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Where is the pelvis? The Importance of an Upright Pelvis in Birth

We often ask, “Where is the baby?” in a pregnant woman, but even more important is the question “Where is the pelvis?”  A new vision is urgently needed in birth.  Anatomically, babies are supposed to be born “out the back.”  In the diagram here of a woman on a bike, note that even in an upright position, small movements in posture affect the angles between the spine and the pelvis.  The arrows depict the direction in which the baby will be born. Today, most women are lying on their backs birthing their babies “out the front” which makes birth more difficult.  Anatomically, babies are supposed to be born “out the back.”

Even though we are not always aware of it, our bodies are always in constant motion with the heart beating, lungs breathing, and blood vessels carrying precious nutrients throughout the body and excreting what is not needed.  Gravity plays an important role in these processes.  Even a newborn needs to start learning anti-gravity positions to start the process of being upright and eventually creeping and walking.  The human body wants to be upright and active to function efficiently.  This includes birthing a baby.

We have gravity because of the dynamic equilibrium of the Earth moving around the sun. The speed with which this happens creates a centrifugal force that balances the gravitational force between the Sun and the Earth.  Gravity is so important to our very existence that astronauts in space need to exercise at least two and a half hours each day to give the body a sense of weight-bearing.

It is much easier and more comfortable to defecate in upright positions.  In the same way, it is easier and more comfortable to birth our babies when the pelvis and the organs within it are in upright positions.  Just picture a section of a water hose held upward at either end.  If this was the birth canal, imagine how much more difficult it would be to have to push the baby up against gravity to be born – yet this is exactly what most women do!  They are lying on their backs with knees pulled up and out making birth much more difficult.  How much easier it would be to turn around onto hands and knees or on knees leaning over a birthing ball or pillows on a chair, or lying sideways with the pelvis shifted forward, or even standing, allowing gravity to be their friend!

Standing, holding onto a rope and taking weight off the feet offers a very important aspect of giving birth not much talked about.  This is the effect of stretch receptors feeling the stretch upward on the upper body.  It is helpful in labor to have the forces going up balancing the forces going down.  It is believed that stretch receptors actually play a part in signaling a woman’s body to go into labor. Gravity plays a role when giving birth as well.

The way in which a woman in labor postures herself, is likely to affect the way the entire birth may go.  This is because the baby has more space in which to move when the pelvis is tipped forward in upright positions.  This allows the baby to move into advantageous positions to move and rotate through the pelvis and helps to prevent dysfunctional labors.

The pelvis lying down appears very different than the upright pelvis.  Even slight angles forward make a huge difference in terms of how the baby comes out as can be seen in the diagram.   Lying down flat on the back, a woman is lying on her sacrum.  The sacrum needs to move forward and backward which actually changes the available space in the superior and middle inlets.  In an upright position, the pelvis is already, normally in an oblique position, tipped forward.  Add to that the help of gravity assisting the baby in coming down, and a laboring woman moving her body, changing positions, all of which can make labor easier. At the same time, the uterine muscle, itself, is working hard to contract down to help the baby move into the pelvis.  If a woman allows gravity to assist this process  by keeping herself upright or at least with her pelvis forward, she is likely to have a shorter and easier labor.  Of course, add to that the presence of a doula or birth companion so she feels safe, and the experience can be much more positive.

If you have seen women in labor lying down, you may notice something interesting.  This has to do with the Rhombus of Michaelis.  These are a bundle of nerves by the low sacrum that have a role to play in labor.  The baby in an OA or Occiput Anterior position, will flex or bend his head to put pressure on these nerves just before the moment of birth.  The mother will reflexively respond by lifting up her left hip and knee with a slight puffing out in her low back. This opens up the birth canal for birth so the baby can be born “out the back.”  With an epidural, you can see women trying to lift up this part of the back with none or limited ability to do so.

So which way do you want to birth your baby? With gravity or without gravity?  It is as simple as that!  Become familiar with upright, forward leaning positions for labor.  Try them out while pregnant so they become familiar to you.  Then know that these are optimal positions for your labor.  But if you need a rest, sidelying with an anterior or forward pelvis is also a good option.

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WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections1

Just 40 years ago when I first gave birth, a cesarean was still considered an operation done only for specific life-threatening conditions as well as when having had a prior cesarean.   Today, it has become an accepted, if not almost routine, way of giving birth.  What has caused this significant and disturbing trend?  Concerns about the sustained and unprecedented world-wide rise of cesarean section has prompted the World Health Organization to issue this report.  In the “WHO Recommendations Non-clinical Interventions to Reduce Unnecessary Caesarean Sections, they stated, “This is a major public health concern. There is an urgent need for evidence-based guidance to address the trend.” Their report was based on evidence of the effectiveness of interventions from an updated Cochrane review of 29 studies.

The importance of this WHO report is that it represents the first global guidelines of a clinical encounter between a health-care provider and pregnant woman in the context of patient care. The purpose of the study is to “provide evidence-based recommendations on non-clinical interventions that are designed to reduce cesarean section rates.” Their report acknowledges that a cesarean is a surgical procedure that when necessary can prevent maternal and newborn mortality when medically indicated.  However, beyond a certain threshold at risk, may result in increased maternal and perinatal morbidity along with both short and long-term health risks that may extend for decades beyond.  This in turn results in substantial increases in health-care costs, morbidity, and mortality for mothers and babies.

In the USA, about one in three births result in a cesarean, having increased dramatically from 5% in 1970 to over 32% in 2016. Today.  it seems to matter what country you are born in and in the USA, which state you live in. In the USA it is better to be born in Utah (22.3%), Idaho (21.9%), New Mexico (24.8%),  Alaska (23%) or Hawaii (25.2%) versus Mississippi topping the list at 38.2% or Louisiana (37.5%), Florida (37.4%), West Virginia (34.9%), NJ (36.2%) or Connecticut (35.4%).

Internationally, Finland has a low cesarean rate of about 16% of births and the UK’s rate is about 24%. Brazil tops the list at more than 50% with even higher rates in private sectors.  Latin America and the Caribbean follow with high cesarean birth rates at 40.5% and North America (32.3%) ranging down to Asia (19.2%) and the lowest in Africa (7.3%).

When cesarean rates vary to this degree, it must be due in part to how birth is managed rather than birth itself. The international health-care community has considered the ideal rate for caesarean section to be between 10% and 15%.  WHO concluded that “at the (global) population level, cesarean rates above 10% were not associated with reductions in rates of maternal and newborn mortality.”

The WHO report acknowledges that although societal changes such as increases in obesity, multiple pregnancies and older pregnant women have contributed to the increased cesarean rate, these are unlikely to explain the variance  of cesarean section rates between various countries or states.  Other non-clinical factors such as women wanting to plan their birth dates, physician factors, malpractice fears, and other economic and social factors are also implicated in the high variability of cesarean rates.

We know today that there are many non-clinical interventions that have proven to be successful in labor and birth but which are underutilized by most women, birth professionals, and facilitators.  These include warm water, optimal pelvic positioning,  the presence of a birth companion or doula, massage, speaking encouraging words, and keeping a positive and private environment.   On the contrary, medical intervention rates are very high with for example a 75% rate of epidural anesthesia and other obstetrical drugs to control pain.

In the WHO report, recommendations to reduce cesarean targeted women, health care professionals, and health organizations, facilities, or systems.

For women

  • Education that addresses fear of pain, advantages and disadvantages of cesarean sections and vaginal birth, risks and benefits of pain relief techniques and obstetrical drugs, and guidelines for indications and contraindications of cesarean sections.
  • Relaxation training and stress reduction programs conducted by nurses
  • Couple-based prevention programs that are inclusive and provide problem solving suggestions, mutual support strategies, and conflict management.
  • Psycho-education for women who fear childbirth itself and that address topics such as normalization of individual reactions, stages of labor, hospital routines, birth process, and pain relief.

For Health-Care Professionals

  • Implement “evidence-based clinical practice guidelines combined with structured, mandatory second opinion for cesarean section” in settings with adequate resources and senior clinicians.
  • Implement “evidence-based clinical practice guidelines, cesarean section audits and timely feedback to health-care professionals.”

Health Organizations, Facilities or Systems

  • Establish a collaborative midwifery-obstetrician model of care where the model of staffing is based on care provided primarily by midwives with 24-hour back-up from an obstetrician who provides in-house labor and delivery coverage.
  • Establish financial strategies such equalizing physician fees for cesarean and vaginal births.

The highest level of certainty evidence was the recommendations for health-care professionals where accountability was required.  Interventions in labor and birth need to be guided by the basic premise that if the harms clearly outweigh the benefits for valued outcomes, they should not be used.

The WHO report stated that women find learning new information about birth to be empowering  but it should not provoke anxiety.  Women want emotional support alongside the communication of facts and figures about birth. But interestingly, there seemed to be no differences in cesarean rates based on computer-based decision aids, booklets, role play vs lecture for women with fear of childbirth, or educational brochures in spite of the fact that women seemed to want such things.

They did not see differences among various ways to present the childbirth information, but none of the discussed formats for learning included an experiential and emotional preparation for birth that is based on basic human values as is available in BirthWorks.

BirthWorks childbirth preparation is designed to build confidence for birth.  We offer a broader systems approach to childbirth that is based on a foundation of human values where optimal pelvic positioning is key.  Women learn how to work with their bodies in labor, knowing that the knowledge about how to give birth is already born within every woman.  Included are also identifying beliefs and releasing fears thus re-framing them to a positive experience,  the role of hormones and the value of the microbiome as well as the importance of mother-baby skin-to-skin contact, mother-daughter relationships, the value of doulas, and grieving and healing.  Classes are interactive and a place of joy and learning which is what the experience of birth can be.  BirthWorks childbirth preparation builds confidence and decreases fear through the integration of mind, body, and spirit.

Reference:

  1. World Health Organization 2018. This report is available under the Creative Commons Attribution –NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO, https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
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Reflections From A Mom With Multiples

Taking care of one baby is a lot of work.  New moms often say they were busy all day but don’t exactly remember what they did!  Just imagine taking care of newborn twins or triplets!  I am a BirthWorks Mentor and one of my students, Sienna Morrow, who is in the BirthWorks Postpartum Doula Program sent a response to the question below that brought me to tears as it made me remember my own experience with my twins.

Question:  When is a baby considered to be premature?  List five main concerns a new mother with multiples might have in the first few months at home and how you would address them.

She wrote:

  • A baby is considered premature if born before 37 weeks.
  • A mother with multiples might be concerned with getting adequate sleep, breastfeeding two babies (tandem), creating a routine that works for both babies, bonding with each baby, and having enough support.
  • I would encourage the mother to tune into the babies and create a routine that works for all of them together by helping her process how things go throughout the days and areas where she is struggling.
  • I would help her connect to groups of moms of multiples in her area and give her time to have conversations with her partner about how they can support one another.
  • I would address any breastfeeding concerns that she has and build up her confidence with praise and words of wisdom.
  • I would also help her explore her own resources and discover things she can do to build a support network in her current situation.”

I, myself, gave birth to my twin boys at 38 weeks and 6 days so they were not premies. I breastfed my boys 21 of 24 hours the first day, and then it was like 16 hours a day until we all learned to tandem feed. I felt stuck in my primal brain for weeks, almost like having no awareness of being human most of the time.  As I reflect back on the experience, I am laughing, remembering some of my chimpanzee robotic-like thoughts that were running through my head during that time:

  • Feed next baby, get other one, feed other….fall down and sleep…are they both safe? …zzz…wake up! Baby must eat…
  • I starving, ravenous, soooo thirsty, give me water
  • Bladder bursting, need to pee
  • Need shower, crusty, smelly, sweaty, sticky
  • Where is Annalissa? (That’s my daughter who just turned four.  This thought would come with adrenaline as I was falling asleep feeding some baby boy – not sure who it was half the time, didn’t care, trusted my husband who rotated them.

These thoughts just repeated over and over, like the film “Groundhog Day”, until around four months.  Then, I woke up, like from a dream, checked we were all alive and when we were, I sighed deeply.

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Creating Sacred Space for Birthing

Guest Post By Bethany Hays, MD

We are the guardians of the most sacred moment in the lives of women and their families, with implications for the long term health of both. That moment is when nine months of hopes, anxiety, planning, purchasing, celebrating, putting up with being uncomfortable, being too big, being not big enough, being in pain becomes separation, relief, responsibility, and falling in love.

Continue reading Creating Sacred Space for Birthing

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BIRTHWORKS FOR NEW ZEALAND’S YOUNG PARENTS

By Rosemary Joyce                                                                                                                                                                                                                                                                                                       January 2015

New Years day saw people celebrating a fresh start the world over. But in Canterbury, New Zealand, the birthing community was celebrating for a different reason. The 1st of January 2015 marked the first day of district health board funding for young expectant parents to do BirthWorks with The Birthing Room, through The Youth Alive Trust. And this is worth celebrating for multiple reasons! Whilst The Birthing Room has been facilitating BirthWorks in Canterbury since 2013, it is the first time the NZ government has actually funded a completely different kind of antenatal education (i.e. one that differs from the medical model). So it is the first time parents in NZ have been able to do BirthWorks for FREE. And BirthWorks changes lives!

The excitement and support from the midwifery community has been wonderful. Midwives are really looking forward to young expectant parents receiving positive, empowering messages about birth. They believe this not only sets up young people for a positive birth experience, but also on a life altering path of good self esteem and gentle, loving parenting.

In February midwives, family doctors, and school and sexual health nurses will be welcomed to an introductory evening of BirthWorks. This will be a special opportunity for key health professions to ask questions, hear from other’s experiences of BirthWorks, and see what the future holds for Cantabrian young parents.

The Youth Alive Trust’s antenatal education for young expectant parents is called BUMP. As well as BirthWorks with The Birthing Room, the BUMP journey includes antenatal exercise, budget advice, nutrition and cooking skills, breastfeeding support, postnatal playgroups, and a mentor throughout each parent’s pregnancy and early parenting journey. The first BUMP course begins on March 31st.

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We Must Do More to Honor Birth as a Peak Life Experience

by Molly Wales, CCE(BWI)

Excerpts from a talk given on Labor Day Weekend, 2012, at the Unitarian Universalist Fellowship of Athens, Ohio.

Molly with her newborn daughter
 My name is Molly Wales.  I am the director of The Birth Circle (a consumer birth group) in Athens, Ohio, and am a BirthWorks childbirth educator.  I’m here today to talk to you about why I believe that we aren’t doing enough in our country to honor birth as a peak life experience.  Perfect for Labor Day!
A short review of where I stand:  I believe that all people are deserving of equal treatment and opportunity.  I believe that a woman is born with the knowledge of how to give birth, and that if Mom can give birth with people who make her feel safe and secure, she’ll be able to follow her instincts and her body and her baby will know just how to work together.  I believe that a woman should have the right to give birth wherever she pleases, with whomever she pleases.  And I believe that birth is a hugely pivotal moment in life, and that the birth experience has a life-long impact on the mother, the child, and on their relationship.
These views do not represent the norm in our society.  Americans, in general, are taught not to trust birth.  Many, if not most, fear it.  And so we keep developing new ways to manipulate and change what already works. And as we force our control like this, the effects are disastrous.
According to a recent Amnesty International report, “The USA spends more than any other country on health care, and more on maternal health than any other type of hospital care. Despite this, women in the USA have a higher risk of dying of pregnancy-related complications than those in 49 other countries, including Kuwait, Bulgaria, and South Korea.”  What?!  WHAT?!  Why is this happening?  What has gone wrong with maternity care in our country?
Imagine a mom has her first visit with her care provider, be it an OB or midwife.  She’s told, “You are capable of having this baby without drugs.  And if that’s what you choose, we will support you in that.  If you or baby needs medical attention, we’ll be here.  But otherwise our job is to let your body do what it was created to do.”  If that were that norm, we wouldn’t be in such a crisis.  Rates of intervention would drop substantially, and our moms and babies would be healthier.
But that isn’t the kind of support that moms in our country generally receive, unless they choose a home birth assisted by a midwife.  Because OBs and hospital-based midwives work under protocol and deadlines that rush the process and place little to no value on the emotional importance of the experience.  Now I don’t mean to say that the OBs and midwives themselves don’t value the experience, necessarily, but rather that they are put under restraints that severely limit what they can do to honor birth as normal and natural, and to work with a mother on her body’s own timeline.
For example:  One of my students recalled going in for her very first visit with her OB, to talk about her exciting new pregnancy.  The doctor told her, “You’ll go into labor, you’ll come to the hospital, and we’ll get you an epidural.”  Notice the commands.  Notice the lack of choice.  Notice the complete failure to acknowledge this mom’s innate ability to give birth to her baby on her own.  In one short sentence, her power was robbed from her.
Or another student, who, while having a perfectly normal labor at the hospital, noticed that everyone in the room kept their eyes fixed on the monitor, telling her when a contraction was coming, telling her how hard it was…when all she wanted, needed, was some eye contact, someone to acknowledge that SHE was doing the work here, and that she was a healthy human mother, not just another illness hooked up to a machine.
And so most moms, at least in our country, never get that chance to realize their own power, that chance to feel accomplished as a mother, right from the very start, those sensations of labor that combine intense vulnerability with unimaginable atomic power.  When a woman gives birth naturally, she has to open up, physically and emotionally, to greet her baby.  It is an incredible start to the mother-child relationship, one of deep bonding, as mom and baby work together through one of life’s greatest challenges.  If we in the U.S., this world power, honored birth as the baby’s start to life-long mental health, and as the mother’s chance to untap her human potential, just think of how we could empower whole generations of women and children.  I remember saying to my little Lola, six short months ago, as I held her there on my living room floor in the darkness of the morning, “We did it, honey, we did it!”  So she was born into that joy, that total soul bearing, that pride.  What an advantage for us both. And I am no extraordinary woman.  Most healthy women are capable of having their babies without medical intervention.  Now certainly homebirth isn’t the right choice for every woman, but imagine what a difference that would make, in our country and in the overall state of our planet, if the majority of mother-baby pairs were trusted, unrushed, and just given a chance to let their bodies work in their own way.
But they aren’t.  Instead most pregnant women in the U.S. are highly uninformed.  They are treated as if their pregnancies are an illness. In labor, they are offered drugs when they should be offered emotional encouragement.  And yes, of course, a healthy baby and healthy mom are the most important things.  But they aren’t the ONLY important things.  There is a chance there for a peak life experience, for both mom and baby, a chance for that relationship to begin with a surge of strength, hormonally and emotionally, that fortifies them for years to come, if not for their whole lives.
In the end, it’s all about creating a peaceful world, isn’t it?  And where better to start, than our barest beginning.