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."


1 comment:

Melissa B said...

I'm a FTM who is 41 weeks today and feeling so demoralized about baby not coming yet. I have until 42 weeks when my midwives -who operate out of a Hospiital with a birth center - will have me admitted to Labor and Deliver for induction -probably starting with a foley bulb.

I feel baby's head bumping my cervix and making it "talk" to me all day long. But I am only one cm dialated but barely - while the outer opening has a nice soft divet the inner opening cannot accommodate a finger tip. No bloody show or mucus plus or waters. I am having regular non-painful braxton hicks at night - but that's it!

Throughout pregnancy I did the balancing exercises of lunges and tons of walking and squats and Kay Bowman alignment. (I did the forward leaning inversion until about 7 months when my midwife told me to stop since at that time the baby was small and she was concerned she would be encouraged to flip breech with continued inversions (not totally confident this was the right advice).

My sacrum and attachments are wonky on the left side (left side higher) and I did lots of physical therapy that I'm not totally confident in. But it kept my back pain very manageable.

What to do at this juncture? SOS! Any thoughts would be so appreciated.

Thank you for all the wonderful info on your website.

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.