Wednesday, September 2, 2015

Preventing The Epidural Labor Stall

Here's a picture from an Austin, Texas Spinning Babies Workshop of a labor progress technique shared by Dr. Diane Peterson, OB.

Purpose: Engage the Baby into the pelvis when mother is on an epidural and can't stand up for the Abdominal Lift and Pelvic Tilt.

Gail was a doula in Minneapolis, long ago before she had the knowledge of Sidelying Release. At one birth, Dr. Diane suggested we help baby move down into the pelvis by draping the determined mother over a ball and having her rock in a wide, and circular motion. The nurse and I stood close by her sides holding her shoulders to keep her from coming off the end of the hospital bed. I would call this extreme circling! It wasn't super fast, but the circles were large.

See how the workshop participant shows how the mother would place the birth ball between her crossed legs? She'll lean further forward as the birthing woman is leaning over her pregnant belly, too!

One hip rises off the bed on the opposite side from the furthest arc of the circle (the direction she leans). After 40 minutes, Dr. Diane checked the baby's progress again. Baby was in the pelvis at last. 

Considered the Cadillac of Pain Relief, Epidural use is common in the technological birth care model.  Few women choose natural birth and so few providers know how to support a vaginal birth with an epidural in place. We can offer good solutions
The side effects of injecting narcotics between the membranes coating the spine, however, may lead to side effects and, thus, more interventions. Pitocin augmentation and cesarean section are more common with an epidural than without an epidural. A somewhat high percentage of epidural users will have lasting back ache.  A somewhat common reaction is a sudden change in the mother's blood pressure causing a later change in baby's heart rate. Very few mothers or babies die or are injured by epidurals. An epidural is not without unwanted and unforeseen emergencies.

Few providers, today, know how to support a vaginal birth when labor slows down or the baby's tipped or sunny-side-up position delays birth. We can offer good solutions to help women have more satisfying birth with and without an epidural.

When a woman has an epidural, many of our favorite techniques are being used when baby's position is not ideal and/or labor progress is slow. Here are 3 ways of using techniques from the Spinning Babies Website may help avoid cesareans even when a woman has an epidural.

1.) Myofascial Releases
The relief from myofascial body work before and labor may potentially eliminate the woman's desire for an epidural since pain relief by natural means may now be sufficient. 

Our most popular myofascial (muscle and fascia, or connective tissue) technique is the Sidelying Release.  Another technique, popular around the world is called Shake the Apple Tree. Vibrating the buttocks as done in this technique might be considered a rudimentary myofascial release.

2.)  Static Stretch
Nurses have even told me they do Forward Leaning Inversion (only during and between 3 contractions per  inversion). These innovative care givers help the mom into an "elbows and knees position" facing the foot of the bed and then lower the foot section of the bed so the birthing woman's head is lower than her knees. Steep inversion may help the cervix dilate easier afterwards. Follow up by resting on the left side and placing the peanut ball between her thighs and calves.

3.) Open the Pelvis Where Baby Waits
We don't just randomly seek techniques to open the pelvis at Spinning Babies. We ask the nurse how high or low the baby's head is and match a technique from the level of the pelvis that baby waits.
Listen, if you heard a knock at the door, you don't just open any door. You don't open the door nearest you expecting the person to enter. You open the door next to the door bell. Otherwise you are only opening the correct door by chance of your location, not the guest's location.

The same is typical of us birth workers. We'll use a favorite technique that works a lot of the time, but may not be specific to where the baby is located. We can improve our success by matching the technique to the height of the baby in the pelvis.

Using a peanut ball between the mothers legs allows the legs to be positioned to open either the inlet or the outlet. An internal rotation of the femur will open the outlet. This puts the mother's knees closer together than her ankles! Sounds contrary to tradition, but this makes the ischial tuberosities further apart.

Rest Smart means, after balancing with myofascial release and static stretch techniques, the mother rests in a gravity friendly position. Place the thighs (femurs) in a position that also helps open the level of the pelvis where more room for the baby is needed.

Conclusion
Epidurals are a mix of narcotics and other drugs injected in between the membranes of the spine. Epidurals can cause fluctuating vital signs which can be dangerous and may lead to an emergency cesarean. Other side effects allow for more time to try non-surgical solutions, such as those listed here. The epidural is the best medical pain relief available today. Natural alternatives may help many women cope satisfactorily without narcotics. 

Saturday, August 29, 2015

Timeline for Fetal Position

Babies follow a natural progression to settle into the final birth position. Well, not exactly final. So I call it, the starting position for labor. It almost always changes for baby to rotate through the pelvis.
Oxorn and Foote, Obstetric text book authors, state that most babies are in position at 34 weeks gestation. This means that fewer babies will change position after 34 weeks.
We assume that the moms in obstetric studies were not balancing out their tight muscles and short ligaments. They weren't using Rest Smart positions themselves and they weren't going to get body work and Chiropractic/Osteopathic.
My doc isn't concerned about the position until 36 weeks. You have plenty of time for your baby to move. -- post on Glow


If you spend any time on this website you will know that I don't exactly agree with that statement. Baby's don't move at random. Their position matches the shape of the room within the uterus. This space is shaped by the abdominal and pelvic muscles, ligaments, and connective tissue (or fascia). The mobility and alignment of the pelvis also make a significant contribution.
So, will the baby move into an ideal starting position for labor at 36 weeks? Depends on the room in the womb, I believe.
Add balance and babies move in response to the room created by the release of tension or torsion in the soft tissues and joints. Tension comes from living in gravity. I don't necessarily mean emotional tension. I mean tightness in the muscle, a muscle, several muscles. This effects mobility and alignment.
We know that in the second trimester that babies are often laying sideways in a transverse lie. Some or oblique (diagonal).

Timeline for fetal position

26 weeks or so

Babies begin to move to a vertical lie, which means either head down or buttock down. A few more will wait to go vertical until 28 weeks and fewer at 30 weeks.
28-30 weeks, the breech (buttocks/pelvis coming into the mother's pelvis before the head does)  baby often flips head down.
A few more will move head down by 32 weeks.
Gentle balancing can be done throughout the pregnancy with the Daily and Weekly Activities listed on this site and other ways of moving in pregnancy.

28-30 weeks

You may like to get more active about body balancing if baby isn't head down.

By 32 weeks

If baby is breech or sideways I suggest getting serious about self care techniques, such as the

If you have a history of difficult pregnancies or births, cesarean or babies in positions that are challenging, then you might want to get serious earlier. Start early, even before pregnancy if you have a history of car accidents, sports accidents, or work and activities that twist you and make a jolt or sudden stop, like soccer, baseball, running, massage therapy, Chiropractic adjustments from the side, lifting patients, throwing bales of hay, that sort of thing...
If baby is breech at 32 weeks get started with flipping activities in earnest and add professional body work no later than 34 weeks. - unless of course, you don't know you should have done this because you've been told it doesn't matter until 36 weeks.
See the Breech Timeline of when to do what in the Breech Section under Baby Positions.
If baby is transverse at 32 weeks, read that article and do the activities listed there.

Left Occiput Anterior 

At 32-35 weeks

Many babies still switch sides. You may feel the weight and mass of the baby switch, but is it your womb leaning or is it baby changing positions?
Tell by where the baby kicks, if that changes, too, then baby changed positions. If baby doesn't switch sides to kick, then the womb and the baby inside it are simply leaning over. Ligaments around the womb are loose. Wear a pregnancy belt for walking and doing activity like house and yard work.
By 32-35 Weeks, if baby favors only your right, and kicks towards your left:
Don't panic, but don't ignore it. There is a gracious center of activity without stress. May we all find it.

By 36 weeks

We expect baby to settle in, change position once or twice a week if there is room, if not, we are hoping baby favors the left by now.
LeahJeff8mos

During the 38th week

Many first time mothers' babies engage. If balance and flexibility are well established this may be less important to have happen. If baby has fingers wiggling in front, add balance. The lack of engagement is an issue for the posterior baby in starting labor or keeping labor going.
At 40 weeks, take a lovely walk and bath. Do something unrelated to pregnancy. Enjoy yourself and don't worry about when the baby is coming. Give yourself a break.

At 41.5 weeks and more

Serious focus on fetal position and engagement takes up your day but again, be chill about it. Just be focused on 3 x a day doing the engagement activities. If baby is truly in a good position, and many providers say so without knowing much about fetal position in detail, then you only have to deal with the politics of labor onset and not likely the actual challenge of helping baby engage to start labor.
Walk and make love. Changes are a'coming.

In labor

Labor wants baby engaged before labor will open the cervix. Since engagement is a result of fetal flexion and fit in the brim and an aligned brim makes engagement easier, balance and engagement activities are useful in early labor. A start and stop labor pattern is a clear sign that engagement help is needed.
Flexibility and softness helps gravity be more effective. Once a series of balancing activities have been done, gravity helps labor progress.
In a fast labor, just hang on and try to relax. You don't likely need to concern yourself with baby positions. You may want to get low to the ground if baby is coming so fast that you aren't prepared with someone there to catch!
In  a long labor, its all about softening the way and moving the pelvis at the level where baby waits to pass by. Using techniques randomly gets random results.
When baby needs helping engaging, Abdominal Lift and Tuck is specific.
When baby needs help turning from facing the side to face the back, and get lower than 0 Station, or half way, then Sidelying Release and the standing lunge or a lunge in bed or resting the leg over a peanut ball.
When baby needs help at the outlet, the nurse or midwife sees a bit of the head, but labor isn't bringing the baby lower very fast, open the outlet with a squat, an anterior pelvic tilt or put your knees closer together and your feet further apart and push in that position. Please consider the birth stool!

Lots of Labor lore and techniques are discussed in Spinning Babies; Parent Class. Stream it to your device, download, or buy the DVD before labor starts so you can get familiar with it.

Enjoy your labor! Its amazing to open up and let a brand new human being into the world!

Wednesday, August 12, 2015

You can tell if your baby is engaged

Engaged or not?
Sometimes the posterior baby's head seems low in the pelvis when checked by vaginal exam. The nurse, doctor, or midwife feels the dome of the head and it doesn't wiggle. So, they think, the head is not ballottable, and that equals engaged. Therefore, the head is engaged.

But that estimation is wrong when baby's facing the front with her or his forehead on the pelvic brim. If the forehead isn't in the pelvis we can't claim engagement.



Ask, Is baby overlapping the pubic bone?
Lay down and feel for your own pubic bone. Now feel just above your pelvic bone. Is there  a little bump, or ledge touching it? Does this object stick out further from your spine than your pubic bone or do you have to reach into your belly skin to feel the firmness of the head?
Pregnant Women can tell if the baby is resting on the pubic bone. Midwives can help them determine whether the head is overlapping or not. They may need to have the possibility of an overlapping head pointed out to them. Its not in the text books. Its only here, at Spinning Babies!

Is baby Occiput Posterior and unable to engage?
If the mother feels little hands wiggling on either side of her center line (the linea nigra of pregnancy) then she can be pretty sure she has a posterior baby and that any bump on the pubes that is not her is, indeed, her baby's forehead.
Compare OP babies 
Is the baby in an ideal position and simply waiting to engage?
Sometimes a woman has a very steep inlet with a pelvic cavity that sweeps back in a 90 degree turn from the inlet. Then a Left Occiput Transverse baby will slightly ride on the pubic bone. The hands will not be felt on the same side as this baby's back. She will have a little ledge at the top of her sacrum which seems to make the buttocks rounder. They rise higher due to the tilt of the sacum. This normal variation can make early labor longer. The tip below can help make engaging baby easier.
Remember, most first babies engage by 38-39 weeks. Engagement seems, practically speaking, like it may be easier for baby if the pelvis is aligned.  A long walk in flat, soft soled shoes helps engage babies. Walk regularly in pregnancy.

Once labor contractions begin, engagement has a friend
Uterine contractions seem to want to help baby engage. That's more important than dilation until engagement occurs. Even if you don't know baby's position, doing a series of posterior pelvic tilts with abdominal lifts during ten contractions
is a technique that is likely to help, http://spinningbabies.com/learn-more/techniques/other-techniques/abdominal-lift/.

  • The OP baby may rotate and then engage
  • The LOT baby engages for the mom with a steep brim
Learn more about engaging babies in the previous two posts on this blog.

References

Debby A Clinical significance of the floating fetal head in nulliparous women in labor.  2003 Jan;48(1):37-40.

D. M. Sherer* and O. Abulafia Intrapartum assessment of fetal head engagement: comparison between transvaginal digital and transabdominal ultrasound determinations Volume 21, Issue 5, pages 430–436, May 2003


Sunday, July 26, 2015

Engaging Baby in Labor


Engagement of the baby into the pelvic inlet (brim) is important because to fit through the pelvis, baby has to get into the pelvis first. Engagement is when the widest part of baby's head enters the true brim of the pelvis.


Figure 1. Diagram depicting the fetal head immediately prior to engagement. The straight black arrow depicts the scanning plane at the level of the pelvic inlet, utilized to depict the presence or absence of engagement of the fetal head, with the transabdominal transducer placed in a transverse fashion above the maternal symphysis pubis opposite the maternal sacral promontory. The curved black arrows depict various possible scanning planes, which may assist in depicting the fetal biparietal diameter either below or above the pelvic inlet (engaged or not engaged). The dashed lines indicate the scanning planes utilized in obtaining Figures 2a and 2b. Note the fetal head is in the left occiput transverse (LOT) position, correlating with Figure 2. (Modified from Norwitz et al.2). http://onlinelibrary.wiley.com/doi/10.1002/uog.102/full


Yes, but if baby doesn't engage at 38-42 weeks, won't baby engage in labor?


Many do.
One study, back in 1999, showed that only 14% of first time mothers went on to cesarean, but in that setting the cesarean rate was normally far lower. My, how times have changed.
Non engagement of the baby is one "flag" that tells us to pay attention to body balance and fetal position. After adding balance, many babies rotate and engage with labor contractions. Labor really is useful!

How can I tell if my baby is engaged?


Tips to tell if baby is engaged. Is baby in ideal starting position which support easier engagement
(but doesn't guarantee it, obviously).
Does baby overlap the pubic bone in early labor or active labor? Is baby Occiput Posterior or Left Occiput Transverse?

How can I help baby to get engaged?

Things that help fetal flexion increase engagement.

Adding body balancing will help a long, free stride, walk in soft soled shoes engage baby.
Some people walk the stairs, sideways, holding the railing, up and down one side and then the other. Go both directions on both sides, to get the best pelvic movement.

Deb Lawrence's Dip the Hip (Figure 8s) or otherwise, releasing the lower back muscles and ligaments to the pelvic crests at the back of the pelvis.

Contractions have not started yet, and/or

Membranes released (water broke) but no contractions yet


Circles on a firm birthing ball. Not so much the up and down bouncing... if the baby's head is on the pubic bone, that is going to be tough on the baby. But flowing circles and figure 8s will also loosen up those pelvic attachments just mentioned and help your little egg drop into the cup of your pelvis.

Psoas Muscle Release (or resolve short psoas issues at www.coreawareness.com)



Will Breaking the Water help baby engage?

Yikes! Please no! Well, in some cases this may work really well. In many cases, its nearly the same as signing the cesarean permission form. That's said pointedly. Add balance and then movement first if you can.

Adding body balance may help baby engage, because engagement is as nature intends, and adding balance returns your innate design closer to that which nature intended for you.


With contractions to help baby engage

Now we're talking. The first task of contractions (other than the practice contractions of pregnancy) is to engage baby. Some babies must be rotated first, and we hope the first baby, or VBAC baby, enters the pelvis from mother's left side. But flexion, chin tucking, is the most important indicator of vaginal birth. I believe that entering the pelvis from the left gives the first baby the most opportunity to tuck their chin.

There are techniques on Spinning Babies that have anecdotal claim of helping engagement.

The circles on the ball may be effective in engagement.

The next three techniques only work with contractions! They do not work in pregnancy.

Posterior pelvic tilt. Flatten your lower back so that your arm can't fit in the space where your lower back curves if you flatten it against the wall. This would only be effective with contractions!

One favorite of mine is Janie King's Abdominal Lift described in her book, "Back Labor No More." I add a posterior pelvic tilt to the "belly lift" and find even greater success for babies that are still high once labor is active.

Walcher's "Open The Brim" is specific to engaging babies at the inlet and has been studied. This is a common technique in Germany and other places in Europe. Its intense and often successful.




References for Engagement



Caughey, Aaron B., et al. "Safe prevention of the primary cesarean delivery." American journal of obstetrics and gynecology 210.3 (2014): 179-193. (...it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught.)


Debby A1, et al. Clinical significance of the floating fetal head in nulliparous women in labor. 2003 Jan;48(1):37-40.  (A persistently floating head with advanced cervical dilation (7 cm) should prompt consideration of cesarean section since little is to be gained by waiting. ) [OMG, Walchers!]

Ghi, T., et al. "Sonographic pattern of fetal head descent: relationship with duration of active second stage of labor and occiput position at delivery." Ultrasound in Obstetrics & Gynecology 44.1 (2014): 82-89.  (13.5% of babies were posterior with a 50% cesarean rate. Posterior babies came down through the pelvis better if flexed as told by observed Angle of Progression.)

Haberman, S., et al. "OP22. 08: To evaluate the value of the determination of occipito posterior position before head engagement and risk of persistent OP and Cesarean section." Ultrasound in Obstetrics & Gynecology 38.S1 (2011): 121-121.  (Before engagement, 76 (43%) fetuses were in occiput posterior position (OP), but 67 (88%) of them rotated to occiput anterior (OA) during labour. Eleven (6%) fetuses were delivered in OP, and 9 of them were in OP before engagement (P < 0.001). 22.4% of cases in the OP group underwent Cesarean section compared to 12.7% of controls (P < 0.001).

Kelly, Georgina, et al. "Women's Perceptions of Contributory Factors for Not Achieving a Vaginal Birth After Cesarean (VBAC)." International Journal of Childbirth 3.2 (2013): 106-116.

Khurshid, Nadia, and Farhan Sadiq. Management of Primigravida with Unengaged Head at Term Placenta 4.2 (2012): 4.
 (The incidence of high head in primigravidas at term was 22%.The most common cause was deflexed head, next was cephalopelvic disproportion. In 40% no cause found. Vaginal delivery occurred in 67% of cases, 33% of cases had caesarean section. No interference i.e., ventouse or forceps required in 60% of cases. In 64% cases labour lasted more than 12 hrs.)

Shaikh, Farhana, Shabnam Shaikh, and Najma Shaikh. "Outcome of primigravida with high head at term." JPMA. The Journal of the Pakistan Medical Association 64.9 (2014): 1012-1014. (The most common identified cause of non-engaged head was deflexed head in 28(28%), while no cause was found in 45(45%) women. Further, 45(45%) women presented with spontaneous labour, while labour had to be induced with prostaglandin in the rest. Vaginal delivery occurred in 59(59%) cases and caesarean section was performed in 41(41%). The duration of labour was <12 32="" cases.="" hours="" in="" p="">

Verhoeven, Corine JM, et al. "Does ultrasonographic foetal head position prior to induction of labour predict the outcome of delivery?." European Journal of Obstetrics & Gynecology and Reprod Biology (2012).

Best outcomes for first time mothers with unengaged babies were found in this 1999 study: 

Roshanfekr, Daniel, et al. "Station at onset of active labor in nulliparous patients and risk of cesarean delivery." Obstetrics & Gynecology 93.3 (1999): 329-331.iology (2012).

Best outcomes for first time mothers with unengaged babies were found in this 1999 study: 

Roshanfekr, Daniel, et al. "Station at onset of active labor in nulliparous patients and risk of cesarean delivery." Obstetrics & Gynecology 93.3 (1999): 329-331.
The rate of cesarean was still dramatically higher for the unengaged, but wasn't near 50% higher as in four other studies. In fact it was 19%, less than 1 in 5. Today 1 in 3 of all women deliver by cesarean section. So I'm not sure what we can derive from this fact. 



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.