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The Importance of Why

One of the beauties of a strong and vibrant community of birth workers is that our conversations quickly delve into conceptual yet crucial topics such as human rights in birth, the effects of language and persona on confidence, power dynamics in the laboring room.  This talk brings us, as birth professionals, to a higher plane in understanding advocacy and the metaphysical aspects of labor.  However, when we share information with expecting clients, particularly in a group setting, it’s important that we are able to seamlessly shift from our hive minds, as birth workers, into the realm of creating a foundation of knowledge with our clients.

Offering too much all at once, although helpful for some who have researched a lot on their own, may feel overwhelming to expectant parents taking their first birth class.  When people experience information overload, they have a greater tendency to tune out, picking up and processing only bits and pieces, and ultimately feeling excluded from the greater conversation.  As childbirth educators, in order to successfully create a foundation of knowledge, we must understand the information our clients are bringing to the class space and we must assume nothing until we have reason to do so.  When we effectively and collectively have formed a knowledge baseline, we meet the parents where they are and have the ability to elevate them to a place of confidence and a space of safety in exploring their own priorities.  This will eventually help them utilize their rights to informed consent OR refusal, and communicate those preferences to their providers.

A simple online search for a birth plan will turn up all sorts of templates with prompts such as “I would like to…” and options including “walk and sit up during labor,” “avoid an epidural,” “have skin to skin right after birth,” and more.  Knowledge of these options are important and parents have the right to request these things.  However, what I have noticed in teaching birth classes, is that often parents are accepting that these are helpful things to do without having any understanding as to why.  Without knowing why, for example, movement in labor is important, clients are left without the confidence to back these preferences and without the ability to assert that these choices are honored.

As educators, we need to be ready to answer the question, from a research based standpoint as to why epidurals may not be the recommended first option against labor discomfort (and, on the flip side, why in some cases they may be beneficial), why movement and the use of gravity in labor is beneficial, why skin to skin has benefits for both the new parent(s) and the baby.  The greatest service we can provide our clients is in helping them understand why certain preferences have benefit so that they can make a conscious choice as to their priorities.  When we simply relay information and lay out techniques, we have merely bombarded expectant parents with more information – information they can often get from a simple google search.  By helping them understand the physiological process and how certain preferences may support or detract from that and how they can affect labor and birth, we are truly creating an environment of empowerment and learning.  The art of childbirth education is in the why.

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Profession forum at the BirthWorks Peace in Birth Conference 2019

At our professional forum our speakers commented on the following:

Question #1: What is the most important thing that women need to learn:

Amber Price: They have the power to change anything. One voice can make change. Consumer
demand is important.
Lewis Mehl Madrona: Consumer demand brought the epidural epidemic. If consumer demand
was for fewer epidurals, it would happen. Women need to see birth as a joyful experience and
not a fearful one.
Nancy Wainer: Remind women that their bodies are designed to give birth.
Michel Odent: The most important question to ask today is, “What is the future of humans?”
Obstetrics is trying to neutralize the cesarean section. Most people are looking at the past –
nobody looking at the role of hormones. We must consider another question, “Are we
neutralizing the laws of natural selection by obstetrics?”

Question #2: What will it take to do this? Is the pendulum swinging in a way to create
better outcomes?

Amber Price: Ways to change the world perspective is through the images that are shown in the
media, at baby showers, and other birthing events. We need to change the words we use around
being a woman and women at birth.
Lewis Mehl Madrona: We need more funding for midwives. Studies do count and need to show
the value of midwives. Maybe midwives can get masters and PhDs, do research, and publish.
Nancy Wainer: Have big billboards saying, “I had a natural birth!” Give talks in elementary
schools about natural birth. High schools are too late – we need to reach younger children. In the
media, have TV commercials of “I had a beautiful unmedicated birth!”
Michel Odent: Before asking the question, it is more effective to analyze the current situation.
We are neutralizing the laws of natural selection. Some women give birth easily and some don’t.
Some mothers and babies die. This is the law of natural selection. But today, some give birth
naturally and some by cesarean section. We have neutralized the law of natural selection. We
need to change our way of thinking. The key word is “protection” against factors that cause
stimulation of neocortical activity in labor.
Lewis Mehl Madrona: I believe that today, epigenetics is more important for the natural selection
of genes. Autoimmune disease is now known to be a change in function of the gene. The
environment is a switch that can turn genes on and off.

Michel Odent: The secret is the evolution of evolutionary thinking. Pure genetics is hereditary
but suddenly some traits are acquired in life through epigenetics. We have to enlarge our concept
of evolution. The mother is transporting genes and the microbiome to her baby long term – we
need to think pure genetics.

Question #3: If there was one road block for peace in birth, what would you replace it
with?

Nancy Wainer: Replace the belief that a cesarean section is an okay way to have a baby.
Michel Odent: It depends on your perspective…there are two places to give birth: home and
elsewhere. Both need to be safely available to women.
Amber Price: The biggest impact is for normal birth to be staffed by midwives.
Lewis Mehl Madrona: Have equal payment for equal work.

Question #4: What advice would you give to birth workers? What can they do today?

Lewis Mehl Madrona: Tell positive birth stories wherever you are be it in line at the grocery
store or at Walgreens. Guide them to think positive about birth.
Amber Price: Use a common language with consumers such as RMC or Respectful Maternity
Care.
Michel Odent: Talk with pregnant women. Birth must release hormones; one is oxytocin, the shy
hormone. Talking with them about birth helps them understand what is happening in their
bodies.
Nancy Wainer: Share your joy.

Question #5: Peace in Birth is achieved through….?

Nancy Wainer: Chocolate
Lewis Mehl Madrona: Peace anywhere is achieved through the process of radical acceptance.
When making a judgment, breathe deeply – realize the whole life that person must have
had…send love. I’d be happy to have a doula come talk to my medical residents. Have the
courage to reach out and have conversations.
Ambe Price: First, find the right persons to talk to. Be willing to have casual conversations, one
on one. This is the modality for moving forward. Invite providers into your community. They
will come because they want to learn more. We can’t change a culture from the outside.
Secondly, birth for one woman may be great and for another traumatic. Women are asking for
the image of empowered birth without doing the work of labor. Technology is here to stay.

They need to see positive images of women giving birth. Monday morning quarter backing is
extremely dangerous as in “If I’d been there, she wouldn’t have had a cesarean.”
Gabe Tullier: If you don’t understand what a person is doing to you, get on the same page. That
releases serotonin and brings peace.
Nancy Wainer: Peace comes from doing the best you can do in each moment. We can’t control
everything.

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Newborn Vitamin K – Yes, They Do Need It

By Michelle Chevernet, CCE (BWI)

An Uptick in Refusal

Not too long ago, somebody in a Facebook group I’m in posted a beautiful home birth picture (yay!), with a caption stating something along the lines of “Born at home, in water, lifted him out myself, no eye ointment, no vaccines, no Vitamin K!  Proud natural warrior mama!”  I experienced a moment of alarm.  This may surprise you, being as I had out-of hospital births for all three of my children and am of course very supportive of this “warrior mama’s” water birth.  The part of that post that got me was the “no Vitamin K” battle cry.  I have experienced an uptick in clients asking about Vitamin K refusal.  What is that about?

Throwing the Baby Out with the Bathwater

I believe that we have a couple of things happening here.  One, some parents are so excited to give their child a gentle, “natural” birth, that they choose to refuse anything that comes from modern medicine.  Two, care providers have perhaps done themselves a disservice by grouping eye ointment administration, Hepatitis B vaccination, and Vitamin K administration together in their “newborn procedures” discussions.  The thing is, the science on eye ointment isn’t that great, Hepatitis B isn’t generally an immediate threat to a newborn . . . but Vitamin K administration DOES have very solid research supporting it, and it IS an immediate and severe (if rare) threat to a newborn.

As BirthWorks educators, I believe that we need to be clear when an issue is truly a matter of “preference” and when there is an actual scientific safety concern.  Sometimes I feel that I don’t want to “alienate” parents by taking a research-based position that they may not like to hear, but I do think it is our responsibility.  While I always encourage clients to consider their own wishes in the face of non-evidence-supported birth procedures, the science is clear here.  So, I’ve started giving a more in-depth and explicit treatment of Vitamin K administration, and decided to highlight this concern in the BirthWorks context.  That said, my job is to present the information and facilitate discussion, and not to judge.  If a parent still chooses to decline Vitamin K administration, I would continue to support them.

The following information is based on Rebecca Dekker’s Evidence Based Birth signature article on Vitamin K, and on the Center for Disease Control and the American Academy of Pediatrics’ recommendations.  Please see the hyperlinked sources for greater detail and actual research citations.  This discussion is meant to raise awareness and introduce the topics to parents.

Are Babies “Deficient” in Vitamin K?

In a word, yes.  Humans can’t make Vitamin K, or store it very well.  We get it in our diets, but there’s not very much of it in breast milk.  It does not cross the placenta very well, so even mothers who consume a lot of Vitamin K will have a baby born “deficient,” because all babies are born deficient.  This is not “unnatural”, babies have many immature systems at birth.  However, it is risky to them, just as their immature immune system puts them at risk for illness.  “Natural” does not necessarily equate with “safe”.

What is the Danger?

Babies with Vitamin K deficiency (all of them, unless they get a shot of it within 6 hours after birth) are at risk for bleeding in the intestines, brain and other locations.  Bleeding can be severe, and babies can sustain lifelong injuries or even die.  There are three types of Vitamin K Deficiency Bleeding (VKDB)

  • Early, within the first 24 hours of life. Usually occurs in skin, brain and abdomen.
  • Classical, within days 2-7 of life, most often days 2-3 because that’s when levels have dropped to their lowest but baby isn’t eating enough to replace it. Often occurs in gastrointestinal system, umbilical cord site, skin, nose, and circumcision site.
  • Late, usually during weeks 3-8 of life. Least common but statistically the most serious as far as fatality and severe injuries are concerned.  Often occurs in brain, skin and gastrointestinal tract.  Babies can experience a late bleed up to 6 months after birth.

Does a Baby Have to Experience Trauma to Trigger Bleeding?

I saw a blog post stating that Vitamin K was administered “in case the baby is in a car accident on the way home.”  WRONG!  First of all, even a gentle birth can cause minor bruising in a baby, and if their blood can’t clot, then “minor” can become “major”.  Secondly, case studies of VKDB often find no known cause.  It can be related to the cord stump or circumcision, but more often than not, they just start bleeding and can’t stop.

Does a Vitamin K Shot Work?

Yes, it does!  Infants who receive Vitamin K at birth have almost no chance of getting VKDB.  A study in England in 2013 showed that out of 64 million births in 18 years, only 2 babies who received a Vitamin K injection developed VKDB.  Two.  Out of 64 million.  Comparatively, data from other European countries indicate that with no Vitamin K, VKDB occurs in 4.4-10.5 per 100,000 births.  In Asia, the rate is higher, 1/6000 births, probably due to both dietary and genetic factors.

Are There Side Effects?

No, not any more than with any other injection – pain (which you can mitigate by nursing through the shot) and redness/swelling at the injection site.  There have been NO reported cases of severe allergic reaction, severe injury or fatality from the modern fat-soluble injection form.  (The form given in the 1950’s and 1960’s was less safe.)  So, there are NO reported fatalities from getting the shot, but MANY reported severe injuries or fatalities from VKDB.

Are There Alternatives?

I will point you toward Evidence Based Birth for a more detailed discussion if you are interested, but 1) there is no FDA – approved oral version and 2) the three-dose oral version given sometimes in Europe is less effective.

This is a very brief overview, and I would invite you to read further from reputable scientific sources such as Evidence Based Birth, the Center for Disease Control, and HealthyChildren.org . . . and most importantly, talk to your care providers!  Natural is great, but in this case, science is definitely better.

 

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You Learned to Breathe When You Were Born

by Cathy Daub CCE, CD (BWI)

Do you believe pregnant women need to be taught how to breathe when preparing for their labors?  Just as women are born with the knowledge about how to give birth, so they have also learned to breathe when they were born.  There are a number of concerns about trying to teach breathing techniques to birthing women.

The Primal Brain

The knowledge about how to give birth is in our primal brains.  That is the oldest part of the brain that is back near the cerebellum and brainstem.  Those are the most instinctive parts of our brain that regulate our primal needs such as the heartbeat, sleep, and breathing.  When a woman is in labor, she needs to be in her primal brain so the part of her that knows how to birth can do so without any disturbance from the neocortex or thinking brain that is the outer part of the brain.

Women who are in their primal brain will have the sensations of people and sounds being in the distance.  They will feel, as Michel Odent MD says, as if they are on another planet. They are neither here nor there.  This means they have surrendered to the process of birth and allowing their bodies to birth in an instinctive way.

There is a wonderful story called “The White Room” told to us by Bethany Hays, OB GYN who is on our BirthWorks Board of Advisors.  She was with a woman in birth who was having very strong contractions and had a petrified look on her face with wide panicky eyes.  Bethany walked over to her and simply asked “Where do you want to go?”  The woman just continued staring.  Bethany said, “Wherever that place is, go there now.”  And the woman left.  She was still there but her consciousness had gone elsewhere.  Bethany continued monitoring the heartbeat and all was fine.  Sometime later, the woman started becoming conscious again and was bearing down to birth her baby.

At a follow-up appointment, Bethany asked her, “So where did you go?”  The woman responded, “I went to the white room where my uncle who passed away three years ago, held my hand.”  This woman had an out-of-body experience that was out of space, out of time, but very much possible in the instinctive brain.

 Ways to Disturb the Primal Brain in Labor

Anytime a woman in labor needs to think about something, she is more present in her neocortex or thinking brain.  This is very important information for any doulas or childbirth educators, and any of the birth team. They need to think, “What might I say that will disturb her labor?”  Anytime they ask a question, they are disturbing her labor and her ability to move into her primal brain.  Imagine a doula asking her “Was that contraction stronger than the last one?”  “Would you like to change positions?” “Would you like a glass of water?”  “How are you feeling right now?”  These all have the potential of keeping her out of her instinctive, primal brain that already knows how to give birth.  More silence and working with energy are needed.

Avoiding Breathing Patterns

In BirthWorks, we do not teach breathing patterns for these reasons because a woman who has been taught different breathing patterns for different parts of labor, will be thinking, “Should I use this breathing pattern now, or that one?”  Not only does this disturb her instinctive brain, but it also keeps her from being in touch with her body that already knows how to give birth.  If she can have faith and trust in her body, she will be able to have it be her guide in labor.

For this reason we advocate breathing slowly and deeply throughout labor and not changing this for any specific part of labor.  Slow deep diaphragmatic breathing has so many benefits:

  • Slows down the heart rate and breathing,
  • Fills the lungs more completely with air increasing vital capacity,
  • Calms the mind, increases the secretion of oxytocin, the hormone of love which also stimulates uterine contractions helping labor to progress,
  • Increases confidence and decreases fear in labor.
  • Sends an important message to the body, keeping it more in balance and equilibrium.
  • Keeps her entire body relaxed.
  • Allows her to relax into each contraction so it becomes more effective in dilating her cervix
  • Helps a woman to have more energy for the work of labor.

Other ways to avoid stimulating the neocortex besides asking rational, thinking, logical questions, include keeping lights dim, having privacy which simply means not feeling observed, and not moving from one room to another.

But most importantly, childbirth preparation classes need to emphasize the idea of slow, deep breathing all the way through labor with all the benefits it offers.  Teaching breathing techniques is a way to disturb labor.  When slow, deep breathing is practiced in life, it is also easier to do when in labor.

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The Rhombus of Michaelis

By Cathy Daub with extracts from midwife, Jean Sutton

“The Rhombus of Michaelis?” people ask, “What’s that??”  Most women giving birth have never heard of it before and yet it plays a key part in every birth.  I first heard about it from midwife Jean Sutton in New Zealand.  She went back and studied the old midwifery texts where it was described but now has been largely forgotten in our modern day technological society.

So what is the Rhombus of Michaelis and where is it?  It was identified in the literature as early as 1932 when a New Zealand obstetrician named Corkill discovered an increased space in the outlet of the pelvis during the second stage of labor.  Later, Michel Odent MD identified a possible link to the Rhombus of Michaelis when he described the fetus ejection reflex.  It might also be called the G-spot.

If you take your hand and place it vertically over the low sacrum so your fingers are pointing down towards the gluteal crease, then the flat palm of your hand is right over the Rhombus of Michaelis.  It is in the shape of a kite and includes the three lower lumbar vertebrae, the sacrum and the long ligament that reaches down from the base of the skull to the sacrum.  It is basically a plexus of nerves that serve an important function in labor.

When a pregnant woman is about to give birth, and if her baby is facing towards her spine, the baby’s head will press against the Rhombus of Michaelis nerves causing them to contract and “open her back”  slightly, with the result of hiking her left hip and angling her birth canal towards the back where babies are meant to be born.

Here is a description of the Rhombus of Michaelis as given by Jean:

This wedge-shaped area of bone moves backwards during the second stage of labor and as it moves back, it pushes the wings of the ilea out, increasing the diameters of the pelvis.  We know it’s happening when the woman’s hands reach upwards (to find something to hold onto) , her head goes back and her back arches.  It’s what Shelia Kitzinger was talking about when she recorded Jamaican midwives saying the baby will not be born ‘till the woman opens her back.’   

I’m sure that is what they mean by the ‘opening of the back.’   The reason that the woman’s arms go up is to find something to hold onto as her pelvis is going to become destabilized.  This happens as part of physiological second stage: it’s an integral part of an active normal birth.  If you’re going to have a normal birth, you need to allow the Rhombus of Michaelis to move backwards to give the baby the maximum amount of space to turn his shoulders in.  Although the Rhombus appears high in the pelvis and the lower lumbar spine when it moves backwards, it has the effect of opening the outlet as well.

When women are leaning forward, upright, or on their hands and knees, you will see a lump appear on their back, at and below waist level.  It’s much higher up than you might think; you don’t look for it near her buttocks, you look for it near her waist.  You can also feel it on the woman’s back.  It’s a curved area of tissue that moves up into your hand, or you may suddenly see the mother grasp both sides of the back of her pelvis as the ilea are pushed out and she is suddenly aware of those muscles that have never been stretched before.  Normally, the Rhombus is only out for a matter of minutes, it comes out just as second stage starts, and it’s gone back in again by the time that the baby’s feet are born, in fact, sometimes more quickly than that.

Positions that interfere with movement of the sacrum include:

  • Women lying on their backs with knees pulled up which presses their sacrum down, not allowing it to move.
  • Women with an epidural have their nerve supply interfered with so that the impulse for it to happen is obstructed.

Jean goes on to tell us what pregnant women need to know:

  • If they want a short second stage of labor and don’t want to spend a long time pushing, they need to make sure their pelvis will open to make enough space for the baby. This is perfectly safe so long as they have something to hold onto, and that the contraction of the nerve plexus (Rhombus of Michaelis) will relax as soon as their baby is born.
  • They shouldn’t allow anyone else to move their legs while they are in the second stage of labor because they can feel which way to move their body to give birth. Another person moving their legs may lower the leg in such a way that the pelvis goes back into the “wrong place” – and women in labor who are feeling their contractions will know what this means.
  • Movement of the sacrum has the effect of opening the diameters of the pelvis. Being upright the pelvis has more space in which the baby can move and a woman births with the help of gravity instead of against it.
  • Although epidurals are great for pain relief, they get in the way of a spontaneous second stage and vaginal birth. In many cases, the reason they’ve got an epidural is that the baby wasn’t in the best position when it started, and the baby in the less suitable positions needs all the space he can get to turn around in.
  • The OP (Occiput Posterior) baby needs the Rhombus of Michaelis to move backwards so he has room to turn around so he can come out as an OA (Occiput Anterior)
  • Many women fear damage to their pelvic floor but if they can be in an upright position with their weight forwards so the rhombus is free to move, very little damage is done to their internal anatomy.

Jean summarizes the importance of the Rhombus of Michaelis by saying that:

If midwives want to be assisting women to have as many normal births as possible…to be able to promise women that birth is quite manageable…that they don’t need to have the interventions…that it’s simple and it’s safe, as long as it follows the process, then having the back open is just part of that process.

References:

Sutton J (2000) Birth without active pushing and a physiological second stage of labour.  The Practicing Midwife, Vol 3, No 4. Pp 32-34.

Kitzinger S (1993) Ourselves as Mothers.  Bantam, London.

Corkill TF (1932).  Lectures on Midwifery and Infant Care.  Whitcombe-Toombs, New Zealand.

Oden M (1987) The fetus ejection reflex.  Birth, Vol 14, No 2, pp 104-5.

 

 

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The Media

by Tara Thompson,  Doula Student   BWI

I truly believe the media as a whole does a grave disservice to mothers-to-be when it comes to pregnancy and childbirth. The majority of what we see on television inaccurately portrays birth in ways that leave women feeling fearful and having unrealistic expectations of their upcoming birth. It also misleads society which effects how women are treated in pregnancy and in childbirth. Overall, normal physiological birth in its rawness is very rarely even seen in the media. I believe this has impacted medical treatment in ways that have led to more interventions, as most providers have likely never seen normal birth and have a difficult time applying the lack of familiarity to their practice. Ignorance can lead to fear of the unknown.
Growing up, I loved watching The Learning Channel “TLC” and their shows that I thought depicted real life. They had shows such as “The Baby Story” or “Maternity Ward”. Many of the episodes portrayed birth as painful and I almost always felt as if it was an emergency in need of medical interventions.  This was my first glimpse into birth, and like me, it was likely many other’s first view into “real life” birth.  It was scary!  Fortunately, I have grown to learn, through education and personal experience, that birth is not often an emergency in need of such interventions, but I often wonder how many people still believe these older shows to be a true depiction of childbirth.  How many people lack trust in their body’s and in women.  The introduction and opening credits to the show says it all.  Here is an episode of Maternity Ward:  http://vimeo.com/12675921

An older movie, The Blue Lagoon, was able to allow viewers an opportunity to see an uninterrupted birth being acted out.  Because the plot of the movie was how a boy and a girl would behave naturally without any influence from society, it was able to show that birth could happen naturally.  The film came with its harsh criticism, and or course, it was acting.  I did appreciate the idea of the human capability of giving birth uninterrupted.

The Business of Being Born made huge strides in showing the world what birth could look like.  It was a great way for mass media to reach a larger crowd on the effects of society and medical intervention on birth and its consequences.  It allowed natural birth to have the spotlight without ignoring that emergencies can happen (though not with every birth) and that modern medicine can play a positive role in birth (when it is needed and necessary).  I had already given birth to my first son before I saw this film, but I am not exaggerating by saying it was this film, paired with my instincts that changed my perception on birth.  I gave little thought to the effects of something as simple as hearing a machine beep during labor to having pitocin.  I didn’t think of the impacts of lacking skin-to-skin immediately after birth, even if my gut was telling me I wanted it.  This film put the science and facts behind what has always been instinctual to mothers.  These include being private in labor, limiting stimulation of the frontal lobe, avoiding unnecessary interventions and encouraging the body’s natural hormones to foster labor, coping with labor, and the mother/baby bond that also affects breastfeeding.  While the Business of Being Born was impactful in many ways and arguably showed birth more truthfully, the audience tended to be those who already agreed with the message.  Here is a clip from Monty Python that was used in the film:  https://www.youtube.com/watch?v=arCITMfxvEc.

I find that as a doula, I encourage women to look within for information on childbirth.  Birth is instinctive!  While the media may or may not get childbirth right, it is never beneficial to ignore one’s natural instincts and adhere to what we see on TV.  Trust your body, respect your body and listen to your body.  Most of preparing for childbirth is relearning what we already knew all along, but perhaps the media has led us astray from that.