Here’s how it works: the pregnant woman’s pelvis is scanned using an MRI.  Then a team creates a 3-D model of the woman’s pelvis, and projects 72 trajectories which simulate how the baby could pass through the pelvis.  Through this process, the team predicts the likelihood that a woman will be able to give birth normally, or that the baby will get “stuck” in the pelvis or need forceps/vacuum to assist the delivery.  Based on the information gained from the simulator, the obstetrician can then suggest to the woman that she elect to have a planned c-section, avoiding hours and hours of labor which end in an “emergency” c-section.

What is wrong with this scenario?  If the simulator is able to predict which women will end up needing c-sections as consistently as researchers claim, wouldn’t this be a good thing?

I vote no.  There are important variables that the MRI and the simulator cannot measure.  They cannot measure the power of the birth process itself.  Birth is more than just measuring the baby’s head and the width of the pelvic opening from multiple angles, and deciding it won’t fit.

Birth is also about the passion and heart of the laboring mother.  I have been privileged to witness many laboring women give birth; women who had previously been told they would never be able to birth vaginally.  Patience, trust in her body to be able to birth, working with the sensations of labor rather than deadening them–all of these factors can help a woman to give birth normally.

Birth is about the efforts of the baby to help itself be born.   As any midwife who has assisted at the birth of a stillborn infant can attest, a living baby does much to help itself be born.  The baby moves not just its body, but its head, in order to find the best fit.  I have seen babies at crowning, still moving their heads to wiggle their way out.

Birth is about the power of the female body to give birth when allowed to do so.  An arbitrary time limit of two hours for pushing may not be enough for many babies’ little heads to mold adequately to fit through the pelvis.  The longest second stage of labor I have ever assisted with lasted seven hours.  The woman was determined to birth her baby normally.  Her spirits and courage were high throughout the process.  She listened to her body, resting for intervals, and then resuming pushing when she felt the urge.  Gradually, oh so gradually, the baby’s head molded and inched its way through the pelvis.  I kept careful watch on both mother and baby’s vital signs.  Both were perfect throughout the seven hour second stage, and she continued to slowly make progress.  Imagine this woman’s feeling of triumph as she finally pushed her baby into the world.  Can a simulator capture that?

Birth is, finally, about the process.  So many of the interventions we have created to “help” birth move along actually hinder it.  Breaking the water artificially may create additional pressure on the baby’s head, leading to fetal distress and and “emergency” c-section to remedy the disaster we created.  Keeping women immobile so we can monitor them continually may lead to a multitude of problems from decreased blood flow to the baby and increased pain for the mother, to an epidural and vacuum delivery because the immobilized woman cannot push the baby out as quickly as we would like.  Constantly intruding on the woman’s privacy during labor in order to monitor her, ask questions for the electronic chart, check her blood pressure, and a myriad of other interruptions, can affect the ability of birth to progress normally.  This then leads to further interventions, such as pitocin, to stimulate the labor that we stalled by intruding on it.  A simulator cannot project the effect that a gentle, respectful, and non-intrusive caregiver can have on keeping the birth process normal, and optimizing the conditions for the baby to be born.

It is indisputable that some births can take place more safely by cesarean delivery.  For that option, I am grateful.  I would not want to be a midwife in the bygone days when there was no recourse but to watch a woman or baby die before your eyes.  We must remember, though, that those instances are truly rare.  For example, the Farm has achieved stellar out-of-hospital birth statistics with a cesarean rate hovering around 2%.  Yet their babies and mothers have better outcomes than the national averages for babies and mothers born in the hospital.   The cesarean births that have occurred with the Farm clients have mostly been for indisputable emergencies, such as a prolapsed cord, or a complete placenta previa.  For the rest of the difficult births, patience and supportive midwifery care have resulted in enviable outcomes.  I wonder how many of the women who have birthed at the Farm would have had a planned c-section recommended to them had they utilized the birth simulator?

Birth is a mystery.  There are many aspects to the process that we still cannot define or know.  Science can only take us so far in predicting outcomes, and the variables it cannot measure or define, are, I suspect, the most critical in determining the birth outcome.

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This reader recently had an amazing birth experience, especially considering the size of her first and second babies.  She reports having seen a chiropractor every 2 weeks during her second pregnancy, and maintaining a good posture for optimal fetal positioning.  Here is her inspiring story: 

Backstory: I was told at the end of my long, very dysfunctional labor with DS1 that ended in c-section that I would never birth a baby vaginally due to an extremely prominent sacral promontory. DS1 weighed a bit less than 5 lbs.

DS2’s VBAC: At 41+4 days, I found I had dilated from a 1.5 in my previous two appointments to 3 cm and was 80% effaced and baby had dropped down to a -1. The CNM did an “aggressive sweep” that produced the desired contractions a couple hours later. I labored at home all afternoon, calling my mom around 3 p.m. to tell her this “might” be it and asking her to come on to the city to take care of my toddler. She said she would, but then called back a few minutes later saying that my dad suggested she just come up and get my son and take him back to my parents’ because my dad didn’t think I was really in labor. I was not very nice and told her I SAID I wanted her now. She said she’d be there. I got in the bathtub to see if it would kill the contractions; it didn’t, but it sure did feel good. My husband arrived home sometime around 4, and I told him I’d been contracting all afternoon and that I’d called my mom because this might be it. I think it freaked him out a little—he worked on keeping my son away from me so I could concentrate on contractions and got his shower and packed up the car. I spent a couple hours laying in the dark bedroom listening to my Hypnobabies tracks. Breathing through the contractions was working fine, and I was trying to get mentally prepared. I alerted my doula that I’d been having pretty decent contractions since noon, and they seemed to be getting closer (they started about 5 mins apart). I noticed that I often had a smaller contraction immediately after a “major” contraction ended, which I was a bit confused about how to time. Little did I know that pattern was only going to get worse…. My doula wanted me to get up and walk if I could, but I didn’t like how intense the contractions got when I did that, so I mostly stayed in bed. Got back in the bath for a while thinking it might be the last time for a while. After I got out, the contractions were stronger and I started wanting to moan through them instead of just breathing. I decided that I was about to pass the point when I was going to be able to deal with the triage rigmarole at the hospital so made the call to go in—it was about 9:30 p.m. when we left. At triage (which was as much fun as I remembered from last time—I answered the question, “Has your water broken?” at least 4 times, twice to the same person), I found out I was 5 cm and 90% effaced with a bulging bag of waters (not that this fact being noted in my chart stopped them from asking if they’d broken a couple more times…). I was a little disappointed that I wasn’t further along, but glad to hear I was in active labor. It took less than 12 hours to get there this time, rather than 30 in my first labor! L&D was having a busy night, the midwife (Deb) particularly. She said Dawn, the CNM I’d seen in the morning, had called and told Deb that she thought she might have sent 3 of us into labor, to watch out. I guess she was right—I was the last of the three to show up.  I was stuck in triage for almost 1.5 hrs. I finally started pitching a fit, demanding that they had to let me out of there because I was hurting too much to be stuck in the bed on the monitors. I was already getting pretty loud during contractions at this point. My doula team had shown up about 30 minutes after we got to triage, and I was so glad they were there—they were already a huge help.

When I finally got moved to a room around 12:30 a.m., the doulas asked what I wanted to do, which was get back in the bathtub if they didn’t think it would slow down contractions. They thought it should be fine, so in I got. I labored in the bathtub for about 3 hours in various positions—at first just reclined, but then my doula wanted to flip me over so I could move a bit more. The pain on hands and knees was horrid without extreme counterpressure on my hips, which was super hard on my knees in the bathtub. It was also really hard on my labor team, I’m sure, but they didn’t complain. It was at this point that I really began noticing the pain/pressure was strongest around my pubic bone—that’s where all my pain would be concentrated the rest of the labor. After about 3 hours in the bath, they needed to do some monitoring of baby, so I got out and got hooked to the telemetry unit. I guess everything looked great because they let me off 20 minutes later. During this time, we did various upright positions—leaning over the birthing ball (I didn’t like), and finally ending up hanging over the bed. I decided I wanted to know how far I was at some point and asked to be checked. I was at 7 cm and 90% effaced, baby still at a -1 with a very bulging bag of waters. I was a bit freaked out at that point because 7 cm is the furthest I ever made it in my first labor. I was afraid of being stuck there forever because I was already hurting so much and didn’t think I could last much longer. We went through a series of several more contractions, mostly with me hanging over the back of the bed (modified squat/hands & knees position) and the team applying counterpressure to my hips and shoulders. At this point contractions were coming so close together that I could barely get moved to try any new positions. Every once in a while I’d get a nice, long 2-3 minute break, which felt heavenly, but usually because I was double/triple peaking, I’d just have a bit of a letdown at the end of a big contraction and then head right into the next one. It was mentally exhausting, and I was doing a lot of yelling. I’m sure I was scaring passersby and the people next door! I told my doula I didn’t think I could hang on much longer—would breaking my water speed things up? She said it would put different pressure on the cervix, so it definitely could get things moving. I said I was scared of trapping baby in a bad position and that the pain would get worse but not speed up. Then I had another contraction and decided I was desperate enough to go for it! We called Deb in, and she broke my water, still with me  hanging over the back of the bed. (She was REALLY great about figuring out how to work with whatever crazy position I was in.) She checked me after she broke my water, and said I was an 8-9 and that baby was at a +1. I asked if the baby had passed the sacral promontory yet, and she said he had. I cried then because I knew I’d passed the point of problem in my first labor. Breaking my water definitely increased the strength of the feeling and did not alleviate any of the pubic pain as I’d hoped. The CNM didn’t leave at this point, but just hung back through a couple of contractions, and then I think asked to check me again (this part’s a little fuzzy); I think I was trying to lay down so she could check me, when a contraction hit, and I landed at a crazy angle with one half of me angling off the half-broken down bed. She checked and said I was pretty much complete and that if I felt like pushing I could. I did not have an urge to push at that point, but I did want Deb to get her hand out of my cervix (I think she was pushing back a bit of cervical lip) and did a bit of yelling at her about that.   A contraction or two later, I was getting the urge to push, and everyone was yelling at me to push, but I yelled back that I didn’t want to, and that I was afraid to push. It didn’t help that I had tried a push and really couldn’t tell what I was supposed to be doing. None of their directions were making sense to me, and I didn’t feel like there was any way for me to get a big breath like they were telling me to do. I was also remembering what Hypnobabies teaches about breathing your baby down, and I thought that sounded really nice at that point (not requiring any work from me!), but everyone was yelling at me that I *had* to push. Also at some point in here, I asked if the baby was far enough for me to touch his head, but when I did, it completely freaked me out because everything just felt so swollen and different. My lizard brain was definitely a bit traumatized by that (rationally, I know this has to happen…). The midwife offered me a mirror to see, and I pretty much shrieked “NOOOO.” It’s funny because I thought I would really like to see/feel what crowning looked like, but not at all when it came down to it! There was also a lot of yelling that I couldn’t do it at this point. Everyone was very reassuring and encouraging that I was doing it—it was almost done if I’d just give a couple of pushes. My doula got the idea of having me play tug of war with a towel; appealing to the aggressive side of my nature turned out to be a stroke of genius. Holding on to the towel, I finally figured out how/where I was supposed to be pushing, and moved him pretty effectively. This was all done in a modified lithotomy position (which was not chosen or directed, just how I happened to crash on the bed when Deb wanted to check me earlier), with one knee pushed way back (and not on the bed) and the other leg stretched out straight. One of the last contractions no one was ready for, and I yelled because no one was pushing my knee back (the counterpressure felt good to me) and my doula wasn’t there with the towel. Deb did some perineal massage/support that was not feeling good to me at all, and I yelled at her that she was ripping me apart (but my husband says she wasn’t even doing anything at that point, so I assume I was just feeling the baby). She held baby back through a push or two to try to get things stretched out a bit, and then when she let go, I pushed and he squirted out completely, head and all around 4:46 a.m. 

Not having pushed before and not knowing what I was feeling, I was terrified during the pushing phase because I kept remembering that average for a first-timer pushing is 2 hours, and I just didn’t see how I could possibly keep it up that long or longer. Little did I know it would only take 4 or 5 good pushes to get him out. Thankfully my evil multi-peak contraction pattern became more normal and lengthened out a bit during pushing so that I usually got a couple- minute break to catch my breath between them. I think it was only about 45 minutes from the time the midwife broke my water to the birth, so it all happened relatively quickly.

I got immediate skin-to-skin contact with my baby, delayed cord clamping, and even no pit for delivery of placenta! I realized later that my heplock was never used. I am a bit regretful of ending up in the lithotomy position (though you couldn’t have paid me to move at the time) because I ended up with a 2^nd degree tear, and I wonder if it might have been at least partially avoided had I been in a better position. This baby was 8 lbs, 22 inches, head circ. 13.5 in. I told Deb she needed to tell Dr. ____ (who did my c/s with #1) that she was wrong about me never birthing a baby vaginally. I was elated and in a little bit of disbelief that I had done it and that everything had gone so perfectly. I am assuming since I didn’t hear otherwise that baby never had a remotely concerning heart pattern, a sharp contrast to my first labor where the monitor alerts went off almost continually during the last 12 hours.

All in all, it was a very good experience, though it was much more intense than I had imagined, and I will admit, when I was in transition, I definitely had thoughts of “why didn’t I just have a repeat c/s??” running through my head. It was worth it. I felt great as soon as the baby was out, and I didn’t go to sleep till 7 or 8 hours later (one of my big regrets with my first delivery is that I saw him for about 15 mins after he was born and then spent the next half-day sleeping). Baby was nursing within the first 5 minutes and was alert and looking around for about an hour after birth.

My doula team (doula and back-up/doula-in-training) and husband were fabulous. I required a LOT of physical work from them, and I can’t imagine trying to have done it without them. I know that I would have ended up with an epidural if I hadn’t had them to massage/apply pressure for me during contractions. Also of note was that I had a completely clueless nurse, who apparently had JUST started the job (considering she needed help putting on the monitoring systems, etc.). She clearly had never worked with a woman laboring without pain medication as she never seemed to have a clue that it was inappropriate to question me when I was yelling through a contraction. I don’t know why she kept doing it, since I never answered her till it was through! She also tried to put the monitor on me while I was in the middle of a contraction just before I had my water broken and didn’t have the sense to wait till it was over to try and put it on. I was yelling through the middle, and she started trying to buckle me in. I took a break from my contraction yelling and snarled at her to wait until the contraction was over. It was a good thing for her that I was physically incapacitated during the contractions or she might have gotten more than just yelled at. (Truly, I have never had so many fantasies of doing bodily harm to other people as I did that night with the triage nurses and my L&D nurse.) Recovery from this delivery isn’t even in the same ballpark as from the c/s. While I have perineal pain from the tearing and stitches, I was able to get up within an hour after birth, and I can get myself out of the bed without help, and I am not living in fear of my energetic toddler jumping on an incision in my belly. VBACing was definitely worth it!

I am so inspired to hear stories of strong women like this who believe in their ability to birth normally.  I hope some woman reading this story will also be inspired to give normal birth a chance.

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]]> http://birthsen.tmdhosting930.com/?feed=rss2&p=1669 3 http://birthsen.tmdhosting930.com/?p=1665 http://birthsen.tmdhosting930.com/?p=1665#comments Mon, 03 Oct 2011 18:43:58 +0000 Birth Sense http://birthsen.tmdhosting930.com/?p=1665 Continue reading →]]> After years of recommending a large episiotomy for management of shoulder dystocia, the American Journal of Obstetrics and Gynecology (AJOG) has published a study that found episiotomy had no benefit in reducing brachial plexus injuries of the infant.  Shoulder dystocia is a condition where the baby’s upper shoulder, after the birth of the head, becomes stuck behind the pubic bone and difficult or impossible to release.  The brachial plexus consists of a number of nerves that control the motion of the arm and shoulder.  Severe injury can result in a deformed arm that is basically non-functional, while the more common, milder injuries can cause temporary paralysis or decreased movement, but gradually return to normal function.

The traditionally taught steps for managing a shoulder dystocia have always included cutting a large episiotomy.  Some entities even recommend a “procto-episiotomy”, which extends through the anal sphincter.  Every class I have ever attended on management of shoulder dystocia has emphasized episiotomy as a legal protection for the provider.  Many physicians will openly admit that episiotomy does nothing to help facilitate the delivery of a baby with shoulder dystocia, because it is not a tissue problem, but a bone problem.  The shoulder is stuck behind bone, and cutting the woman’s perineal tissue does not resolve the problem.  Then why do it?  Most physicians I’ve spoken with admit it is simply a matter of protecting themselves legally: by cutting a large episiotomy, they can show they’ve done everything they could possibly do to try to deliver the baby.

Now, the AJOG studyhas cast doubt on this practice.  As the rate of episiotomy in general declined, so did the frequency with which providers performed episiotomy with a shoulder dystocia.  The investigators conclusion?  “The episiotomy rate with shoulder dystocia dropped from 40% in 1999 to 4% in 2009  with no change in the rate of brachial plexus injuries per 1000 vaginal births.”

The American Academy of Family Practitioners conducts courses called Advanced Life Support in Obstetrics (ALSO).  In their article on management of shoulder dystocia, they mention the Gaskin Maneuver, a non-invasive method of dealing with shoulder dystocia that midwives frequently use, but put it aside as impractical due to the length of time it would take to move a mom to her hands and knees (2-3 minutes) and the immobility problem of many women delivering in US hospitals with epidurals today. 

As a midwife who currently works in a hospital setting, with many “immobile” women, I can assure you that it does not take 2-3 minutes to move a mom to her hands and knees, especially when she knows her baby is stuck.  Additionally, even a fully immobilized woman (and most women with epidurals have some movement of their legs) can be moved by two nurses into a knee-chest position.  I have done this several times in women with epidurals and it took about 30 seconds.  The attitude of some physicians toward the Gaskin manuever simply underscores modern obstetrics’ difficulty with thinking outside the traditional delivery procedures they have been taught. 

However, the AJOG study indicates there are physicians who ar stepping outside the norms of modern obstetrics and bypassing the episiotomy as a set in management of shoulder dystocia.  Will more physicians join them, and jump on the no-episiotomy bandwagon with the results of this new study?  Or will CYA-medicine continue to compel the majority to perform unnecessary surgery on women?

 

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]]> http://birthsen.tmdhosting930.com/?feed=rss2&p=1665 2 http://birthsen.tmdhosting930.com/?p=1661 http://birthsen.tmdhosting930.com/?p=1661#comments Tue, 20 Sep 2011 19:19:25 +0000 Birth Sense http://birthsen.tmdhosting930.com/?p=1661 Continue reading →]]> Induction seems to be on everyone’s radar these days.  From hospitals proudly announcing they will not induce a mother for non-medical reasons before 39 weeks (no problem having an elective induction after 39 weeks, though!), to medical groups urging ever-earlier induction deadlines, pregnant women have a lot to consider.

For every woman who waxes poetic about her marvellous induction, there are three who had a more difficult birth experience than necessary because of an induction.  What makes for an “easy” induction?  Physicians like to talk about a “favorable” cervix, meaning that the cervix is ready for labor.  They have even developed a chart by which they can calculate the likelihood that induction of labor will be successful.  This is called the Bishop’s Score:

As you can see, there are multiple factors which predict the ease of induction.  Cervical position, whether the cervix is behind the baby’s head and difficult to reach (posterior), or smack-dab in front of the head and easy to reach (anterior) is assessed first.  The consistency of the cervix is also important.  An “unripe” cervix has the texture of the tip of your nose.  A ripe cervix can feel as mushy as  cooked oatmeal.  Effacement refers to how much the cervix has thinned.  An uneffaced cervix is can be as much as two inches long.  The cervix must gradually thin to almost paper-thin.  Dilation, of course, refers to the opening of the cervix itself, and station refers to how high or low the baby is the pelvis.  Any minus (-) designation indicates the baby is above the spines of the pelvis where it must engage, and any plus (+) designation indicates the baby is moving below the spines of the pelvis (a small projection on either side of the pelvis, close to your “sit bones”. 

One would think that having a high Bishop’s score, meaning your cervix is soft, thinned out, dilated, and the baby is low in the pelvis, would set you up for an easy induction, right?  What many women are unprepared for is the length of time it can take to actually get labor started, even when they are already significantly dilated.  Consider an induction an acquaintance of mine, Brenda (not her real name), recently experienced.  Brenda was having her fourth baby.  She was already dilated to 4-5 centimeters, her cervix was fairly thinned out and soft, and the baby was engaged in the pelvis.  Her doctor was doing out of town for a conference, so suggested Brenda be induced.  “It will be a piece of cake,” Dr. Alberts said.  “Your cervix is favorable, your last labor was only two hours long, and you get to give birth at the time and day of your choosing.”  Brenda was all for it.  She arrived at the labor ward as instructed at 7:00 a.m. on the designated day, about six days before her official due date.  She chatted with the nurse as her IV was started, and smiled through the pitocin-induced cramps she couldn’t even feel.  Dr. Alberts broke her water shortly after Brenda was admitted, promising that “with your cervix already almost five centimeters, your labor should just take off!”  But it didn’t.  Hours dragged on; afternoon, evening, night.  Brenda wasn’t allowed to eat anything because she was being induced, but she wasn’t in labor!  She was hungry!  She devoured ice chips, trying to quiet her hunger pains.  She was uncomfortable; not in serious pain, but strapped to monitors and unable to reposition herself without the nurse having to adjust everything.  She was tired of her labor room and tired of her bed, and just wanted to go home.  Finally, about midnight, she felt the first contraction that hurt.  Another one followed with only a 30-second break in between.  Brenda describes it as being similar to jumping onto a moving train, and hanging on for dear life.  The next several hours were miserable, and Brenda had more frequent contractions than customary for a normal labor.  The contractions, rather than gradually building and then receding, as in a normal labor, peaked almost instantly, causing Brenda to tense all her muscles just trying to cope with the sudden onset of pain.  Finally, she felt the urge to push and gratefully pushed her baby out.  Would she do it again?  Brenda responds, “I learned that just because my body appears to be ready doesn’t mean it is ready.  There are factors that trigger labor which we don’t yet understand.  I don’t know why it took so long, but my body clearly was not ready for labor.  If I have another baby, I will definitely wait for labor to start on its own–even if my doctor is out of town!  You want to know the ironic thing?  My labor had taken so long to get going, my doctor went home to sleep for a while.  She only lived five minutes from the hospital, but when I finally dilated, I dilated so quickly she missed the birth!”

A while back, I took care of Annie (not her real name) during her labor.  Annie was a first-timer.  She was five days past her due date, and one of my colleagues decided to strip Annie’s membranes.  Annie’s cervix was not favorable in the least.  It was only one centimeter dilated, thick, and felt like the tip of your nose–pretty firm.  It was very painful to strip the membranes, as at one centimeter, the cervix is not open enough to admit the average person’s finger, so it must be manually forced open.  The examiner then runs her finger around the inside of the cervix in a circular motion, peeling the membrane away from the inner part of the cervix.  This is thought to release hormones that trigger labor.  In Annie’s case, she began painful contractions immediately.  Annie really wanted a natural birth, so she waited at home for 12 hours before coming to the hospital, expecting that she would be well dilated after that time.  When she arrived, Annie’s cervix was only 2 centimeters dilated and still thick.  She was in so much pain, however, that she begged to stay at the hospital and get help with coping.  She still did not want medication, so we tried the shower, the jacuzzi, walking, massage, positioning, the birth ball. . .you name it, we tried it.  Annie’s baby was “OP”, an acronym for occiput posterior, meaning the baby’s back is lying along the woman’s back, rather than toward her belly.  This causes intense, often knife-like pain in the back during and between contractions.  None of my tricks were working to turn the baby.  Annie was not dilating, but was having 90-second long contractions every two to three minutes.  She finally asked for an epidural, but the anethesiologist was unable to get the epidural to work, despite repeated tried.  Annie felt every contraction.  Finally, her cervix began to dilate a little, but it still felt very firm and almost lumpy in texture, not soft and stretchy as a “ripe” cervix feels.  After nearly 24 hours of painful labor, Annie finally delivered a beautiful baby girl.  By then she was so exhausted, she could barely hold her baby.  I went home sad, wondering if Annie’s baby would have been in a better position if labor had not been forced to start, but instead begun as the baby moved into the optimal birth position.  I couldn’t help wondering how Annie’s experience might have been if she had been allowed to begin labor on her own, rather than subjected to an aggressive stripping of the membranes with an unripe cervix.  We’ll never know, but I do know some things:

• If you are not in labor, your body is not ready for birth, whether or not you are past your “due date”.
• There are unknown factors involved in the onset of labor.  By forcing labor to start, is it possible we are not allowing critical processes to take place before labor begins?  Perhaps in 100 years, OB providers will shake their heads at our ignorance in inducing labor and missing out on essential factors for health that would otherwise have occured.
• What your cervix is doing is meaningless if you are not having regular, close contractions.  If you are 7 centimeters dilated and are not having contractions, you are not in labor.  If you are past your due date and have not started labor, it is because your body is waiting for important things to occur before labor begins.

Be smart and make your labor as easy on yourself as possible.  Unless there is a medical reason for which it is safer to have the baby out than to continue the pregnancy, don’t agree to an induction, regardless of your cervical dilation.

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]]> http://birthsen.tmdhosting930.com/?feed=rss2&p=1661 10 http://birthsen.tmdhosting930.com/?p=1656 http://birthsen.tmdhosting930.com/?p=1656#comments Thu, 08 Sep 2011 12:30:45 +0000 Birth Sense http://birthsen.tmdhosting930.com/?p=1656 Continue reading →]]> Before we begin any discussion of how to turn a breech baby, it’s essential to consider an important question:  Why is my baby breech?  Is there a reason why it’s best for my baby to be born breech?

Instead of looking at breech birth as a terrible, risky undertaking, we can view it as our ancestors did:  a variation of normal birth, which may require a different approach to birth, but should not automatically be considered cause for a c-section.

How can you tell if your baby is breech?  The most accurate method is by ultrasound, but an experienced practitioner can often detect a breech baby by a combination of feeling your belly to determine baby’s position, listening to where fetal heart tones are the loudest, and doing a cervical exam to feel the baby’s fontanelles (soft spot) on its head.  Even with all of the methods we have to determine breech, some babies still surprise us and the first time we know the baby is breech is when we see a little bottom or foot coming out first, instead of the baby’s scalp.  For this reason, it’s important to look for a provider who is experienced with vaginal breech birth (often a rarity these days).

There are several folk methods that are used to encourage a breech baby to turn.  Some have evidence to support them, and others are simply methods that someone tried and had success with.  Among them are:

• Breech tilt position: some studies have shown this to be effective, but others have not been conclusive
• Using cold on your belly up by the baby’s head to coax baby to move the head downward:  I am not aware of any studies that have been done to investigate whether this works
• Using music (holding a speaker or earphones on your belly just above the pubic bone) to coax baby to move head down toward the music:  I am not aware of any studies that have been done to investigate whether this works
• Walking on your hands in a deep pool:  I am not aware of any studies that have been done to investigate whether this works, although I have had several clients who swore it did the trick for them
• Positioning in the weeks prior to labor (also said to be helpful in preventing babies from being “sunny-side up”, or posterior.  Spinning Babies is a website with lots of information and references.
• Moxibustion:  While some studies have shown evidence for moxibustion’s efficacy in turning a breech baby, the Cochrane collaboration found more research was needed.  See it demonstrated here.
• The Webster technique:  a chiropractic maneuver designed to adjust the pelvis, correctly aligning the uterus, and freeing the baby to move into a better position.  See a demonstration here.
• External cephalic version (ECV):  manually turning the baby to a head-down position with the aid of ultrasound to view where the cord and placenta are.  To see ECV being done, click here.

Laci was a client of mine, and was expecting her first baby.  Two weeks before her due date, I was surprised to find the baby had turned into a breech position.  I was concerned, because it is unusual for a baby to turn so late in the pregnancy, and there wasn’t a lot of room left for the baby to easily maneuver.  I explained to Laci that I did not have experience delivering breech babies vaginally (I have since had that opportunity), and that if the baby did not turn, she would need to give birth in the hospital.  Our state regulations did not permit home breech births.

Laci was understandably upset, because our local OBs did not do breech births except by c-section.  She left my office teary-eyed, stating, “I will get my baby to turn!”

Next week, back for her regular appointment, the baby was head down again! I asked Laci what she’d done to get the baby to turn.  Her answer surprised me:  ”I just talked to my baby and told her she needed to turn so that we could have the peaceful birth we’ve been planning.  I massaged my belly every day and tried to massage her head in the direction I wanted her to turn.  One day I was weeding my garden, and I just felt her flip over!”

While Laci’s experience might not work for everyone, it should encourage us all that a baby can turn even late in the pregnancy.

I have also had a baby turn during labor.  Julie was having her third baby, and typically had very short labors.  She arrived at the hospital 6 centimeters dilated, and while the baby was not particularly low in the pelvis, I could clearly feel it was breech.  I did a quick ultrasound to confirm this, and then was required by hospital policy to let my backup OB know.  He instructed me to prepare Julie for a c-section.  I reluctantly told her what the OB had said, and we discussed her options (refusing the c-section, etc.)

Julie was scared of trying to deliver a vaginal breech, especially after the labor nurse shared a few horror stories, so we went ahead with preparation for a c-section.  Before we even rolled back to the operating room, Julie suddenly said, “I feel something different!  Lots of pressure”.  I quickly checked her cervix and was sure I felt the baby’s head down now.  Double check with the ultrasound again–and the baby was indeed head down.  We went ahead with a normal birth a half an hour later.

In my next post, I’ll discuss the vaginal breech birth option.  Some breech babies just won’t turn, and for some of them, a vaginal delivery may be a good choice.

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Your placenta does not stop functioning on your due date.

Let’s summarize what we’ve discussed so far:

• Due dates are based on a 28-day menstrual cycle, and assume the woman ovulates on day 14
• Ultrasounds are believed to be accurate within 7 days if done in the first 13 weeks of pregnancy; accurate to 10 days if done between 13-27 weeks of pregnancy; and increasingly inaccurate for establishing a due date beyond that point.  As a general rule, the earlier the ultrasound is performed, the more accurate it is for establishing a due date.
• Providers are increasingly wanting to have babies delivered by 41 weeks’ gestation.
• The average length of pregnancy for first-timers is eight days longer than the traditional 280 days (40 weeks).

Lidia had a history of overdue pregnancies.  Now pregnant with her fifth child, she planned a natural hospital birth.  Yet as 41 weeks approached, her doctor began dropping hints about “nudging things along”.  Lidia agreed to a vaginal exam, and was told that her cervix had not begun to thin out, soften, or dilate–all indicators that labor may happen soon.  The doctor wanted to insert prostaglandin gel into Lidia’s cervix to “ripen” it and hopefully prepare her for spontaneous labor.  Lidia did not consent, as she correctly believed that this type of intervention would put her a greater risk for further interventions and complications.

Next, her doctor began presenting her with scary statistics.  The incidence of still born babies increases after 41 weeks.  Her baby was more likely to have meconium in the fluid.  He became more and more persistent, despite Lidia’s calm assurance that her baby was doing just fine and would come when ready.

The doctor wanted her to have twice-weekly non-stress tests and biophysical profile tests.  The first involves spending 20 or more minutes strapped to a fetal monitor, so a nurse or provider can observe the fetal heart rate for accelerations–increases of 15 beats or more in the baby’s heart rate, that last for 15 seconds or more, and are usually associated with baby movements.  A baby with several accelerations on the monitor strip is a healthy baby.  The biophysical profile involves doing a regular ultrasound, but looking for flexion of the baby’s limbs, breathing motions of the chest, the amount of amniotic fluid, the condition of the placenta, and so on.  The baby is then given a score out of 8 points, with 8/8 being the best, and 7/8 considered very good.  If there is a good biophysical profile along with a good non-stress test, the provider can be reassured the baby is doing quite well.

Just one little problem:  Lidia did not have health insurance, and these tests cost over $1,000 each time they were performed.  She declined the tests, nearly sending her doctor into a fit.  Lidia argued that her baby was very active, and if an active baby on the biophysical profile meant a healthy baby, wouldn’t that be a good indicator that her baby was doing fine?

She continued to walk, rest, eat healthfully, and be observant of her baby’s movements.  When she reached 42 weeks, her doctor told her she could not wait any longer for the baby to come.  He threatened her with dire predictions of fetal injury and death due to the baby growing too large, or complications due to the baby not getting enough nutrition from the aged placenta.  Lidia held firm.  “Are you saying you will not deliver my baby if I come into the hospital in labor in two days?” she asked politely.

The doctor hedged around, but finally acknowledged that he could not force her to enter the hospital, nor could he refuse to deliver her baby if she came in days later in labor, unless he had given her 30 days written notice that he was resigning as her care provider.  Women do have the right to autonomy over their bodies, her admitted reluctantly.

Lidia continued with her usual routine, quietly confident that the best plan was to allow her baby to grow undisturbed until he was ready to be born.  At 42 weeks and 3 days, she woke to mild but regular contractions.  The contractions persisted throughout the day, but did not get stronger.  Lidia went to sleep that night and awoke two hours later in active labor.  She arrived at the hospital just an hour before her healthy, 7.5 pound baby was born.  Although overdue, he did not look late at all by his gestational age assessment. Lidia’s doctor made one parting comment as he walked out the door of her labor room:  “You’re lucky your baby is OK.  You dodged a bullet this time.”

Lidia’s story is one extreme, in contrast to the woman who agrees to an early induction to prevent all sorts of potential problems.  There are several steps you can take, however, to avoid this type of conflict all together:

• Keep track of your menstrual cycles, and learn to chart your fertility signals.  Most women I see in my practice do not know for sure the day of their last menstrual period.  Writing it down ensures that there are no mistakes.  Keeping track of cycles for a period of time before you try to get pregnant ensures that you know if your cycles are regular, consistent, and how long they normally last.  Two great books to help you become familiar with when you ovulate are Your Fertility Signals and Taking Charge of Your Fertility
• If you are trying to get pregnant, stock up on a few home pregnancy tests.  Make sure the box states that the test is accurate on the first day of the missed period, or even a day or two earlier.  Write down the first day you get a positive result, even if it is a very faint positive.  The earlier a positive test result is received, the more useful it is for establishing a due date.
• If you have irregular periods and are trying to get pregnant, take a pregnancy test once a week.  This will avoid the risk of being several weeks pregnant before you realize it.
• If you have irregular cycles, your last period was very short and light, or you do not know when you menstruated, consider an early ultrasound to help establish a due date.
• Remember that it is average for a first baby to be about eight days “overdue” and a second or later baby to be about three days late.  This probably reflects the actual normal length of gestation, not a baby truly being overdue.
• Understand that if late babies run in your family, you are more likely to have a late baby.
• Determine your position ahead of time.  Will you agree to an induction at 41 weeks or sooner, even if everything is going well?  Do you want to wait for labor to start on its own?  Do your research and decide what you are comfortable with.
• Find a provider who is respectful of the information you provide, and who acknowledges the limits of ultrasound. If your provider is not a team player, look for someone else early in your pregnancy.
• Most of all, remember a due date is NOT an expiration date.  Your placenta will not suddenly stop functioning on your due date.  There are factors that stimulate labor which we do not understand.  Consider the wisdom of trusting your body and your baby to know when it’s time.

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