Wednesday, April 13, 2016

Assessing Progress; the art of knowing when to do something for a birthing woman

Assessment is a necessary and primary skill of baby catchers and health care workers.

Benefits of assessment are that we establish if a motherbaby pair in our care is currently normal, showing all expressions of health or has one or more signs of disease, disfunction, or distress.

The role of assessment when a motherbaby is not expressing health in the best known ways would be to determine if and when to act to return health progress to normal or support what isn't normal for the wellbeing and success of motherbaby health and approximation to normal. Assessment helps us know when to intervene.

Monitoring normal labor is an accepted and worthy activity of the care provider. Fussing about it, is not worthy of the care provider. There is a balance to finding out how mother and baby are doing without disturbing the birth.

The assessor must change her or his way of being perceived by the mother to become non-obtrusive and yet be reassuring when the mother seeks reassurance.

For the benefit of this discussion, let us assume the assessor, midwife, nurse, or doctor, knows how to respect the privacy and hormonal wellbeing of the birthing mother. By feeling that we have a lovely care provider we can turn our focus on to how we assess and what is the perspective Spinning Babies has to offer routine assessment in antepartum (in labor).

The current view on assessment might include: 

  • Mother's vital signs
  • Baby's vital signs
  • Signs of labor progress

Signs of labor progress were well described by Penny Simkin as

  1. Cervix moving forward
  2. Cervix softening (ripening)
  3. Cervix thinning (effacement)
  4. Baby descending
  5. Baby rotating
  6. Cervix opening

The Bishop Score was designed to help providers know whether a pregnant woman is a likely candidate for a successful induction of labor. In other words, trying to get labor started wouldn't likely end in cesarean, although the risk of surgical birth is consistently higher after induction.
Having a Bishop Score of 8 is reassuring of vaginal birth.

March of Dimes warms parents and providers that the last 3 weeks of pregnancy leading to the 40th week are crucial for brain development and inducing even during this time that babies are considered by most to be full term compromises brain development among healthy babies. See March of Dimes At least 39 Weeks.

There are social and emotional assessments by mental health workers (specifically) and providers (generally) for which many are bet successfully by the peer support of a doula. The doula doesn't do medical or midwifery assessments herself, nor does she do medical management tasks. However, the social well being, the medical outcomes and birth satisfaction ratings of doula-supported women are far above women who had midwifery student act as a doula (but lacking the peer-aspect) or family support, even partners who are present. See Cochrane Data base on maternity care practices.
Promoting Positive Mother-Infant Relationships: A Randomized Trial of Community Doula Support For Young Mothers.
Hans SL , Thullen M , Henson LG , Lee H , Edwards RC and Bernstein VJ
Infant mental health journal, 2013, 34(5), 446
Publication Year: 2013

The problem

Assessing cervical dilation as the leading indicator of labor progress reduces attention on the rotation and descent of the baby.

While many providers take an interest in fetal position and may notice if the fetus is remaining high or coming down into the pelvis, current thought sets these observations to the status of a side dish, some diners will like them better than the main dish, but they seldom are the focus of conversation.

Adding pressure to force the cervix open and getting the mother anesthesia as a compromise to her inconvenience is a typical current approach.

If the Bishop Score is favorable, breaking the mother's water may be suggested. An opening to the womb has then occurred with its increased rate of infection. The rising risk of infection leads to policies or protocols to do a cesarean if birth isn't imminent in a limited amount of time, often 24 hours.

Now with the membranes released,  more pressure is often suggested via artificial oxytocin known as Pitocin or Syntocin by intravenous drip (IV). An inexpensive drug may be an alternate,  Misoprostol

may be more effective, but the side effects, if experienced, include maternal and infant death.

Balloon or dried seaweed is also used to pry open the cervix to start labor. And if labor stalls near the end, a manual opening of the cervix is not unusual. Many women experience their midwives pushing the last cm of cervix over baby's head.

When we examine the relationship of anatomy to the progress of labor we add understanding and potential opportunities to allow labor to progress on it's own. I'm not talking about giving more time, though that is a fine idea and often successful.

In this case, motherbaby wellbeing is considered to benefit from intervention. Time was given, or the mother struggles on the verge of suffering, or there is a clear understanding that the baby's position or lack of descent is indicating a variation that deviates from an easy labor pattern.

Spinning Babies contribution to assessment

We will consider that anatomy is more than labeling the geography of the birth organs and passage. There is more to the cervix than being a hole that opens. Cervical ligaments play a role in cervical placement, the available room immediately above the cervix and the ability of the baby's head to apply on to the cervix, as well as ease in opening. Other factors may include collagen fibers, fear, psoas muscle length and tonality (is it long and supple or short and restrictive?), and privacy and safety.

We also look at baby's flexion or extension in the fetal back which may be indicated by head position. The posterior baby is often extended in the spine whereas the anterior baby is more apt to be flexed. Flexion increases moldability and baby's success in helping with the birth process. Shoulder, head, and back movements are more able to respond to increasing space in the pelvis and immediately above the cervix.

We look at pelvic station to see where baby's presenting part is waiting. If baby is high we respond with maternal movements and positions to open the inlet. This seems obvious, but current practices may suggest a squat or a lunge more commonly than a position that opens the top of the pelvis.
More can be learned about opening the pelvis at each layer at the Spinning Babies Workshop or on our Quick Reference download. 

Nicole Morales, CPM and Approved Spinning Babies Trainer muses,
"Some day 'assessment' (if needed at all) will move away from being cervix centric. It starts with us as birth workers asking different questions like Where is the baby in the pelvis? Which might not mean a vag exam but listening to the mother and her contraction pattern and the baby's movement and where she has pain or discomfort or if you can see the head overlapping the pubic bone or what sounds she is making or the shape of the belly or has she eaten or rested, or the location of baby's head in relation to mother. Not that the cervix or potential scar tissue doesn't matter, but it is a shift in perspective. Kind of like the universe revolving around the earth instead of the earth revolving around the sun. All players are important."

Sunday, April 10, 2016

Sacrotuberous Ligament Release

The Sacrotuberous ligament is living tissue that functions to support the pelvis. When flexible the ligament makes way during the fetal ejection reflex when the sacrum shifts outwards making the path of the fetus more roomy for childbirth.

Looking at the back we see the diagonal ligament connect the lower sacrum down to the sitz bones, or ischial tuberosities.

Looking down from the top, we can more easily see the larger sacrotuberous ligament behind the ischiococcygial liagment, also bridging the sciatic notch.
Healthline says this about the ligament: "...largely comprised of collagen fibers and is strong enough to support the sacrum and prevent it against moving from its position under the body weight.
"The connective tissue in this ligament joins with various other tissues, particularly the biceps femoris muscular tendon, which is associated with an important muscle of the hamstrings on the posterior thigh region. It is also a ligament of the sacroiliac joint, which is connected to the sacrum."

The ligament can become short and tight from a sports injury, trauma, and perhaps chronic sitting.

When that happens the ligament will thicken and shorten and the result is pulling the sacrum, tailbone and sitz bones close and tight.

This can pull the top of the pelvis open and the bottom of the pelvis closed.

You know it when the baby engages easily in a good position earlier than usual, like at 8 months, but
the mother's buttocks look more android from behind. Wide hips, small buttocks with the sitz bones close. The round buttocks are not there, they are replaced by narrow buttocks, but it is not about muscle or fat. In this case, "size" is actually shaped by the placement of the bones.

The Sacrotuberous Ligament Release
Body workers understand the benefit to a mild pressure on the ligament for about 2 minutes. You are making a mild stretch, but it is a stretch. The ligament will release and seem to melt away from your fingers.

The pressure isn't strong, but it is quite firm and determined. Firm is not always full strength, you see? But to reach this ligament you have to use arm strength to get your fingers placed on the inner surface. Lift up and away in your "stretch." Your angle is distal and superior; up and away from her tailbone angling towards the hip a little, not straight up.

Some practitioner will get their finger on the inner side and then lift and pulse, 2 seconds on and 2 seconds not "on" in the sense of the pull, but not letting go. I've given up on that because I lose the ligament.

Consider a Sacrotuberous Ligament Release When:
  • Standing Sacral Release isn't mobilizing the pelvis
  • In labor, the baby comes to the midpelvis in Posterior position but can't descend and can't rotate (compare to Open-knee Chest and "Shake the Apple Tree")
  • In labor, you see 1 cm of the baby but descent can't continue (not a perineal issue as the baby isn't truly on the perineum yet)  

Alternative: Logan Basic Chiropractic Technique may be quite helpful and can be done in pregnancy.
For chronic return of the ligament back to the shortened length, in other words, if this doesn't work, add Craniosacral therapy with Myofascial therapy to release the cranials and neck which hold the fascia at the opposite end of the mother.

Dr. Carol Phillips finds Gail's subluxation.
Stephanie Williams, DC, says, "The sacro-tuberous ligament is super important for maintaining sacral/pelvic balance. I would say most Chiropractors probably don't think about the ligament outside of pregnancy, but as a pregnancy Chiro I do. It's really effective for any craniosacral work and is really effective for babies and digestion/colic. Webster trained Chiropractors are trained to check and release the sacrotuberous ligament each time using the Webster Technique.  I usually have the woman/person cough which makes the ligament jump out so its easier to find. It's also usually tight on the opposite side of sacral subluxation / misalignment. "

The Sacrotuberous Ligament Release done alone may last for a couple hours. Repeating it may make it last longer. So if done in pregnancy, repeat in labor.

Tuesday, April 5, 2016

The Sacrotuberous Ligament: The Key to Unlocking a Long and Difficult Labor

Our Guest Blog Story comes to us from the mother, Jes, who experienced this birth. 

“Is Dr. Martin on call?”

One hundred and ten hours into labor, my confidence was waning.

“No, Dr. Martin won’t be in until Tuesday.”

It was Thursday. I’d been in labor since the previous Saturday, and for all of that work (without so much as a half an hour of sleep) I had gained just 6cm. However, I knew that with all of the things I’d want done a certain way, I’d need my own doctor in order to be comfortable with a cesarean. With that option no longer a possibility, I was desperate to figure out what was holding my baby up, literally.

But in both my labors, I had done every Spinning Babies recommendation I could think of. Again, and again. Not only in labor, but also for months beforehand.  I had also done Chiropractic adjustments. And acupuncture. And Dynamic Body Balancing.

At 117 hours into my second labor, here I was, a VBAC, desperate to find a way out. 

I called Gail Tully. 

I had first met Gail Tully at a conference two years earlier. At that conference, I told her how, despite all of my efforts and exercises, my first birth ended in a Cesarean after 34 hours at 7cm with no progress. Gail had mentioned during her lecture that Spinning Babies maneuvers, when done faithfully, would help most women. But, for some, labor would just click and everything would flow beautifully. As a doula, I’d seen it happen—side-lying release really is magic.  For other women, the same maneuvers would allow them to just barely avoid a cesarean—it would still be long and difficult.

After carefully asking questions, Gail suspected that the problem area for me was likely my sacrotuberous ligament.

Looking up from the bottom or outlet, of the pelvis
we see the sacrotuberus ligament (with the ischiococcygeal ligament)
connecting the sacrum to the sitz bones (those you sit on when you sit up).
When spasming they shorten. Matthew Duncan, OB, wrote that
short sciatic ligaments are short they reduce the room in the pelvic outlet.
 (same ones, but his name notes their locationby the sciatic notch and nerve)
Tip: Babies are often engaged earlier than usual and long before labor begins
because the inlet of the pelvis is significantly opened by the closing of the outlet.

A ligament of the sacroiliac joint, the sacrotuberous attaches the posterior sacrum and upper coccyx to the ischial tuberosities on either side of the body.

This fan-shaped ligament also blends with the posterior sacroiliac ligaments to attach to the posterior superior iliac spines, creating strong stability for the sacrum and preventing its movement under body weight. (Confused? Check out this interactive anatomy link for clarity.)

Ideally, the sacrotuberous ligament is slender enough that it cannot be externally palpated. However, when the ligament is stressed, usually by aggressive physical activity or injury, it can become thick and tight.  This can cause a number of issues, including ossification of the ligament and pressure on the pundendal nerve; but the main difficulty for pregnant and laboring women is the shortening of the ligament, which in turn pulls the coccyx and the ischial tuberosity closer together.

Besides causing substantial positioning issues for any baby trying to get into that pelvis, the tightening essentially closes off the outlet to some degree, causing long labor by not allowing the baby to pass.

Gail shows a Dad (Mom is just out of view) how a chronically spasming
sacrotuberous ligament draws the pelvic outlet closed and because
midwives and doctors are often unaware of this possible cause of
labor dystocia, the mother has a cesarean to finish the birth.
Photo Ginny Phang, Four Trimesters Birth Services, Singapore 

I remembered when we talked at that conference two years previous, Gail had palpated my sacrotuberous ligaments.  On my left the ligament was as thick as a pencil and the space between my coccyx and ischial tuberosity was much shorter than normal. Not surprisingly, I’ve had issues with my hip on my left side, and my left leg is shorter than my right, indicating a tightness that chiropractic adjustment would remedy, only to have it return.

So when we spoke 117 hours into my second labor, I began to understand that the possibility of the sacrotuberous ligament was the culprit in this, my second and incredibly long labor.

After our conversation, I called a physical therapist who agreed to come over and stretch the ligament. Her work on me included testing me for what Physical Therapists refer to as a pelvic upslip (sure enough, I had every sign of one) and treating me for that.  After an hour of bodywork for the upslip with a specific focus on stretching the sacrotuberous ligament, labor came on fast and furious, and within a couple of hours, I was 10cm and pushing.  

The sacrotuberous ligament should be considered if any of the following apply:

  • A long and difficult labor in which normal remedies (Rebozo Sifting, Position Changes, Spinning Babies Maneuvers) are not fully effective
  • Persistently malpositioned baby
  • Highly athletic mother (especially those who are highly athletic into their pregnancy)
  • History of any trauma in which the ligaments of the pelvis could have been affected (accidents, falls, etc.)
  • A visible Pelvic Upslip: One (usually left) iliac crest superior to the other, one leg (usually left) functionally shorter than the other.

Although I had a physical therapist work on me extremely effectively, it may not be necessary in every case. A simple palpation and gentle stretching of the ligament by the birth practitioner, or by the woman herself, may do the trick. [If you succeed at doing this yourself please let me know, I would be interested in how you managed to do it! - Gail]  The point here is to stretch the ligament, giving the pelvis it’s natural space and allowing the baby to move freely through it.

Consider the sacrotuberous ligament whenever you’ve exhausted your resources in a slow labor.  You just don’t know what you might find.

Jes Mejia is a wife, mom, Certified Professional Midwife, Labor Coach, and Birth Educator.

She is the founder of (coming June 2016); a site that gives new and expectant moms the resources and support they need to create their joyful and ideal postpartum experience. 
Her mission is to help women be fully prepared and supported as they care for themselves and their families through life after childbirth. 

Monday, March 7, 2016

Confluence of Birth and Bodyworker

Like two rivers merging to flourish the earth, the Spinning Babies 2016 World Confluence joins birth and bodyworkers to address the increasing rates of fetal positioning challenges.
This conference brings top names in birth and bodywork together with rising stars whom you may not have heard of yet.

Wednesday, September 21, we'll invite our international and other long distance travelers to attend a Spinning Babies Workshop. There will be a local Spinning Babies Workshop in Minneapolis/St.Paul, MN and one in Eau Claire, Wisconsin (2.5 hour drive to the SW of St. Paul, MN) this Spring and Summer for regional birth workers. See the calendar for more US and international workshops.  Attending this workshop will only make the conference that much more comprehensible and raise the value of your learning. (7 continue education credits or CEUs. Registration will appear at the end of February, you will want to register fast!)

Thursday, September 22nd offers pre-conference workshops (with 5 or 7 continuing education credits per 5 or 7 hour workshop). See the details for Thursday pre-conferences with Carol Phillips, DC; Phyllis Klaus, on Hypnosis and other BodyMind approaches to complications of pregnancy particularly premature labor and hyperemesis gravidarum - a great preparation to understand how to work with women, including hypnosis for women with breech babies which she covers on Friday afternoon); Angelina Martinez Miranda, Mexican Midwife; Adrienne Caldwell, MT;  Jenny Blyth and Fionna Hallinan, Australia's Birthwork trainers; Sarah Longacre, Prenatal Yoga Instructor Trainer, on integrating Daily Essentials into your yoga studio offerings - she'll get you moving!; and myself on Belly Mapping for pregnant parents for a 2 hour presentation which includes painting a few bellies (no CEUs).

Friday, September 23rd is "Interest Track" day, with quality presentations on current birth and bodywork topics:

Penny Simkin gives 4 presentations with her excellent presentations which are worth gold to providers and birth activists alike. Professionals and educators across the birth spectrum find her quality presentations changing practice and approach. The world of birth workers have praise for Penny on their lips at every given minute around the world.

The first baby I (unexpectedly) caught was my friend's breech baby girl. So it's a natural for me to have a day on breech for providers. I've invited Jane Evans and Anke Reitter because these two give a concrete and practical understanding of how the baby moves through the pelvis o,r gets stuck - and unstuck! In this track, I present a new conference learning technique I call, since so many of us are birthies, "Precipitous Presentations" which are 18 minute presentations on a single important point from a speaker's topic. Friday, Adrienne Caldwell does a single technique for turning a breech, Phyllis Klaus presents on Mindbody for turning a breech and Angelina Martinez Miranda talks about the beauty of breech birth from a traditional Mexican perspective. Take notice! Angelina will be teaching on traditional midwifery practices for pregnancy on Thursday! A panel with Obstetrician Dennis Hartung, Midwife Nicole Morales, and parents of breech babies brings us back from lunch. Anke Reitter, Jane Evans, and I will go into detail with providers about breech birth complications and the practical solutions of rotation and flexion to save lives.

Jenny Blyth and Fiona Hallinan are the Birthwork duo from Australia that can't be missed! Follow them to San Francisco after the conference where they'll give their complete workshop for 3-days on the pelvis, pelvic floor, and more. It's experiential and movement based. And a lot of fun!

Penny Simkin will start Saturday's discussion with her Opening Keynote Presentation on how Spinning Babies fits into birth trends and Dr. Anke Reitter will discuss her study (with Andrew Bisits and Betty Anne Daviss) on pelvic diameter changes with maternal position change. I will follow with the new way to look at birth preparation and progress with Spinning Babies approach to birth anatomy and care.

Learn more here about who else is coming as I receive their contracts - and commitments!

Sunday, March 6, 2016

Waterbirth and Breeches

I've been talking about maternal positions in general and the previous blog post gives you basic knowledge. This post talks about water birth and breech.

For the safe breech water birth you need to have uterine moment and an open pelvis.
Cornelia Enning, German Midwife, solved that by having the mother standing in a rain barrel. Literally a rain barrel. That is quite different than a typical water birth tub.

When a woman gives birth in a regular birth tub she is:
  • Less likely to rock fully back and forth bringing the baby's arms through the curve of carus, the curve of the pelvis
  • Unable to put her chest to the floor which opens the brim when women are on their knees
  • Less likely to raise their buttocks to protect their baby from taking a breath of air only to be dipped back under water

This picture of a recent breech birth "in air" shows the baby in the ideal direction for the arms to be born. The baby's spine is towards the mother's front. The mother's kneeling position encourages this position. Her rocking encourages muscle relaxation and the little movement helps baby descend.
This baby's right elbow has just been born. Baby's toes are curled showing good tone. The cord is actively circulating blood and the baby is an active particpant in bringing the arms and head out.
Muscle movements in the baby's abdomen (seen more easily with mother on her knees) show the baby flexing to bring down the larger parts of her own body.

This baby has floated into the oblique diameter after the birth of the arms. Is the head oblique, too? The mother is curled over her knees, shutting her pelvis down a little bit. This baby required help to get the head out. See the mother's deep crease compared to the above picture of the full perineum? 
This is a clue that the head is not flexed. The lack of maternal movement in the tub or length of descent in any breech birth - even before the umbilical cord is seen - can reduce oxygen when the placenta may begin to separate. Don't wait when you see a deep crease. Go get your baby. 

Open the diameters of the inlet by putting chest to floor... oh, oops, you can't dunk the mother to do this. So she can open her pelvis by: 

  • Raising her bottom by pushing up on the top of her feet - starting to straighten her legs
  • Anterior pelvic tilt (increase the curve shape of the lower back by pushing the buttocks out)
  • Standing and anterior pelvic tilt 

  • Get out of the tub (Seems dangerous to baby's neck! Seek chiropractor for atlas adjustment.)
  • Kneel on the floor and put chest on the floor

and in both cases Midwife does one of the following to flex the head: 
  • Frank's nudge (touch subclavical nerve under the collar bone, between shoulder and ribs in the dip. This is the 2009 version as explained by Adrienne Caldwell in 2012. I like this version because it uses physiology rather than force.)
  • Mariceau-Smellie (pronounced Smiley)-Cronk (not Veit, in all-fours position)
  • Lift the baby's chest to the perineum (towards baby's chin) and then slide baby forward to mom's belly
  • Finger forceps the perietal bones to tuck the chin. Do this by rotating the top of the head with your finger tips on either (or one) side. This is like making baby nod "yes" and the chin will tuck.

Then the midwife can use fundal pressure to bring baby out if the mother can't push the baby out. 
Remember the head is in the vagina and not every uterus will push out the baby's head by the time involution is well under way, though of course, by far, most will. When you need baby out to help start breathing and heart beating, you can do Kristeller's maneuver which is simply push down on the TOP of the uterus. This is not suprapubic pressure as in shoulder dystocia. You get on the top of the uterus and give a tap or a mighty push, depending on which is necessary. How hard you press depends on whether the pelvic floor is that of your average pelvic floor or of an athlete. 

Baby's head must be flexed and facing mom's anus, not her hip, to fit out the bottom pelvic level. 

Breech birth is a clever adaptation of the baby when the baby doesn't have room to be head down in the pelvis. Balance the ligaments, fascia and muscles to allow baby head down. Some breechings stay breech because of uterine shape (bicornate or other shape), anterior placenta, low thyroid function, or physical anomaly. I believe it is more often a twist in the pelvis, sacrum, or cervical ligament causing the breech position. A second twin or a triplet may just be matching available space and can flip head down once their sibling is born or with a little help from maternal positioning with gravity or the provider's skill, if necessary.

Because I mention some things about breech here, doesn't mean this is the whole story of all you need to know to help a breech or that I am not mindful of the skills needed. I simply want to address one issue of the breech and water birth in the "horizontal" birth tub. 

We can't compare Cornelia Enning's breech water birth outcomes with other tubs. Mothers stand up in her "vertical" tub and she has them put one foot on a stool. She gets into the tub if the baby needs help (Midwifery Today, Oct. 2013; Sao Paulo, Brazil SiaParto, June 2015; Midwifery Today, Bad Wildbad, Germany, Oct. 2015) Her pool water is typically cooler than American custom, as well.
My supposition is that standing with a foot on a stool opens the pelvic diameters while allowing mother to move instinctively. Babies might still get stuck, but not because of the mother kneeling over her knees.
Now the midwife can touch the self-progressing breechling.
Mom has lowered her shoulders to the bed and opened her pelvic diameters to release her baby.
Photo by Indigo Birth Photographer, Allie Parfenov.

In a horizontal tub, sitting upright on a stool may be better for birthing a breech. But the two times I've helped in that position the babies needed help, one for an arm and one because the placenta separated before the birth was complete. But in hands and knees water birth I've found issues due to maternal position. 

Now midwives will say, "But, I've seen breech babies shoot out in the water." Yep, so it isn't all breeches. It's simply too many to ignore. A surprise breech will come fast most of the time without getting caught. That is one reason there wasn't time to transfer to the hospital or even discover baby was breech. Planning a breech birth puts the matter in to another category. 

Learn the diameters of the pelvis so you know what maternal movements open which part of the pelvis. You can then suggest a subtle move that can save a life. You can also know how to rotate baby to free the stuck body part (arms or head in the breech) and figure out what to do more easily if the
baby is stuck in a way that is not in the books. That happens when baby is stuck inside the symphysis pubis, for instance, and baby can be lifted and rotated or the arm brought back into the pelvis.

Ok, I've exhausted this post. Learn more about breech at the Spinning Babies 2016 World Confluence, Sept. 23rd on the Interest Track day's breech session. Dr. Anke Reitter and Midwife Jane Evans will be sharing the skills they've spent their lifetimes perfecting. 

Maternal Postions at the levels of the pelvis

Much has been written about maternal positioning in labor. Some of it validates and some of it seems to contradict what we have been recommending. I'd like to offer a look at maternal positions for pregnancy and labor from a "3 Levels" perspective.
Get the entire set in the Quick Reference Cards Download.
These are not cards, but a download you can print and make cards with.

In pregnancy, the assumption seems to be that positioning mothers with gravity is enough to reposition the baby also. Providers don't expect an immediate change. However, common questions arise by those who haven't rejected the Optimal Foetal Positioning approach, "How long does a fetal re-position take?" or "Which position will rotate a posterior baby or flip a breech?"

In labor, maternal positions are chosen for comfort by mothers and are suggested for progress and comfort by providers.

Rest Smart simply means maternal positioning with gravity. Alignment promotes muscle relaxation and an open pelvis.

In Pregnancy use alignment in your posture to allow better function of the muscles.
This means sitting on the front of your sitz bones and not lounging back on the sacrum in a semi sitting position very often. Sitting up makes the belly a hammock, as Midwife Jean Sutton describes in Optimal Foetal Positioning.

Spinning Babies adds muscle balance to allow room for baby to settle spine to front in the anterior position. We understand that when gravity alone doesn't bring baby head down, and then over to mother's left side, then there may be a reason relating to the uterus having enough room to let baby slide into place. Sometimes that is a placenta or a unique shape to the uterus, like a septum in the upper uterus holding the head in place, - or a twin in the way! But more often it seems to be a bit of a twist or tightness in the ligaments, connective tissue or muscle. A lack of room might be because the mother's hip is rotated (twisted) enough to shorten a leg or pull the cervical ligaments over to one side, creating a fold or slight twist of the lower uterus.
The normal uterus often seems to lean to the right. The fundus, midway through pregnancy,
is often noted to be slightly higher on the right than the left. The right side is steeper and the left side more round.
Normal "right obliquity" of the uterus makes the uterus steeper on the right side. Baby's flexion
is likely to result from laying on the round side (usually left) and babies who are extended may be more likely to
come from the steep side (almost always the right side).
Balancing the muscles and ligaments and aligning the pelvis may support a good fetal flexion.

Movement in special ways to lengthen and "balance" the muscles helps make room for the baby.
Yoga in general is good. But yoga in and of itself may or may not balance the pelvic muscles. Whether or not the muscles that a particular mother needs help with is addressed in her yoga class depends on the full range of motion and style of yoga promoted by her class instructor. Daily Essentials download video is designed for that full range of motion that seems to help the majority of women using it from 20 or 30 weeks gestation.

Addressing ligaments and the fascia (connective tissue) helps address the levels of the pelvis - a fancy way of talking about baby's pathway in birth.
Above the pelvis is the respiratory diaphragm, broad ligament and round ligaments.
At the pelvic brim is the sacral promontory, they symphasis, and inguinal ligaments.
Deep in the pelvis are the pelvic floor, ishiocavernosis and performis (on the back side, but effecting sacral movement and the internal surface of the sacrum is deep. Ok, the analogy needs tolerance.

Use Balance, Gravity, and Movement to enhance pregnancy comfort and potentially ease childbirth.

Now in labor, open the inlet with the posterior pelvic tilt to make room for baby to drop down.
MRI of the Pelvic inlet with and without the line showing anterior-posterior diameter of the inlet. 

Once baby is half way through, at or near the ischial spines, the peanut ball is a helper, or the diagonal lunge (stand and lunge towards the side while still facing forward).

Once the nurse can see baby's head, doing an anterior pelvic tilt opens the outlet. The lunge will help again. And the birth stool is brilliant! Make it a medium height birth stool so the mother isn't in too deep a squat for strength in pushing and have a squat when baby is almost crowning. Or a hip squeeze.

You can learn more about the levels of the pelvis with these three products

  1. Insights for Labor tear-off sheets for educators and providers which gives parents a one-page handout, two-sided, to refer to during labor. Maternal positions are illustrated so they know what to do when, for comfort and labor progress. These cost shipping, and can't be mailed to Australia or South Africa, two countries where my products seem to disappear into customs. See Capers Bookstore in Australia to order your copy, Mate!
  2. The Quick Reference Cards (not cards, actually, but a download) which I sometimes call the 3 Levels Cards, but they include brief instructions (reminders really, the full instructions and contraindications are on the Spinning Babies Website. 
  3. The video download, Spinning Babies, Parent class which goes into the balancing techniques and the tips for labor - in depth! The 3 levels of the pelvis are well explained. You will learn a lot even as a provider from this "birth geek parent" video. This can be ordered as a DVD, too.

Tuesday, February 16, 2016

Maternal Positioning Needs Better Understanding

There is a lot on the blog-o-sphere lately about the failure of maternal positions to rotate the posterior baby. My point is that we can't say maternal positions aren't useful to help a baby rotate until we get smart about which positions to study.

Hands and knees is a comfort measure but no longer thought of as the position to rotate a posterior baby to anterior.

The posterior baby's chin is up making the top of the head enter the pelvis instead of
the smaller "crown" of the anterior and flexed baby.

There are empowered labor and delivery nurses, doulas, and midwives everywhere that have their "swear by" positions.

"oh, we just do this..." they'll say and go on to describe a position they put a mom in over a peanut ball or the rolling hospital lunch tray, a pile of pillows or off the bed. It's happening all over.

Why don't these tips and tricks show up in the literature?

The positions studied are the ones most easy to train and replicate. Throw a leg over a pile of pillows... ok, and the person does it in such a way that is most comfy for mom. The nurse will correct, "oh, no, that won't do, put the pillows higher, bring that leg up higher and bring that hip up and around..."

Or, "no, put that roll under the trochanters, not the sacrum."

Many nurses develop a 6th sense about maternal positions and figured out some way to position mothers based on a birth they saw a dramatic change. Repeating it, they saw it work again.

The positions are often quirky. One midwife showed me a complicated dance of having a woman gently fall into the wall in front of her from standing back away from the wall. She was to do it in a sinewy way that rocked her pelvis to engage the baby. Nurses and a chiropractor showed me how a kneeling women could lift and press the baby's head just above her pubic bone while rising to jut her belly out to help engage a baby. There are as many tricks as crones. Observation is a great teacher.

Positions studied are often hands and knees, or a variation on child's pose. The brim is neutral or closed. Dr.s Anke Reitter and Andrew Bisits worked with Betty-Anne Daviss to study a position they recommend to measure the effect on the pelvis inlet but the MRI machine didn't have room for the mother in that position. So they studied the pose she could do in the restricted space - and found a different part of the pelvis widening (Reitter). (Good studies show something useful even if not able to follow through with the original intent.) We can say more studies are needed, but really, we have studies on squatting, Walcher's, child's pose, lithotomy, semi sitting, McRoberts, and now a kneeling position with knees wide apart.

We have a funny way in our country of saying, well, we want everything we recommend to be evidence based (and yet so much practice continues which is against the evidence). In this model, we assume everything good is studied and if it isn't studied, well, then it must not be worth studying. And yet how few women are allowed off their backs to birth their babies even when they request an upright position. Something worthy has been studied but the benefits are still not available.
Other worthy approaches may not be studied because complex processes aren't always feasible to study. The mother doesn't fit in that pose in an MRI machine or the position is more of a technique or even a string of techniques. Posterior presentation may be a result of a number of variables and babies can get stalled in their way down the pelvis at different levels of the pelvis where different moves or positions are needed to create room.

Trying to study something that takes 3 or 6 steps to complete is not going to get studied. Something that takes one step will get studied - especially if it has been studied before. "Which one of those steps will show the most effect?" Imaging stu asdying stair climbing and have the research team ask which one of those stairs will bring you to the top fastest, because, seriously who has the time to walk up each one of them? That's too expensive to study. Can't you pick the best step?

But until we get it figured out that isolating one position isn't going to solve the need to make room in a 3 level pelvis (and I might argue 4 levels when we think of the disengaged Right Occiput Posterior baby at - 2 station) we can at least pick a position that corresponds to the need a posterior baby has to enter the pelvis. It's "pretty easy" to help a posterior baby rotate while above the brim but it takes a series of techniques for most women.
If the baby just needs a little room, the abdominal lift and tuck will do... oops, that's two things, can we study that? Maybe not, so Walcher's -has been studied a few times. A tough position for most women, but most effective for one technique.

If the baby is in the pelvis but not fully engaged and posterior, I call this a misengagement. Backing the baby out and letting baby have room is a process as well, not a single technique. Better not study that, then. Too complicated.

Ok, then, how about the outlet? The posterior baby in the outlet trying to fit out. Hands and knees might be better than on the back, but a birthing stool is really great. Oh, wait, too many moms on epidurals, the study population will be too low. Ok, the peanut ball! That'll be great, we expect good results.
The technique studied, though opens the inlet and now we want to see how to open the outlet because the baby is low. Oh, you didn't know there was a different technique for that? Yep. Let's save the knees apart for when baby is still high and put the knees together with feet apart for when baby is truly low. Beware the false engagement of the posterior dome and don't miss finding that over lapping head.

You see, sorting out the posterior can take a little more "real life" than applying one simple technique. And we haven't gotten to pelvic shape yet.

Well, we have - a recent study sums up posterior like this, if the mother has an anthropoid pelvis, expect she can still have a vaginal birth. If she has a gynecoid pelvis, go in and manually rotate the baby. If the mother has an android pelvis (or presumably, a platypelloid pelvis) go for a section.
 The current recommendation for posterior is if the baby isn't coming, the doctor reaches in and turns the baby by hand. While this is a technique to keep handy (mind my pun, don't step in it) its recommended also because it fits the approach of what we can do. What We can do, meaning providers. Its a use of force. Where as addressing the soft tissue "shape" of the pelvis isn't spoken of in the obstetric or midwifery conversation.

Let's make room for the mother by adding length in the muscles to her pelvis with some static stretch techniques and then move the legs and lower back in a particular way, not randomly through our pelvic playlists. There is a method to the mystery.

Spinning Babies is about helping babies have an easier way of rotating and thereby, easing the birth for mothers and birth workers, too.

I get specific in the Quick Reference "Cards" which are really a handy pdf. download to print yourself. These pages show the techniques to lengthen the muscles with the forward leaning inversion and sidelying release and what to notice to choose the technique indicated. In other words, what to do when is listed on the Quick Reference Cards. Remember you make them into cards, or just view them on your device.

Changing the Earth by supporting Birth

Mothers bring forth life; medical corporations do not. Birth can be simple, powerful and loving. Fetal positioning, natural birthing and practical help for normal birth.