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Pushing in Labor??

By Horatio Daub MD, MPH  and Cathy Daub PT, CCE and CD(BWI)

A recent study in the Journal of American Medical Association1, October 9, 2018, found that delaying pushing once full cervical dilatation is reached for 60 minutes vs. immediate pushing had no significant effect on the rate of spontaneous vaginal delivery (85.9 % in the immediate group vs. 86.5% in the delayed group). However there were significant differences in the incidence of postpartum hemorrhages (2.3% in the immediate pushing group vs. 4.0% in the delayed pushing group) and chorioamnionitis  (6.7% in the in the immediate pushing group vs. 9.1% in the delayed pushing group).

This contradicts the previously held beliefs that delayed pushing results in a better chance of having a spontaneous vaginal delivery and is safer for the mother and baby.  In fact, the study was stopped early because of lack of effect of the delayed pushing on the percentage of spontaneous vaginal births and the significantly increased morbidity from higher rates of postpartum hemorrhage and increased rates of chorioamnionitis increasing the morbidity for mothers and babies. The new recommendation to not delay pushing once full cervical dilatation is achieved is supported by the findings of this study because of the significantly decreased morbidity for mothers and babies with immediate pushing.

There are some important points to consider:

  • First, regional anesthesia would confine women in labor to beds and not allow them to walk & move their bodies thus allowing easier movement of the baby down the birth canal assisted by gravity rather than fighting it when they are confined to bed in a supine position.
  • Second, this study assumes that the experience and outcomes of birth are improved with regional anesthesia numbing them to the experience of birth. There are no studies to support this hypothesis.
  • Third, the study ignores evidence that using non-pharmacological comfort measures in place of regional anesthesia reduces cesarean sections in birthing women when they are mobile, upright and free to labor in whatever place and position, works for them.
  • Fourth, the study assumes women with partially paralyzed, desensitized abdominal muscles can effectively push a baby out of the birth canal. Birthing women are basically being set up for failure by being anesthetized and partially paralyzed and being confined to the “stranded beetle” position hindering the natural progression of labor and delivery. In addition, with regional anesthesia, both motor and sensory nerves are blocked, making it impossible for her to walk or use her legs to change her position.

But what if women learn that positioning themselves in such a way that they are working with gravity instead of against it, only bearing down slightly when their body demands it at the top of a contraction, to be a less stressful and easier way to birth their babies?  Then they don’t need as much power from their abdominal muscles and they can more gently birth their babies.  They instinctively follow the cardinal movement of their babies moving and rotating through the pelvis to be born.

Reducing unnecessary cesarean sections was the topic of the recently published “Non-clinical interventions to reduce unnecessary caesarean sections by the World Health Organization (WHO). (Read more in our upcoming November Enews).   These recommendations target women, health-care professionals, and health organizations, facilities or systems. For women it addresses what they call “Psychoeducation” where childbirth preparation can help address fear of pain and labor, and explain stages of labor, hospital routines, the birth process, and pain relief among other topics.  Their recommendations include nurse-led applied relaxation training programs, and normalization of individual reactions.

Today, too few pregnant women are receiving comprehensive childbirth preparation for their upcoming births.  In BirthWorks, we advocate birth education to be very early in pregnancy or even before pregnancy.  Our program is comprehensive and integrates the mind, body, and spirit through the practice of human values.  Working with the mind means helping women to release fears and feel safe having women choose the people & environment for her birth.  For the body, it means finding optimal pelvic positions that ease movement of the baby through the birth canal, the value of mother/baby skin-to-skin contact, the physiology of birth, and more. For the spirit, it means knowing that all women are born with the knowledge about how to give birth, believing it, and having patience.

Non-pharmacologic methods to ease labor pain and reduce cesarean section are well known but underutilized.  These include relaxing in warm water, moving in labor, keeping upright positions as much as possible, having the presence of a doula to help a woman in labor to feel safe, and having early childbirth preparation. The way to decrease cesarean sections is not to have women lying on their backs with regional anesthesia, unable to move out of bed, but rather allowing women to move and assume the positions that work for their birth.

Why not concentrate instead on ways to help pregnant women develop a new paradigm about birth- one that includes being upright, walking, having comprehensive childbirth preparation that offers both an academic and emotional preparation for birth, finding a safe place to birth, and the value of a doula.

Given the fact that most women in the USA give birth with epidural anesthesia, the researchers were trying to develop strategies to improve the percentage of spontaneous vaginal birth .  Not surprisingly, they found no improvement with pushing early or late in labor in this outcome.  They did find that immediate pushing decreased postpartum bleeding and infections.  In order to make significant decreases in cesarean section and instrumental deliveries, we believe the logical conclusion is to decrease the numbers of women who are anesthetized for their births in the first place.

We recommend that allowing women to use movement and gravity to assist their births along with other non-pharmacologic measures, is what will improve outcomes  for women and babies and decrease cesarean rates the most effectively.

  1. Sperling JD, Gossett DR. Immediate vs Delayed PushingDuring the Second Stage of Labor. JAMA. 2018 Oct 9;320(14):1439-1440. doi: 10.1001/jama.2018.12877. No abstract available. PMID:30304414
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Tips for Sleeping Through the Night During Pregnancy

 

After announcing your pregnancy, one of the first pieces of advice veteran-parents will likely give you is to “get as much sleep as you can now because once the baby comes, you’ll be missing it”.

Unfortunately, it’s not that simple. According to an study published in Sleep Medicine, women experience “short sleep duration, poor sleep quality, [and/or] insomnia” throughout all three trimesters. The study went on to find a direct correlation between sleep quality and stress, and looked at how sleep impacts pregnancy as a whole. Sleep deprivation has a significant impact on cognitive abilities, such as reaction time, alertness, general performance, and even emotion (as if pregnancy by itself doesn’t make managing emotion hard enough).

The good news is that there are a number of ways to help promote quality sleep throughout pregnancy – and even sleep through the night. It may take a little trial and error, though, as there are a number of factors that may be contributing to restless nights.

One reason for poor sleep during pregnancy is general discomfort. As your pregnancy progresses, your body shape changes, making it difficult to find a comfortable position to sleep in. If you are typically a stomach or back sleeper, you may feel particularly miserable, and even unnatural, trying to sleep on your side. To remedy this, try putting a pillow between your knees to help align your hips. You may also find some relief by putting a soft pillow under your growing belly to help support some of the weight. If you’re lacking in extra pillows around the house, there are a variety of “pregnancy pillows” designed specifically for this purpose.

As your baby (and belly) grows, there will be more and more pressure on your bladder – resulting in more and more trips to the bathroom. This is particularly frustrating after you’ve finally fallen asleep (and gets increasingly more frustrating each subsequent time after). Unfortunately, there aren’t any miracle cure-alls for this one, but you can be strategic about hydration. Try to load up on water as much as possible during the morning and mid-day, and then by the evening start to taper off your liquid intake (of course, don’t risk dehydration just to avoid that 12 am wake up).

Stress is another common reason for poor sleep quality for anyone – but even more so for pregnant women. A 2014 study examined stress hormone levels in pregnant women and found that as gestation progressed, the hormone levels increased incrementally. Pregnancy is stressful as it is, there is a lot to worry about (especially if you’re a first-time mom) so the added hormone levels only make it worse. If you’re experiencing insomnia as a result of a racing mind, try using a sleep-focused guided meditation app on your phone to help you fall asleep. Consider investing in a mouth guard if you find yourself clenching or grinding your teeth due to tension. Finally, if the stress is so bad that you still feel exhausted despite getting a full night’s rest, try implementing (appropriate) moderate physical activity, changing up your diet, or limiting your social commitments to allow you to get more rest. Always remember to consult your healthcare provider if the stress, or exhaustion, is overwhelming.

Sleep is essential to a healthy pregnancy, but don’t be too discouraged if you’re not getting as much sleep as you did before pregnancy. The best thing you can do is give yourself some grace and permission to rest during this time, even if that means saying no to a few social events or taking a midday nap to make up for those frequent overnight bathroom trips.

Sarah Johnson

sjohnson@tuck.com

Tuck is a community devoted to improving sleep hygiene, health and wellness through the creation and dissemination of comprehensive, unbiased, free web-based resources. Tuck has been featured on NBC News, NPR, Lifehacker, and Radiolab and is referenced by many colleges/universities and sleep organizations across the web.

 

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A Look at Pregnancy and Birth Trauma and Polyvagal Theory from the Perspective of Prenatal and Perinatal Psychology

by Sally Dear-Healey, CCE(BWI), CD(BWI)

Prenatal and perinatal psychology (PPP) provides a unique and critical awareness of the process of conception, pregnancy, and birth that is lacking from most childbirth education programs, doula trainings, and provider’s educations. One of the main benefits of pre- and perinatal psychology is that it recognizes the need to consider not only the mother and her experience, but also the baby and their experience.

Polyvagal Theory, developed by Stephen Porges (1994) provides us with a dynamic understanding of how and why mammals shift between a calm states that promote intimacy and optimize health, growth, connectedness and restoration to flight, flight, or freeze states, which are normal autonomic nervous system (ANS) responses to threat, fear, and lack of safety. Individuals with a history of trauma are especially vulnerable as their “neural reactions have been retuned towards a defensive bias and they (have) lost the resilience to return to a state of safety” (Porges, S.W. and Dana, D., 2018). The goal of Polyvagal Theory is to keep an individual within their “window of tolerance” in their sympathetic nervous system (SNS) (fight or flight –aggressive defense system) and parasympathetic dorsal vagal complex (DVC) (freeze – passive defense system) and focus on feelings of connection, safety, and orientation to the environment which are part of their parasympathetic ventral vagal complex (VVC), otherwise known as the social engagement system (SNS).

“An estimated 70 percent of adults in the U.S. have experienced a traumatic event at least once in their lives” (https://www.sidran.org). This estimate may be low. According to a Journal of Trauma and Stress article, “Most respondents (89.7%/N = 2,953) reported exposure to at least once DSM-5 Criterion A (trauma) event” (Kilpatrick et al., 2013). Specific to birth, a study investigating the prevalence of Post-Traumatic Stress Disorder (PTSD) following childbirth found that 17.2% of women had symptoms of PTSD following childbirth (Shaban et al, 2013). Again, these statistics may be low as PATTCh (Prevention and Treatment of Traumatic Childbirth) reports “Between 25 and 34 per cent (sic) of women report that their births were traumatic” (http://pattch.org/resource-guide/traumatic-births-and-ptsd-definition-and-statistics).

Returning to pre- and perinatal psychology, Thomas Very, M.D. and David Chamberlain, Ph.D., both pioneers in birth psychology and founders of what is now APPPAH, the Association for Prenatal and Perinatal Psychology and Health, realized “There is a growing body of empirical studies showing significant relationships between birth trauma and a number of specific difficulties; violence, criminal behavior, learning disabilities, epilepsy, hyperactivity and child, alcohol and drug abuse” (Verny, 1981). For mothers and babies birth trauma often results from birth-related difficulties including but not limited to premature and postmature births, breech births, inductions, anesthesia, forceps deliveries, and cesareans. Trauma may also result from a mother’s feeling a lack of safety and support, which is transposed directly to her baby.

This is where Polyvagal Theory provides us with a method of understanding how trauma manifests during conception, pregnancy, and birth and how we can actively create feelings of safety, thereby facilitating increased social engagement, improving bonding and attachment, and increasing the overall short- and long-term health and wellness for mothers and their babies/children.

Polyvagal Theory proposes that cues of safety are an efficient and profound antidote for trauma. According to Porges, “The theory emphasizes that safety is defined by feeling safe and not simply by the removal of threat… and is dependent on three conditions: 1) the autonomic nervous system cannot be in a state that supports defense, 2) the social engagement system needs to be activated to down regulate sympathetic activation and functionally contain the sympathetic nervous system and the dorsal vagal circuit within an optimal range (homeostasis) …; and 3) cues of safety … need to be available and detected via neuroception (2018, p. 62 & 62).

Birth is an intimate event, and according to Porges “Intimacy is a state-dependent behavior.” He goes on to say that “For mammals, immobilization is a vulnerable state” (2018, p. 63). To help women achieve the state of intimacy necessary for conscious conception, pregnancy and birth we need to work with women prior to conception and throughout their pregnancy so that they – and subsequently their babies – are able to regulate and change previously disruptive autonomic states by accessing the social engagement system and ventral vagus so they are not re-activated by previous or current trauma. The social engagement system is recruited through “cues of safety such as a quiet environment, positive and compassionate … interactions, prosodic quality (e.g., melodic intonation) of … vocalizations, and music modulated across frequency bands that overlap with vocal signals of safety… (Porges, 2018, p. 66). In other words attitudes and behaviors, what people say but how they say it, as well as their facial expressions.

The primal perspective is one of the foundations of prenatal and perinatal psychology. As David Chamberlain is often quoted as saying, “Newborn babies have been trying for centuries to convince us that they are, like the rest of us, sensing, feeling, thinking human beings.” To be clear, this research is not meant to induce guilt since parents often get caught up in the type and hype of birth practices that are prevalent at the time and even the normal pressures of life can contribute to a stressful pregnancy or lead to a traumatic birth. Instead, its purpose is to increase awareness and effect changes in policies and procedures that might otherwise cause or contribute to trauma and subsequent short- and long-term harm in mothers and their babies/children. For those that have already been affected, help is available. Play therapy, womb surrounds, craniosacral therapy, birth simulating massage and various other forms of therapy and bodywork have been found to be highly effective. For more information on prenatal and perinatal psychology and polyvagal therapy, as well as opportunities for healing and working with these individuals please go to https://birthpsychology.com.

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Birth Story – Hospital VBAC

by Krista Haggerty

My first birth was a cesarean after a long labor.  It was hugely disappointing, and I struggled with feelings of failure.  When I became pregnant again, I knew I wanted to have a vaginal birth with no interventions.  I switched providers two times and met the OB who delivered my son at my 37 week appointment.  I went into labor 5 days later.

My water broke early in the morning with a slow leak without contractions.  At my morning appointment my OB told me to go right away to the hospital even though I wasn’t ready to go.  He also told me he didn’t think I could have a VBAC because I was so small (I am 4’11”) but he would let me try anyway.  I was furious!  I spent so much time researching VBACs this pregnancy, and knew that his reasons were not evidence based.

I didn’t want to be put on a clock, so we went home from the appointment.  My husband and I packed a bag and tidied up the house.  We went to a late lunch and voted in the presidential election.  Finally, around 5pm, the OB called my husband and told him to bring me in.  By this time my contractions had started in earnest so even though I still felt hesitant because of the OB’s attitude, I knew it was time.

We arrived at triage where a midwife from the hospital met us.  She told me she would have to take a sample of the fluids to make sure it was my waters and that she would check me.  I told her I didn’t want to be checked until I was ready to push, but she insisted it was hospital policy.  A moment later I had a contraction, and she checked me.  I told her “No, get out!” but she ignored me, and just said “You’re 7 cm”.  She left and about 15 minutes later I told my husband I felt like pushing.  He ran out to find someone and there was a whirl of activity as nurses came in, put me onto a bed, and wheeled me upstairs to the maternity floor.  My headphones were removed from my ears without anyone asking, and during the trip up I was checked another two or three while I yelled “No!  Stop, Get out!”  Not once was I asked or even warned that someone was checking.  I felt violated, like all they saw of me was my uterus, and not me as a person.

Once we were in the room, the OB checked me (without asking or acknowledging me at all), declared I was at 10 cm but had a lip, and left the room.  The nurses told me to stop pushing, which was what happened with my first baby.  I couldn’t stop, it felt impossible to fight the urge.  I began to panic; my doula wasn’t there yet (we had just called her) and no one would tell me what a lip meant or what I could expect.  I told the nurse that if they wanted me to stop pushing they would have to give me an epidural.  My husband asked—mid contraction—if I wanted to just have a C-section.  I managed not to punch him.

While I was waiting, a tech came in and told me she was going to draw blood for my STD test.  I had already been tested early on in pregnancy and it was negative, so I declined.  She left for a moment, and when she came back she said if I didn’t allow her to take blood now, my baby would be taken and tested as soon as he came out.  I was shocked; I felt threatened and angry, but I also didn’t want to be separated from my newborn for an unnecessary blood test, so I reluctantly agreed.

Soon the anesthesiologist came in and prepped me for the epidural.  He had me sit up, and as I sat I felt the baby move down into my pelvis.  I almost said something to the nurse, but at that point I felt so out of control of the situation I just rode it out.  After the epidural was in, they had me lie on my back, which was extremely uncomfortable.  I started to shake badly and was freezing.  As the anesthesiologist walked out, my doula walked in.  She saw what was going on and asked if anyone had checked me for the lip before the epidural was put in.  I almost started to cry when I realized they hadn’t. She went to work soothing me and making me comfortable.  She sat with my husband and helped calm him a bit, and things got quiet.

A little while passed, and I was checked again.  I was ready to push!  They sat me up in the bed and the nurse had me practice pushing before the OB came in.  I took a moment to talk to my baby, telling him we were going to do this together and that I couldn’t wait to meet him.  I pushed once and was immediately told to stop; he was right there and ready to come out!  The OB came in and I pushed twice more, and my son was born.  He was placed on my chest but there were too many other sheets to really hold him, with all the fussing from the nurses.  They took him aside because he wasn’t breathing well, but after I insisted I hold him, he perked up.  He was perfect, and the whole labor lasted about 4 hours.

In many ways I felt like a warrior; it felt like a battle to birth the way I wanted, and though I felt wounded by the care I received, it could not diminish the triumph of what I accomplished once I held my son for the first time.  I felt invincible!  Despite the struggle to have my voice heard and to be treated respectfully, I was able to do what no-one in the room (except my doula) thought I could.  As I held my son for the first time, all I could think was “WE DID IT!”

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The Nocebo Effect

By Cathy Daub, PT, CCE and CD(BWI)
I remember once talking with a pregnant woman in the hospital who had just been tested for gestational diabetes. She looked up at me confused saying, “I eat healthfully and there is no history of diabetes in my family.” She had a look of despair in her eyes and I could tell any confidence she had had in her body to give birth had suddenly been diminished. I saw her later and found out that the test was a false positive and that she didn’t have gestational diabetes after all, but the lingering effect that something could go wrong in her body remained and affected her deeply. A woman giving birth needs to have a lot of confidence in her body for the work of labor for it may be one of the hardest but most rewarding things she has ever done.
The word Nocebo comes from the Latin word “noceo” which means “to harm” whereas the word “placebo” means “to please.” More simply put, nocebo means words that are said that cause harm. The nocebo effect is basically the effects of the power of suggestion. For example if a doctor tells a woman that she has a small uterus, and then as her belly grows, if she believes what he said is true, she may not believe she can birth her baby and a cesarean may be the outcome.

The nocebo can also have the effect of taking an inert harmless substance that ends up causing a harmful effect, simply because someone believes or expects it will harm him/her.  The power of suggestion and our beliefs are very strong and can actually alter and control physiology by simply changing a thought.  Therefore, results of the placebo or nocebo are actually a mind plus body effect. “Changing thoughts can actually create a brand-new reality.”1 “Considering that the latest scientific research in psychology estimates that about 70% of our thoughts are negative and redundant, the number of unconsciously created nocebo-like illnesses might be much higher than we realize.”2

Joe Dispenza in his book “You Are the Placebo” writes:  In other words, in exactly the same environment, those with a positive mind-set tend to create positive situations, while those with a negative mind-set tend to create negative situations.  This is the miracle of our own free-willed, individual, biological engineering.”3  These are the reasons that in BirthWorks certification programs, we focus a great deal on identifying beliefs related to birth and work to change those not perceived to be helpful.

At a recent BirthWorks Childbirth Education Workshop, Krista shared the following story of her birth, one full of the nocebo effect, but also of her power as a woman to rise above it.  This, itself, takes much courage and determination to make the best out of any situation.  But just imagine after reading it how different her experience would have been had she received the respect she deserved during her labor.

References:

  1. Dispenza, Joe, You Are the Placebo: Making Your Mind Matter, published and distributed in the United Kingdom by Hay House Hay House Inc., 2014. p.31.
  2. p.45.
  3. p.45.

 

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The Truth About Lips

 

 

 

 

 

elliptical

When you see these diagrams of an opening cervix, you can see how a posterior lip would be unlikely        because in actuality, the cervix opens in an elliptical fashion and not concentrically.  The baby’s head dilates the cervix more with each contraction pulling the anterior part of the cervix with it.  When the head is not centered evenly on the cervix, one side may dilate more than the other resulting in an anterior lip.

Wikipedia defines an anterior lip as:  “The anterior section of the cervix is nearly always the last part of the woman’s cervix to be finally taken up into the lower segment of the uterus.  An anterior lip occurs when the top of the cervix swells, but the rest of the cervix has completely dilated. An anterior lip can slow the woman’s progress from the 1st to 2nd stage of labor, because the swelling will usually take time to reduce, before enabling the woman’s cervix to be pulled up, and around, the baby’s head.”                                                                                                                                                                                                                                                                    concentric

 

Women are frequently told they may have a swollen anterior lip that is impeding progress in labor.  What can a woman in labor do?

  • Try to push through the cervix but only if she feels an urge to push. When the cervix simply isn’t ready it can just become more swollen.
  • Changing positions a lot throughout labor will help to avoid malpositions. Position changes will help keep the baby moving and rotating into optimal positions so the baby’s head will be presented evenly on the cervix.  Upright positions or hands and knees are best. Try lunges, trunk rotation, walking up and down steps or marching in place, rocking the pelvis, or hanging from a rope. Using a rebozo can give even more sway to the hips when used to make a figure eight in a standing position.
  • Some midwives will place an ice cube on the lip and leave it there for a few minutes. They say this works every time for them.

The woman who was told she had a posterior lip – well, it just shows we have to be informed consumers.