protection and as Liz said, “psychedelic experience”.

August 7th, 2008

What is a Doula?

Over the last few weeks I have received so many inquiries about doulas. What is a doula? What does a doula do? How much do they cost? How do you interview a doula? So, I thought I would try to answer these questions to the best of my ability.

The word ‘doula’ is derived from Greek and means ‘woman of service’. (In my opinion this sounds a little negative - I prefer ‘labor assistant’!) There are two different types of doulas: labor support and postpartum care. Postpartum doulas are also considered ‘mother’s helpers’. They help mother the mother after her birth, perhaps showing her some newborn procedures, helping establish a schedule for mom and baby, and doing basic chores like cleaning the house, food shopping, and laundry. (I chose to be a labor support doula. I figure I am not that good at cleaning my own house or doing laundry, and to be honest taking a trip to Fairway is a low point in my weekly routine - so my skills are best used to help mom during labor.)

Labor support doulas are usually hired by the couple, although some hospitals provide them free of charge to offer nonjudgmental emotional and physical support. They are also equipped to help answer many questions about the labor and birth process and medical interventions. While most doulas are not trained medical assistants and do not perform medical procedures, they have quite a bit of knowledge that may assist the couple when making decisions about the path of their labor and birth. Personally, I never make a decision for the couple, but rather provide answers to their questions and both pros and cons of any options that are presented. This way, when the couple has to make a decision, they are doing it from a place of knowledge, not fear.

Another reason a doula may be a good person to bring along is that several studies have shown that the presence of a doula can reduce the rate of routine interventions and cesareans. Her assistance tends to result in shorter labors with fewer complications, reduces negative feelings about one’s childbirth experience, reduces the need for pitocin (a labor-inducing drug), forceps or vacuum extraction,and reduces the mother’s request for pain medication and/or epidurals.

There are currently two principle groups that certify doulas: ALACE (Assocation of Labor Assistants and Childbirth Educators) and DONA (Doula Organization of North America). I was certified through DONA. Both groups firmly believe in the importance of consistent, continuous support throughout labor and in respecting the couple no matter how they choose to birth.

I am often asked by concerned mothers who want to have an epidural if that is likely to be ok with a doula. The answer may vary from person to person, but most doulas believe that they are there to assist in the best birth experience a mother can have through her own vision and wishes. I firmly believe that each woman needs to birth how she feels is best for her and her family. The experience of birth has a lasting and profound effect on a woman, and the doula is there to help ensure that it is empowering and satisfying.

Once you have found a doula who you think you would like to work with, what is the next step? I would suggest a ‘meet and greet’. This is an opportunity for the mother and her partner to sit and chat with the doula and inquire about her style, beliefs, price, availability, back-up support, etc.

Here are a few questions that may be useful:

1. What is your philosophy on childbirth? Do you only attend and support women that are intending to do a natural birth? Are you open to the use of pain medication?

2. What are some of the non-pharmaceuticals pain methods that you use?

3. How do we determine when you join us? Do you come to our house at the beginning of labor? Or do you meet us at the hospital or birthing center?

4. Have you worked with my doctor, practice, midwife or at the birthing center or hospital where I will be giving birth?

5. How many births have you attended?

6. What kind of training do you have?

7. Do you have a back-up doula in case you are not available when we need you?

8. What is your cost?

9. Do you have references we can check?

10. How many times before the labor do we meet? Do you help us with our birth plan?

One of the most common questions I encounter is the cost of doulas. There is a range based on several factors - where you live, for instance. A doula in NYC will probably cost more than outside the metro area. Experience is another determining factor. At this time the average range for a doula with a fair amount of experience, which I would say is at least 25 births under her belt, is $1500-$2500. I have heard of very seasoned doulas who have attended hundreds of births charging upwards of $4000. If these numbers sound outrageous, you could also consider finding a doula who is in training and would probably only ask you to cover her expenses - taxi fare and food. Some doulas even work on a sliding scale. But keep in mind when digesting this figure that the doula is making a commitment to you to be on call and available for three weeks prior to your due date up until you have your baby. It is possible that your doula will be on call for you for a whole month!

I hope this helps explain the role of the doula and the benefits of having one as a member of your support team, and that you now have some insight as to how to find the doula who is right for you.

June 27th, 2008

Home Birth: Is This the Next ‘Right to Choose’?!

On June 18th the American Medical Association (AMA) issued a resolution in support of the ACOG statement that “the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.” as well as a resolution “to develop model legislation in support of the concept…“.

The statement from ACOG and the subsequent resolutions from the AMA are very likely due at least in part to the increased attention from the media on home birth, brought to the forefront by the film “The Business of Being Born” and its producer Ricki Lake. I have seen the film multiple times and think it is a very responsible, well-done documentary on the subject of home birth. The overall message is that home birth is a safe option for a low-risk woman who has a trained, certified midwife in attendance for medical assistance.

The midwifery model of care is based on the concept that pregnancy and birth are normal life processes - not pathological medical conditions. However midwives are trained medical experts. They monitor the mother and the baby throughout labor with a dopplerscope, come equipped with oxygen and resuscitation skills, and bring Pitocin in the event that it is necessary. They are also at the ready to make a call to transport the woman to a medical facility should she need more advanced medical attention. But unlike many medical professionals within hospital walls, they allow the birthing mother a great deal more choice - for instance the position she wishes to take to birth her baby - with fewer restrictions.

There have been numerous studies demonstrating that a home birth with a trained midwife can be a good choice for low-risk women who want to avoid unnecessary routine interventions. The largest and most rigorous study of home birth internationally to date found that among 5,000 healthy, “low-risk” women, babies were born just as safely at home under a midwife’s care as in the hospital. And not only that, the study, like many before it, found that the women actually fared better at home, with far fewer interventions like labor induction, cesarean section, and episiotomy (taking scissors to the vagina, a practice that according to the research should be obsolete but is still performed on one-third of women who give birth vaginally).

Other eye-opening statistics indicate that though the US has the most expensive births, the maternal and infant mortality rates are on the rise. According to Mother Magazine, US infant mortality rates continue to rank it below 30 other countries. Twenty-two percent of all pregnancies are induced, and most worrisome of all, in the last four years the maternal mortality rate has risen above 10 per 100,000 for the first time since 1977. These statistics can not be blamed on home birth since only 1% of US women are birthing in their homes.

If you look outside the US, many other countries are strong proponents of allowing women the choice to birth at home. The Netherlands with over a third of all births being planned homebirths. The Perinatal Study Group came to this conclusion about the Dutch system of maternity care: “This is an important exception: this country also has one of the lowest mortality rates in the world for both mother and baby. This maternity system is worthy of close evaluation and emulation.” Across the pond, the British OB/GYNS respond with “There is no reason why home birth should not be offered to women at low risk of complications… it may confer considerable benefits for them and their families. There is ample evidence showing that laboring at home increases a woman’s likelihood of a birth that is both satisfying and safe…”

Home birth is not a choice for everyone. Several states in the US have made a home birth attended by a direct-entry midwife illegal. These states include Alabama, North Carolina, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maryland, Missouri, South Dakota and Wyoming. One of the concerns of home birth advocates is that the AMA is trying to persuade individual state legislators to see home birth as harmful to the baby, equating it as child abuse, for which the woman may be criminally prosecuted.

How a woman chooses to birth should be based on her needs and what feels right for her and her family. She should be educated about her options and empowered by her choices. Wherever a woman is most comfortable, supported and heard is the best place for her to birth her baby, whether that be at home, a birthing center or a hospital. Throughout history women have fought long and hard for the right to make decisions about their own bodies. Birthing is a natural ability with which women come naturally equipped. Shouldn’t we be able to choose how and where?

June 20th, 2008