Wednesday, June 15, 2016

Making birth balance real with the Montessori Method

My strength is taking knowledge about body work and birth anatomy and turning it into simple and practice methods to help babies start and fulfill birth with the physical power of themselves and their mothers. In other words, I help parents and providers know what to do when to return labor to a normal progression.

I admire people like Marsden Wagner, Rebecca Dekker, Henci Goer and Penny Simkin who take current literature and relate it to current practice.

My talent is more humble, less institutionally trained, and has more to do with visuals. I take what we know on paper and help midwives know it in their hands. The things "we know" are not always common knowledge, sometimes I learned them at a birth and then found them in the literature often ignored because no one realized the importance of taking subtle concepts and illustrating them so that others could understand it. How do I do this? It began with my first teacher.


Maria Montessori 1933
 Maria Montessori was a graduated medical doctor - the first modern Female Doctor in Italy. She overcame great obstacles, like having to dissect cadavers alone after dark with only a candle to light her explorations of the human form. She was not allowed to practice with the boy's club.

A crisis in the municipal housing projects brought her to early childhood education where she inspired the likes of Piaget, whom she turned down to work with her because he was too proud to sit on the floor with children. Instead she choose the janitor's daughter because she came with no miseducated ideas about how children learn.
The Great Educator 1949

Maria Montessori said, "through the hand into the mind." She taught kinesthetically and systematically. She knew more about children because, as she said, The child is the teacher, and she was an excellent, observant student. She noticed how stimulating the world was to the child, many details flooded the child's attention. She simplified each detail into a "lesson" and then let a series of subsequent lessons lead the child spontaneously back to the conclusion of the whole. In her first year with the preschool children, the group of them began to spontaneously read and write because each of the separate details of how to hold a small object, how to sound the letters, to trace a letter, to hold a pen, all cumulated into the whole of writing. The children learned with several steps of success because they didn't have to sit down and learn the entirety in a week or a month.

One way Maria Montessori learned to show child a complex concept was to begin with the the 3-dimensional objects representing the concept. For instance, I'll use the same example I used in making my teaching manual during Montessori training in 1981.

The small child approaches Advent. They have the figurines of a Nativity Scene/ Later they hold a flat object, like a puzzle, of the same scene. Finally, an abstract such as a painting.

This process is a formal version of a more simple and rapid approach in which I show anatomy and concepts for the Spinning Babies premise to experienced birth workers. In this way we can show the reality of gentleness in preparing for and in assisting the natural progression of labor.

Here is a picture of me with Madame Elizabeth Caspari, Maria Montessori's friend and personal secretary.  Together they met in India just as WWII broke out. They spent the next four years in a locked containment camp called a "hill station." Using their time constructively there, they began to develop Montessori in botany, music, math and English language. These are the gifts Madame Caspari brought. She had been a famous children's music teacher in Paris, though she herself was Italian like Madame Montessori. In 1946, Elizabeth Caspari introduced Montessori to America in St. Louis at her first Children's House.

Madame Elizabeth Caspari, 88, with Gail Tully, 20, in 1980

I spent 9 months near her, including the first cycle of Montessori training after which I left for University and plans to become a midwife. I later decided to become a CPM through practical learning and not institutionalized education, though I did get a BS in Family Dynamics. Because I followed Madame Caspari around, often sitting by her feet on the floor, she called me her "little chick."

I can only thank these women and my family tree of teachers, plus an older brother who loved to teach me by Socratic method as to why my workshops win frequent praise and being the best education that many midwives have experienced. Are you a kinesthetic learner? You may like the workshop. Are you an experienced midwife? What you know that is not in the books will be validated and you will feel enthused. That is simply the nature of finding your own.

Wednesday, May 25, 2016

Maternal Positioning isn't the only thing

Gravity first?

The idea of using gravity to swing baby's back around to a pregnant mother's abdomen is a popular hope with a misunderstanding of the cause of challenging fetal positions. It seems that people, even in birth work, think that the baby is floating randomly and settles into position only by virtue of gravity pulling the baby downward. This idea is popular because we look at one variable. Gravity.

I think gravity is only one important variable of maternal position. Others include the state of the mother's anatomy. Are there muscles and ligaments that are too tighten, too twisted, or too loose to do their job?

Specific types of pregnancy body work seem to address these soft tissue structures to the uterus and pelvis quite well. Not just massage but therapeutic pregnancy massage, and skilled myofasical releases, cransiosacral and osteopathic/chiropractic structural care combine for improved fetal position.

Myofascial therapy is a term I use broadly and can be Maya Abdominal Massage, a mother's own activities, often with a helper, Rebozo abdominal sifting, and foam roller work. Homeopathy, Acupuncture and other methods add benefit.

Balance First!
 Once "balance" is restored, then the maternal positions aligning with gravity maintains the space. A baby follows the space to get ready for birth and to move through the pelvis. Developing habits of balance may promote a good fetal position - that's one that in which the baby fits the pelvis.

Then we cycle back to maternal positioning!
In labor when baby needs help to enter the pelvis, pelvic brim opening positions are better than pelvic closing positions!

Posterior Pelvic Tilt
Abdominal Lift and Tuck
External rotation of the femurs
Back extension such as a supported bridge pose or Walcher's

When baby needs to rotate in the mid pelvis,
we start with Sidelying Release and then add
Lunges

When baby needs room to get past
the tuberosities (sits bones) at the bottom of the pelvis
(the nurse gets the first glimpse of the baby's head with her flashlight!)
then we choose positions such as

Anterior Pelvic Tilt
Internal rotation of the femur
Deep squat or low birth stool










The flexed thigh positions explored by Guittier this year in a published article, "Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial." BJOG: An International Journal of Obstetrics & Gynecology.



I commend Guittier's attempt, but was sad that all 6 of the kneeling and forward resting positions chosen had the mother flexing her thighs. This is a comforting pose for labor for sure. But while some muscles are relaxed and gravity helps pull baby off the mother's back, they also constrict the front of the pelvis where the posterior baby needs room to change position. They open the lower pelvis but the baby's rotation is best achieved at the brim. Once the baby is low enough for this position to work, the pushing efforts are either not strong enough for the average posterior baby in this position, or we still need an upright or extended back which this position doesn't allow. Therefore these are really best at comfort positions for the well progressing labor. 

Whoops! 





So maternal positioning can only be the leading action for improving a fetal position when we make useful room in the pelvis. In pregnancy and labor this is by "balancing" muscles, really restoring the balance that the body would have if not for sudden stops during a twist in earth's gravity. In other words, a fender-bender, a fall, a bad posture habit or work or play that twists us a bit while we lift, carry or stop suddenly.

The simple vertical positions of standing and walking help most babies become head down. The key time is second trimester. Expect baby to settle head down in the womb by 28-32 weeks.


Babies fit the space available
For those with less room in the womb, for instance, a septum or single "horned" uterus, having the baby head down as early as 14-20 weeks may be important to avoid a breech presentation.

More common, however, are twists or tensions in the supporting ligaments and muscles to the pelvis and uterus. These can press or pull on the womb and actually reduce the space in the lower uterine segment where baby's head needs the space to settle downwards.



A flash from the past

In labor, many women prefer being upright, and though we can, after giving birth in an upright position imagine that women have preferred this since the beginning of time, it was in
Birth Journal in 1979 that Roberto Caldeyro-Barcia M.D. reported the following:
Birth

Birth

Volume 6,  Issue 1pages 7–15March 1979

 Labor was 36% shorter in primiparous women and 25% shorter in all women who were upright during labor. Maternal position had no effect on fetal head molding or Type I and Type II heart rate patterns. The upright position was preferred by 95% of women.


Birth Journal also reported that squatting shortened the pushing stage in
Golay, J., Vedam, S. and Sorger, L. (1993), The Squatting Position for the Second Stage of labor: Effects on labor and on Maternal and Fetal Well-Being. Birth, 20: 73–78. doi: 10.1111/j.1523-536X.1993.tb00420.x


Why is it that so few women can really move freely in labor? IV poles, monitoring and beds indicate a passive position in bed, but poles can be pushed and monitors have portable options now. Beds are great for kneeling on and hanging off of... .read more about Forward Leaning Inversion to get that joke.  Why are women still lying down to push babies out?

Safety? The provider is trained to do delivery maneuvers with the mother on her back. Not to mention that all the training for rescue maneuvers (suction, shoulder dystocia maneuvers, unwinding a cord (not often tight so its uncommon that the cord needs unwinding), etc.

But just as we had to learn driving skills in many situations, providers can learn skills for all these situations in a variety of maternal positions. Even epidural medications can be adjusted so that women can "walk" meaning, be on their feet or at least somewhat mobile with a constant companion helping to prevent a fall.

Maternal positioning and solutions for a long or stalled labor are best explained in the Spinning Babies; Parent Class and once you have seen that or a Spinning Babies Workshop, then the Quick Reference download will be a constant companion to the provider of birth care.




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

COMMON BRAND NAME(S): Cytotec
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."
http://www.healthline.com/human-body-maps/sacrotuberous-ligament




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 mypeacefulpostpartum.com (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. 









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