Friday, September 26, 2014

Breech then and now

Thirty one years ago I caught my friend's breech baby in Omaha, Nebraska. I was thinking of this Monday with a group of midwives and doulas at the lovely Mommy Fitness Omaha with Julie Summers and Kelly Langfeldt of Five Stones Massage and Birth Services. Kelly invited me down to present a Spinning Babies Workshop to the now thriving Omaha birth circle.

My friend's midwife was unexpectedly delayed on that night so long ago.  But I'd done my best to  prepare for just this contingency. She'd loaned us the resources she had; Williams, Oxorn, a booklet by Sheri Daniels, and the already popular Spiritual Midwifery by Ina May Gaskin and Farm Midwives.
The week before her birth, I'd called Sheri Daniels, Pamela Hunt at the Farm, and a midwife in Minnesota to gather words of wisdom. The consensus --get to the hospital and don't do this at home! If the baby gets stuck the baby could be brain damaged or die. We were looking for hospital options.

My friend's hospital option: cesarean surgery, ten day stay, no husband allowed to hold the baby until baby is home. My friend's history: her aunt had her first baby breech at home with a veterinarian some decades earlier. My friend's decision: stay home at all costs.

Now there is a change that happens in life between the waiting for and the holding of a baby. Her decisions were during the "waiting for" period.  My nights were spent on my knees after reading through the books again and again.

She found a willing doctor, who could take her on Monday when her insurance coverage could be changed over. Friday, this doctor tried to do an External Cephalic Version but the baby couldn't turn with it. Her labor started Friday suppertime. In the wee hours of Saturday morning her little girl was born. Seven pounds of wailing wonder.

Today women face similar politics. Women struggle to find care in the hospital. Few doctors have breech skills. Few midwives have them either and those that do are generally home birth midwives without hospital privileges.

Today we have emerging breech skills. England is taking full responsibility to train doctors and midwives in breech skills and birthing women can find the options with a internet search or word of mouth referral. North of England Breech Birth Conference starts tomorrow in Sheffield on 27-28 September. My dear friend Jane Evans is speaking on the mechanisms and physiology of breech birth and Dr Frank Louwen will present on the dynamic benefits of "upright" maternal position for breech - the knee-elbow (very similar to hands-and-knees) for breech birth. I heard them in Ottawa in 2009 and know that breech lives have been saved for the goodness of their sharing their wisdom.

The three pillars of safe breech birth are:

  1. Don't touch the breech (when rotating and descending spontaneously), 
  2. Knee-elbow position for the woman (spontaneous upright positions are supported or hands and knees suggested for new breech providers and when other upright positions aren't spontaneously chosen by the mother (not the midwife or doctor), and 
  3. Don't cut the cord (the baby's blood in the cord returns to the baby expanding air sacs and reviving most slow to cry breech babies).


With these beginning guidelines the rates of complications for breech drop dramatically. Frank Louwen will be sharing data from over 350 upright breech births in Frankfort. Babies get stuck far less often. When they do get stuck babies need a practiced provider to free most of them. Good luck only goes so far. Practice with a doll and pelvis until the techniques live in your hands.

I wish I were in England this weekend with Jane, Helen, Frank and friends. I'm grateful to my Omaha friends for starting me on this grand adventure I call Spinning Babies! 

Thursday, September 25, 2014

Why won't this labor start properly?

This post discusses onset of labor.

A woman is commonly considered in labor when her cervix is progressively opening and continuing to open. Stages of labor are the first stage of cervical dilation, the second stage of "pushing" or until the actual birth of the baby, and third stage which begins after the baby is out and until the placenta is out. A fourth stage of labor is described as the following period of newborn and mother's adjustment from birth to physical stability.

Early labor from 0 or 1 cm to 3-4 cm.
Early labor is a time we expect baby to be engaged. In an experienced mother, engagement may not occur before latent labor in an on and off labor pattern, or in early labor, where dilation is gradually moving to 3-4 centimeters. A minority of women are open to 3 or more centimeters when labor begins to open their cervix further.

In first births, for first time mothers and for many VBAC (vaginal birth after cesarean) we expect baby to engage before labor starts. When a first baby isn't engaged until labor begins the rate of cesarean is high. (Oboro; Siddiqui; ROSHANFEKR) Fortunately, we can let babies engage in labor with the help of labor contractions in certain maternal positions described at www.SpinningBabies.com.

This baby is not engaged although the nurse can feel the back of baby's head.  The forehead overlaps the pubic bone.  Overlapping the pelvic brim may keep labor from starting smoothly, or, oddly enough, the woman can get to 10 cm and pushing but the baby remains high at -3 station. The overlap can only be felt when a woman lays on her back. 

The slow labor start up.
Women may have contractions that keep them awake. Yet when the cervix isn't dilating they aren't considered to be in labor. Doctors and midwives often tell them to go home to bed and come back when contractions are longer, stronger and closer together.

The stop and start labor.
Other women may feel their contractions come strongly but then they taper off and stop. They can get very strong, but seem to back off. Later the contractions may start up again only to stop again. The cervix isn't changing or isn't changing in any encouraging amount.

Strong contractions like transition, but the cervix is 2 cm dilated.
Once in a while a woman has many symptoms of strong active labor. She may feel a bit nauseous, shaky and have hot and cold flashes. Sometimes she feels like pushing. Rushing to the hospital, she and her loved ones and doula may expect to find out that the baby is coming quickly. Imagine the frustration when the nurse checks and finds out that the baby is still high in the pelvis or even above the pelvis. The cervix is hardly opened and the os or opening of the womb is still tilted far back.

If labor doesn't start smoothly, determine through an exam or your own exam if baby is engaged well or not. Engagement is the first step to labor progress.

The help to engage is within the mother's body. Balancing the body (fascia, ligaments, muscles and joints) help soften those anatomical features that may be tight or shortened, spasming or asymmetrical. Simply put we release what is tight.  The psoas muscle pair are key players and walking is a way to support their length and suppleness.

She does an abdominal lift while flattening her lower back.

Dad helps with an abdominal lift in early labor to engage baby and let labor progress.

In labor, the abdominal lift and tuck through ten contractions often helps baby engage. See more on this great technique devised by a mother, Janie King, in her book Back Labor No More.

Only if this technique doesn't work, try Walcher's Open-the-Brim position. For details on Walchers and more on Engagement in Labor see www.SpinningBabies.com

Tuesday, September 16, 2014

Flexion matters

The Anterior Positions and LOP

At Spinning Babies, fetal position matters.

Babies positioned on mother’s left side more often curl and tuck their chins more easily (flexion, flek’-shun). This makes baby’s head measurement smaller and lines up baby with the pelvis to be able to help in the birth process.

Flexion is more imporant than position. Muscles and ligament “balance” is more important than size.
Discovering how to tell your baby's position is in the Belly Mapping book and the Spinning Babies website.


A flexed head can measure up to 2 cm smaller than the same baby's head extended, or having the chin up.

Not only that, but a flexed head molds even smaller. An extended head takes hours longer to mold, if it needs to. And first babies almost always need to reshape the top of their heads to fit the bones of the pelvis.

A flexed baby can use their spine, back and shoulder muscles to help themselves be born. Flexed babies bodies are lined up to make their kicks at the top of the womb (fundus) be more effective in moving them down through the pelvis. Most babies on the left are anterior and flexed. The Left Occiput Posterior baby may be flexed and rotate readily with the help of strong labor contractions.

Gail and her sister, Kathleen, will be exhibiting Spinning Babies at the great Lamaze DONA 2014 conference. Come to our booth and see the book. If you're pregnant, come for a free belly painting!  

Sunday, September 7, 2014

A new start for active labor, a new question for progress

The new guidelines from ACOG

Recent changes in defining active phase of labor from 4 cm to 6 cm. This change is intended to help first time mothers avoid being given a cesarean when labor is simply slower than what was considered normal. Longer labors can certainly be normal. So when the question is asked, "How far dilated is she?" or "How far dilated am I?" the pressure for progress is extended to 6 cm now.

Active labor was considered 4 cm and a changing cervix. A long stall at 4 cm, meaning the labor is not progressing past 4 cm though contractions are regular may be a reflection of the distraction to the mother. A social gathering that seemed supportive before labor began may actually be the delaying factor for a woman who is waiting for privacy to enter the active labor phase. Tension or distrust in the environment or people in the immediate area may keep a woman from "relaxing into" labor. Or, she may simply be waiting to arrive at her birth place upon when her labor may take off quickly once she feels safe to open.

ACOG had long stated that doing a cesarean before active labor for length of labor alone (and not health indications) was unfounded. In a move to reduce the unhealthy and high cesarean rate, ACOG has taken another step. Moving the start of active labor to 5 cm for an experienced birthing woman and to 6 cm for a woman's first labor gives women more time to labor.


The better question is, "Where's baby in the pelvis?"
The woman and baby may need this time to help baby engage if engagement hadn't happened yet. The baby is high, at "-3" station. Often a mother hears that baby needs to come down more and the nurse or midwife doesn't explain station. Its OK to ask. An approximate station is helpful information even if there is a little variation in the number.

Another way to ask is, "Is the baby in the pelvis? Is the baby ballotable or well engaged?"
Answers like, "The baby is high," or, "The baby isn't in the pelvis yet," also mean "-3" station.

Engagement in labor is often due to the mother choosing a position that opens the brim, and is less likely in the first time mother to be by chance or time. Opening the brim with Abdominal Release, or an Abdominal lift and tuck (not at all a tummy tuck, ladies!) can help the baby enter the top of the pelvis in about ten contractions time.

During the phase of labor near 5 cm, the first baby would often be already engaged and moving onto the pelvic floor in the midpelvis. The fetal station would be "0" or nearly "0" at "-1" or "+1".

Giving extra hours for those women having a longer labor whose baby is near "0" station may give time to help baby rotate through the pelvic floor.
Easing this time is often helped with the Sidelying Release. Choosing a myofascial release is choosing the first Principle of Balance. Labor may pause an hour as the uterus has a short rest and then will resume. Sometimes, though, baby comes quickly so be where you want to have the baby. If labor doesn't proceed when baby is in the midpelvis, a lunge will give room for the bones and for the tighter pelvic floor to open on one side. Do the lunge through a contraction for 3 contractions on each side and then repeat.

Waiting for a labor to progress that is holding at 6 cm, or 5, hour after hour may reflect a misunderstanding of labor progress. First attend to the soft tissues and alignment (or balance) of the pelvis. That's why Spinning Babies first principle is Balance. Then open the brim or open the midpelvs depending on how far down baby has gotten with the Principles of Gravity and Movement. That's where were find the techniques and moves to open the pelvis.

Understanding the rotation needs of the baby and the levels of the pelvis, we can support labor progress more smoothly and save a woman many hours of waiting. Sometimes, as in lack of engagement, or transverse arrest waiting can take days and still not lead to progress. Let's increase our observation skills and ask the right questions to find out where baby is and what baby needs to make the next turn on the journey.


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.