Tuesday, December 29, 2009

March of DImes Prevent Prematurity with Midwives & lowering induction

Medscape interviews Dr. Fleishman, expert from the March of Dimes, on the prevention of prematurity. The March of Dimes has gotten my respect these last 7 years for their prematurity prevention campaign. In the beginning, I used to muse, what we midwives could teach these folks. Well, someone else must have been thinking that same thing. And better than that, Dr. Fleishman is watching the numbers.
Here are some of Dr. Fleishman's bold statements:

"About 72% of all premature babies are now born "late preterm," defined as 34 and 0/7th to 36 and 6/7th weeks' gestation. That so many of these babies are being born early is directly correlated with actively managed pregnancy... We believe that a substantial proportion of these births are not medically indicated.

"...actively manage pregnancy has gone overboard. It has caused any small change -- any increase in blood pressure, any concern about diabetes, or fetal well-being -- to result in a very aggressive management strategy with inductions before they're needed. Inductions tend to result in cesarean deliveries.

"The other thing that has increased iatrogenic prematurity is the fact that both women and health professionals are scheduling deliveries. This clearly has convenience benefits for both parties, but I don't think we were sufficiently aware of the serious consequences of doing this....

"The reason we're fairly certain that much of the late prematurity is iatrogenic [Doctor caused (and could be midwife-caused, too, if the midwife induces early] is because of what happened at this symposium. We invited the Hospital Corporation of America, Ascension Health, Premier Health, Geisinger Health System, Intermountain Health, and United Health to give us their data. All of these programs have done interventions of one sort or another to decrease early -- pre 39 weeks -- inductions and consequent cesarean deliveries. And, in fact, when they do that, they dramatically decrease, first, their late preterm birth rate, second, their C-section rate, third, their neonatal intensive care admission rate, and they have better outcomes and lower costs with no increased adverse outcomes of pregnancy, and no increase in stillbirths.

"What we see from those programs -- and we now have published data, which were presented at this meeting -- is that you can decrease these inappropriate iatrogenic deliveries and have better outcomes without any adverse effects. So, that proves the hypothesis that some of these [early births] are certainly unnecessary."

So what he's saying is that when the March of Dimes acts as a Watch Dog group and fewer inductions are done before the mother is 39 weeks pregnant, injuries and illnesses are reduced without causing more problems in other areas.

Women are often told to be induced because amniotic fluid is low, their baby is large, or their blood pressure is a little high (if it is a lot high induction can be a good idea, especially if no one knows to counsel the mother to eat high protein, greens, water and a bit of salt immediately and daily).

Anyway, such generalized reasons for induction are not proving induction is good but that induction is bad. When mother's are not induced before 39 weeks, there are not more problems. If induction was a good idea then we'd have seen healthier babies after induction. We do not generally see that. Some doctors and midwives understand this and do not generally induce.

When to induce? There are times, perhaps lack of fetal movement even after feeding the mother (and so the baby), lack of fetal heart rate variability (and not just for the baby's nap) or when the mother is truly sick with high blood pressure or worse - the kind of thing that only giving birth can solve (though you know from my other posts that I have seen amazing things from 100 grams of protein daily plus other dietary rescues). There are times to induce labor, but rarely.

More from Dr. Fleischman: "...I think that the increase in cesarean rate directly correlates to the increase in induction rates. If you induce women early, when the cervix and uterus aren't ready for labor, you will have an increased cesarean rate. Once the woman is admitted and induced, and her membranes are ruptured, that's a train that isn't going to stop until the baby is born. The increase in the rate of cesarean deliveries is a big part of the increase in late preterm births.

"The obstetric community, to its credit, is absolutely in favor of no inductions or C-sections before 39 weeks unless there is a clear medical indication. ... We're helping them [our obstetric colleagues] to learn... to insist that women not deliver before 39 weeks.

"... we can't leave it up to doctors alone. We can't leave it up to the nurse who's booking the induction or the C-section; we've got to create rules in hospitals with clear standards. That's why quality improvement -- analysis of data, the creation of rules, and holding people accountable -- is so important.

"...there is an increase in prematurity around the world; we reported in the March of Dimes White Paper on Preterm Birth: The Global and Regional Toll that in fact there are 13 million premature babies born every year around the world. About a million of those babies die. The United States leads the increasing rate of prematurity in developed countries. North America and Africa are the 2 regions with the highest rates of prematurity. "

Read that again, folks. North America and Africa lead with prematurity. We know Africa is afflicted with a drought and AIDS and I guess American pregnant women have a drought in their aid. They aren't getting the simple care they need to prevent prematurity.

Now it gets fun.

Dr. Fleishman, expert at March of Dimes, goes on to say,

"In comparing outcomes between women using midwifery, home birth, or expectant management vs a more active management strategy ... there is no question that the midwifery programs end up with deliveries not being induced unless there are clear indications. Midwifery services don't just wait until 39 weeks; they wait until the initiation of labor, which God in Her wisdom used to think was a good idea, and I think that it's probably a good idea for most women, yet only about half of the women in America are being allowed to go into natural labor. So yes, there is a lot of benefit to thinking about the expectant management, "high-touch," caring approach, which we think is quite appropriate."

Read more straight talk from Dr. Fleishman at Medscape.

Pregnant women today need to know that some midwives, as well as some physicians, will push for induction for practice standards rather than indicated reasons. This means that when they advise for induction they will give scary reasons why a woman should comply. It may be that all women in their care are induced by 42 weeks, or if fluid is low, the baby is big, etc. And to get free-thinking women who chose midwives to agree to questionable intervention fear is sometimes played upon, let's be honest. I've seen it played out many times.

Even if a woman who is 42 weeks has a baby who is active, passes her biophysical exam with and 8 out of 8, etc, the midwife is still so unlikely to say Your particular baby is healthy, we can wait a few days on this induction. No, she will push for induction to maintain a working relationship in her clinic and hospital (to get along with her colleagues).

Thats the dark side of Standards of Care. There is a bright side, too, but I'm ranting here.

Women will comply rather than disrupt their support system, rather than alienate their midwife. They will go home in tears and rant to their doula and come back and get induced. They will sit by their babies bed side in NICU and hold their head in their hands and not go back for their second birth, but they will not walk away from the bad idea of induction for a less than obvious health reason.
Dr. Fleishman says March of Dimes is teaching Dr.s a script to hold women off from inducing so that grandma can give postpartum care during her scheduled visit.
Midwives and Birth Activists must give women a script for talking to their doctor or midwife when induction is discussed.

Its not uncommon for a woman to be told she must be induced to save her baby's life on, let's see, theirs an opening on Thursday morning. Your baby's life is in danger, so come Thursday morning. And then on Thursday morning it may be that there are no available beds. So the mother is told to come back tomorrow. Now, finally, she has the evidence to see that there is no emergency. Yet she is so scared by now that she can't relax. She fears that some crisis is impending and she wants her baby to survive it. She now begs to be induced when instead, she can go home, eat well, relax in her own bed, and come back when labor starts on its own.

How can a woman tell when an induction is necessary and when it is not?
How does a woman navigate the fear of her providers?
How can women disagree and still hope to get compassionate, quality care during spontaneous labor? Leave a comment and tell us!

Thursday, December 24, 2009

low hormones and posterior babies!?

I've been promoting iodine in pregnancy for a couple years now.
And didn't even guess low thyroid levels could be related to posterior fetal position! I just had a hunch we were seeing more slow starts to labor, to the frustration of the mothers and to a point that didn't seem like a simply gentle start. Also, for women who had a tough time getting pregnant due to hormone issues.

So this new study by researchers from the University of Tilburg is a Christmas present to Spinning Babies :
12-23-09 BBC news (http://news.bbc.co.uk/2/hi/health/8425901.stm)

"Low hormone levels in pregnancy linked to hard birth

Too little of the hormone thyroxine is already known to complicate pregnancy, increasing the risk of miscarriage, premature birth and pre-eclampsia.

Now a Dutch team has found even "low to normal" levels of thyroxine may cause problems, Clinical Endocrinology says.

Babies were more often positioned wrongly, making labour more difficult.

Although still head down, the babies tended to face the wrong way - towards their mother's back rather than stomach.

Not only are these labours generally longer and harder, they are also more likely to end in an assisted delivery with forceps, ventouse or a Caesarean."

It does highlight the importance of checking thyroid hormone levels in pregnancy
Hormone expert Professor John Lazarus

Friday, December 18, 2009

Where fear is seen as compentency

Another surge of gratitude for not having gone through the system.
Read this insightful report of this test for an "OB" class.

The blogger, I can't see her name, compares a care plan for a woman who has a breech baby at the end of pregnancy.

Of course, I've met many dozens of wonderful hospital care providers. And many that would like to trust breech, and a few that actually do. But usually, I notice that if I speak with a hospital provider about breech in such a way that reveals my trust in breech birth I am met with an incredulous and even offended look. The message I get is that if I don't fear breech birth then I must not know much about it; that somehow I'm irresponsible to trust birth.

This is a trained response that tightens the hospital community into a shared culture of fear. An "appropriate" level of fear is bonding. Shared meanings create shared perspectives and allows one to be part of the group. Doulas, childbirth educators, and parents can fall into this response to breech birth, not from education or information, but to feel connection with the nurses, midwives and doctors. Not just fear, but a shared "awe." By adapting the same emotional response in the manner of the person with more authority or power - the person with less power seems to rise in status and get brought more securely into the group.

The radical birth trusters are those that stand a bit apart. Sometimes they can win the respect of the hospital staff when relationship and repeated results are favorable and their communication style is winning. This is the case for the calm and calming obstetrician who continues to attend breech babies in spite of ACOG and the fear culture within obstetrics and maternity care.

Homebirth midwives trust breech birth in more numbers, but not universally. In this group education is more likely to expand trust, especially when the content reflects birth physiology and the natural progression of breech through spontaneous cardinal movements when the mother is leaning forward. Midwifery traditions have safe breech practices, but not all midwives know the traditions and techniques.

Carol Phillips, DC tells how the forward leaning position shifts uterine ligaments in a favorable way for spontaneous birth.

We can trust birth when we know how to support spontaneous birth. Often, this is to do nothing. Providers can learn quickly to distrust birth when they see, time after time, difficult outcomes. They may never link how the outcomes follow a course of prenatal care without relationship, nutrutional counseling, community support and connection, and other ways of helping a healthy woman stay healthy throughout pregnancy. They may never link how bad outcomes follow multiple interventions, including multiple doses of various drugs. They may never link any of this because they don't have the opportunity to see the woman's life before and after the birth to gain understanding of lifestyle influences on birth, or medical intervention influences on breastfeeding and newborn alertness.

Well, that's my soap box for the evening. Stay warm!

Monday, December 14, 2009

Belly Mapping Problems

Women have contacted me lately with some frustrations doing Belly Mapping. (See Michelle's comment to the previous post.) I haven't been hearing the details of what the problem is, but it sounds like there is some confusion. I'd like to address that today.

Belly Mapping becomes easier the later in pregnancy the mother attempts it.
Here's a mom beginning her third trimester.
She lies down to relax her abdominal muscles.
She is exploring, deeply, what is in the lower part of her uterus. She is glad to find the round head. She has to reach deeply.

Think about what you find in the top of the uterus, and what are on each side and whether the lumps are different on either side.

Then take a doll and match the head. If the head is presenting, or leading the way out of the womb, then put the doll's head there.

Put the doll's back where the largest firmness is, the solid back.
Put the doll's feet where the most kicks are being felt.

Fine tuning comes with practice.

Try this and see if it makes more sense!

Wednesday, December 9, 2009

Dynamic body balancing weekend

Last weekend was really amazing. It started out with me having a meltdown into the magma of unworthiness. Forget "inadequate pelvis," my head, my heart, my whole life sucked. Maybe being on such a steep learning curve curve with life was getting to me. I really lost my peace.
Anyway, the Dynamic Body Balancing class was about to start and I felt that I was facing a cliff to climb to get my attitude together to attend.
Carol Phillips, the Chiropractor who teaches this mixture of methods, called to see if I had time for lunch Thursday. What a blessing. We sat at The Good Earth. Soon she was reassuring me with her story of how shaken her world became until she devoted herself to writing her book, Hands of Love.
Discontent with everything, she also left her practice and began writing...for 8 years (doing a quieter practice on the side). Her story made me feel much better.
Much of my angst is from going in too many directions. I surrendered myself to the weekend. It was the last of four weekend workshops with Carol.
How will I ever have time to practice these new skills? Right now, I have every day booked for my various projects. God would have to decide how this would work, if at all.
As I put on my coat to leave the house, I felt strongly that I had to go back and listen to my phone messages. Confession- I hadn't listened to messages for two days while I was in my snit. I heard those tell-tale etheric bells even as I heard a woman's voice tell how she was facing an induction for her VBAC at 42 weeks. Her baby wasn't engaged in her pelvis. Her first baby never engaged either. She and her midwives had noted that this baby was posterior so she had begun the techniques from Spinning Babies and saw a Chiropractor.

I headed over after class to see what we could do. Her baby had just rotated to LOT the night before, a lovely starting position - except that this baby was still not engaged. I bit my tongue rather than say she was at an increase risk for cesarean because her baby's head was yet above the pelvis (Stronge; and Shin; both studies say 12 x the risk for cesarean, Shin's study is for 1st time moms over 41 weeks). Well, its a second baby, I rationalized, that may be why the head was up. Early labor might yet bring the baby into the pelvis. Though I didn't think so. Her history indicated a torsion in her pelvis. She'd been in a car accident two years before when a woman ran a red light. So, we did a series of activities Friday night.

Sunday, just before the workshop ended, I got a call from the hospital.
She'd been induced the night before with IV Pitocin. Super strong contractions resulted. The Pit was turned off to let her uterus rest (and avoid a rupture). In the afternoon, the midwife broke her water to see if she could labor without more medication. No contractions came so the Pitocin was turned back on. Her cervix was 4 cm dilated (10 cm is fully open and ready for the pushing urge).
What could they do? I suggested a psoas release and Carol's famous three-some: the forward leaning inversion (again), the sidelying release and the standing sacral release. After the workshop, I called back and offered to come out to the hospital. Everyone was tired so a fresh face was welcome. They'd been at the hospital about 24-hours now.

Her labor was just revving up as I arrived. We went through as many of the myofascial release techniques as I could with her standing and contracting every 2-3 minutes. As she stood and leaned towards her husband, I noticed her sacrum and tailbone were pulled unusually inward. Bilateral pressure anteriorly on both insertion points for the sacrotuberous ligaments had a most beneficial effect. I did specific massage to relieve her TMJ, including inside-the-mouth pressure point release. Afterwards, she wanted to lay down on her side. Then I was able to do some cranial fascial release. For an hour, I followed her around like a sucker fish on a shark.

The nurse-midwife came in and offered to check her cervix for dilation. The mom was laboring internally and didn't answer. The doula and I had been with her that hour and we said we couldn't discern a change, though the contractions were closer and quite strong. So the midwife left saying, just let me know...
The very next contraction brought the urge to push. The nurse was there and asked if she should check. Yet, the mom felt no downward pressure and her sacrum was still pulled anteriorly. The next contraction came and again I said, well, the sacrum hasn't come out yet. The mom still complained of the same discomfort she was having from the head being on her bladder.
The third contraction was quite different! The sacrum flared out and I smiled at the nurse, now her sacrum has come out. Now this could have been the fetal ejection reflex (Michel Odent) or it could have been that the ligament release let the sacrum become free to move.

The midwife returned and found a bit of cervix left, but baby was coming down. She went from 4-10 cm during the hour I did the body work. She coped so well I wasn't sure she was progressing; it was easier for her to cope in transition than when she was first on the Pit getting to 4 cm, probably because of the tension in her pelvic floor and sacrum from her car accident. Suddenly, she was getting relief and felt hope. Ultimately, she had to push very hard to bring her baby out. He was quite a good size.
The nurse and midwife were pretty impressed. I guess it could have been a coincidence. I don't think so, though.
Thank you, Carol Phillips, for all you've taught me. I'm pretty sure it saved this mom from having another cesarean. It took all four classes. TMJ and a tight psoas...I think these were the issues. The TMJ can pull up the sacrum or something... let me check my notes... Anyway, never underestimate the fascia!

What a fun way to learn. Take the class during the day and go to a birth in the evening. God arranges everything!
Carol is returning to St. Paul, Minnesota in 2010. Here's Carol's schedule:

2010 Dynamic Body Balancing Workshops with Carol Phillips, DC
Each 20-Hr workshop is $400/$450 with CEU's

Minneapolis / St. Paul, Minnesota
Level I February 12th-14th
Level II April 9th-11th
L III Pregnant Women and Babies July 19-20th?
Level IV October 1st-3rd
Level I December 3rd-5th

Annapolis, Maryland
Level I March 12th-14th
Level II April 30th-May 1st
Level III August 20th-22nd
Level IV October 15th-17th

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.