Saturday, January 30, 2016

Don’t say Posterior? Does silence serve?


Doulas and patient-centered providers of all types have a well-placed desire to protect a woman’s confidence to cope with childbirth. 

Birthworkers must navigate the topic of fetal position between a natural birth ideology and the medical research on posterior presentation.
I didn’t say we have to choose between natural birth and research, mind you. But we move from personal proclivity to interpreting complex and sometimes incomplete research from which to make sense of fetal position changes. 

Social ideals for natural birth pull against the expanding variables of fetal rotation. My interest is to offer a functional understanding from which the doula and provider can discuss posterior position with parents and others in an empowering way.  

You can read a portion of such a discussion with midwives in my article Posterior Perspectives in Midwifery Today, Issue 114, at https://www.midwiferytoday.com/enews/enews1716.asp#main

Rachel Reed, midwife and PhD, and insightful blogger of Midwife Thinking poses the fact that “most babies rotate” as ideology in Celebration of the OP baby,  “These situations only become problematic when we apply generalised expectations about how labour should be to an individual woman, baby and situation.” To quell the fear-factor risen about posterior fetal position over the last two decades, Catie Mehl from Ohio, and Angela Horn from Arizona, two active doulas doing good things for families in their communities promote the ideological viewpoint which seems, at first, to reject challenges due to fetal malposition. Each blogger seeks to cast fear from the examination of proclaimed complications about birth, through which stating concerns might alarm pregnant women: the large baby, the overdue baby, and in this case, the posterior baby. Their post at once acknowledges the risks of posterior, and rejects the advantage of proactive support of the woman’s  birth companion, or doula (doo-la), in  discussing activities to prevent or prepare for such a labor. Selina Wallis keeps a scholarly eye on posterior issues on her blog, Magical Birth. She did a fine job discussing  Catie and Angela's conclusions so I will say less rather than more. 

Our heroines claim their resistance to educating women is because evidence is lacking to support maternal position changes to rotate babies out of the occiput posterior position (OP). They propose doulas should not discuss OP as a concern in pregnancy with clients, as these have the “potential to influence how pregnant women perceive their preparation for birth and the experience itself.” For now, let’s look at the justification for discarding proactive preparation. The ideology over physiology argument rests on missing data points and over stating research conclusions. We’ve already established the value of these doulas in their community so we will follow this advice from Angela Horn with what might be missing from her assumptions.

“The research shows us that most babies will be OP at some point in labor, and the vast majority of the time it does not cause issues with the labor. When it does, we need to focus on the comfort of the laboring person rather than rotation, as there is no evidence to suggest maternal posturing will fix baby’s position, and most babies will rotate just fine on their own.”

Does the fact that “most babies” will rotate on their own is true, permit well meaning doulas to ignore those that can’t rotate for themselves in our discussions with pregnant families?  Sizer found 65% of OP babies rotated to OA and Lieberman found about 4 out of 5 posteriors rotated at each labor phase observed for fetal position.


Relying on the fact that  “most” babies rotates leaves, the 15-35% of babies that don’t rotate to potentially long labors with cesarean surgery, or as Angela Horn cites, uterine rupture and occasional death (Fantu). And though Lieberman shows 20% of posteriors turning to face a hip, 24% of those ended labor with a cesarean for deep transverse arrest.


Randomly posterior?

Lieberman’s 2005 study seemed to limit posterior studies to comparing ultrasound diagnosis to the doctor’s fingers until recently. If fetal position changes were random, then why study fetal rotation? The fact that Lieberman observed that 36% of the babies were OP at one time in labor is not equal to their requirement to be OP, or that some women’s pelvises must have an OP baby.

Assuming the wrong conclusion slowed research. The question should be, if one variable doesn’t explain the pattern of fetal position changes, what else might we explore?

Going back to the 1800s we see physician description of right obliquity of the uterus (Dakin). This anatomical normality of uterine shape then might be a variable in deciding flexion or extension of the fetal spine and, so, head diameter. Spinning Babies Workshops illustrate this possibility.

“It’s a hypothesis, GG. A hypothesis is a way of looking at the world to see if something you think about will work in that world,” Alton, my four-year-old grandson, told me while I tucked him in at bedtime after his Little Scientists class.



Accuracy to determine occurrence and cause may need the addition of multiple variables. Extension and the dynamics of the pelvic floor are two such variables. 
Pelvic floor dynamics play a part in the extended baby rotating to posterior as the more front of the head becomes the rotation denominator, rather than the round crown. 

So the baby from the Right Occiput Transverse position will more often rotate to posterior (Sutton). So if the Occiput Transverse position whether right or left was counted as one single data point in Lieberman's study, for instance, flexion and extension are ignored twice, once because the angle of the head for flexion was not measured and two, because right or left occiput transverse was not considered different.

Variables of fetal position may include degree of fetal head flexion or extension, size of baby, asynclitism at or after 0 station, and shape of parietal eminences; maternal anatomical features -- such as which of three levels of the pelvis (described in America as stations of the pelvis) in which the baby was, and whether the diameter of that level matched the baby’s anterior, transverse, or posterior position (which is to say, the head was in an unfavorable diameter) -- pelvic floor tone and relative symmetry, sacral mobility, size of pelvic outlet, and location of placenta.


Can a variable have a variation?

If the strategy for support and care for posterior labors hung only on the seeming randomness of a single variable fetal position change and the usual success of the birth process, might we only expect 80-90% of babies to survive birth. And would rejecting proactive measures seem to have the doula accept William Barth, Jr.’s sobering treatise on the high maternal morbidity of OP? Not to repeat Fantu’s heartbreaking report on obstructed labor in Ethiopia. The justification for neglecting proper pregnancy counseling is confusing.

Thankfully, we do have medical interventions for the mothers of the persistent and non-fitting few OP babies, especially since repeated studies find only 17.4% of first-time mothers with OPs have a spontaneous birth without medical interventions (compared to 76.2% of anterior), with 64.7% of women finishing their posterior labor with a cesarean (compared to 6.3% anterior, Lieberman).

While maternal position research study sample sizes are small, they open evidence-based pathways to application of techniques. Maternal positions studied were found favorable as comfort measures. Guittier et al studied maternal positions suggested by de Gasquet  in Trouver sa position d’accouchement Paris: Hachette Livre; 2009:126. But none of the proposed positions opened the inlet. (Reitter, 2015) where the posterior baby needs the room to move from the anteriorposterior diameter to the oblique or transverse direction of the opening to the pelvic passage.

Desbiere’s interesting attempt to compare three maternal postures to rotate baby did find that all women that used hands and knees position and recumbent were successful in rotating baby out of the posterior position. Strebler also found some success. There is evidence for maternal positioning to rotate a baby out of posterior.

For birthworkers, Ms. Simkin advises, “Avoiding OP positions is a worthy goal” (Simkin 3). I agree and bet my life work on it. The challenge comes, of course, in choosing truthful words to speak to a mother whose baby remains OP. Spinning Babies serves doulas, providers and parents who choose to explore the small samples in the research and explore concepts proven in physical therapy models and apply them to birth.

Spinning Babies celebrates physiological and spontaneous birth and seeks to understand the variables to replicate the environment of success for that still-significant percentage of women whose babies won’t spontaneously turn. Many don’t need a cesarean.  Many avert their cesarean by applied techniques without control study evidence. .

How do we reach these women? We actually don’t have to speak of posterior fetal position! We can easily promote the comforting and effective maternal positioning techniques “to make room for the baby!” Many women enjoy being proactive in her pregnancy. Women seek physiologic options before resorting to obstetrical and mechanical interventions.

I will continue to help women have a healthy, safe, even happy birth with the mother's reports as my evidence. Its true that some women would have had a shorter easier second birth than their first posterior labors, but the frequency of short subsequent labors might be worth investigating. The Spinning Babies approach to maternal positioning strategies for fetal rotation are sufficiently successful and ever improving. Gentle techniques with scant research but abundant anecdotal evidence to support them are now spread worldwide with the social networking enthusiasm of birth activists and appreciative parents. Certainly, women are benefiting now from my and others recommendations for maternal positioning. (Gizzo) I add myofascial (muscles and connective tissue) passive stretch techniques to make room, or reduce tightness, in the path of the baby.

World fame may be transitory without convincing research. I so want research specific to Spinning Babies’ approach to provide a third leg of the stool to balance the two opposing strategies of Wait-n-see vs. Cut-em-out. There are more than two answers to any argument. And this is certainly the case for labor progress solutions for posterior and other challenging positions.


A Research Dilemma

How shall we study something as complex as a paradigm?

For a premise like Spinning Babies, scientific clarity begs multivariable factors for the
flexion, rotation and descent of normal cardinal movements of birth. For instance, we cannot consider that all the factors for a progressing labor are exactly similar in a non-progressing labor. Most pelvises have been shown to be “adequate” after cesareans. Most babies estimated to be large are found, after the cesarean, to be smaller. Might there be other elements of the anatomy than that bony pelvis at play with birth?

Can the most simple solution be the answer to a complex problem? The Karminia study is often cited to disregard maternal positioning, though only hands and knees and pelvic rocking was studied and only 11% of study subjects fully complied to the 2 ten-minute periods for the full three weeks before birth. Even with that low compliance we should have seen a difference in outcomes for those few. But we learned that this highly-recommended comfort measure is not also a rotation measure in pregnancy. That’s all. In labor, hands and knees position helped OP babies rotate (Stremler), especially when adding Rebozo sifting (Cohen) .

At Spinning Babies, our solutions to stuck labors begin by looking to the level of the pelvis where the baby waits to match a corresponding technique(s) (Vitner, Iqbal). In other words, we don’t use an outlet technique for an inlet problem and expect it to work. While squatting might work for an OP baby below the midpelvis, the Abdominal Lift and Tuck with a flattened lumbar (Janie King’s Abdominal Lift with Penny Simkin’s adaptation of counter-nutating the pelvic sacrum) is specific for helping an OP baby rotate off the inlet. However, the research community prefers a single variable study. How one variable may determine the validity of a holistic method seems more suited to starting a study than applying it in real life situations. Single variable investigation is the nature of control studies that confounds scientific exploration from paradigm review (KC Johnson).



Conclusion

Neglect of prenatal and intrapartum care for the laboring woman and her posterior fetus may result from a lack of understanding on the part of her doula or provider in interpreting evidence. There is sufficient evidence to justify the doula and the provider offering non-medical, “physical theory” prophylactic strategies for the posterior fetus. Anecdotal evidence of a collection of concepts and techniques put forth as Spinning Babies is gaining popularity for comfort and resumed labor progress for posterior and undetermined fetal positions collected through the timestamped emails and posted Facebook testimonies. Increased understanding of the birthing baby’s rotations through the pelvis may come from combining variables in prospective research observations.

By rephrasing our advice to pregnant women away from concerns about fetal position, towards the enjoyment of bonding (“binding-in” in pregnancy), we are truly proactively preparing for easier childbirth. “Making room for the baby” replaces potentially trauma-inducing words like “uh-oh!” and “malposition” or “stuck baby”.  The diagnosis of fetal position becomes suddenly less vital. Meanwhile we are sensing and observing, guiding a pregnant women towards full range-of-motion for the best flexibility, mentally and physically, for the upcoming expression that is her birth.

Call to action: I need a research assistant to help prepare for studies who has office software skills and is in school for their doctorate or is post-grad. Email me at Gail@ you know the website! (robot dispelling email hint)

Sunday, January 24, 2016

Spinning Babies and High Blood Pressure and Pre eclampsia

Spinning Babies seeks to reduce the struggle of Good morning Gail,

Just had to share a success story with you.  We had a 38 week induction for severe pre-eclampsia on the floor.  She'd been on pitocin for hours, was up to 22mu and still only 5cm, -3 or -4 station, head ballotable and seeming to be caught on the brim of the pelvis (with an epidural).  

Her labor nurse had been to a midwife conference last fall where there must have been a workshop on spinning babies. [Yes, I presented Engaging the Inlet; Labor onset beyond cervical ripening, at the American College of Nurse Midwife chapter of Minnesota conference, Oct. 2, 2015]. 
So we talked about doing some Spinning Babies moves.  I went in to help her and we did Side-lying Release and a "modified" Abdominal Lift and tuck on her knees on the bed. [Consider this variation for when the moms had an epidural. Be sure she has a person on each side of the bed holding her steady.]  

An hour later she was 6cm -1 station, and another hour later she was 9-10cm.  Can't tell you how happy I was for that patient and the ability to help her!  

As a side note, I happened to be teaching a student clinical that day (not actually working the floor) and my student was able to see this fantastic work and can't wait to be an OB nurse. 

Thanks for all the work you do, Lisa B. RN


The nurse's testimony came the same day this week that I got a consultation call from a second time mother hoping for an upcoming vaginal birth after her previous baby was born by cesarean (VBAC).

Jess Tate (not her real name) was 36 weeks and 5 days pregnant when we spoke. She wanted tips to avoid another cesarean for transverse arrest, the cause of the cesarean for her first birth. If you do, too, check out, http://spinningbabies.com/learn-more/techniques/the-fantastic-four/sidelying-release/

I asked if there were any medical reason not to do a forward leaning inversion? See the contraindications and instructions for when its safe to do at http://spinningbabies.com/learn-more/techniques/the-fantastic-four/forward-leaning-inversion/

She said her doctors were watching her for high blood pressure, although it wasn't quite 140/90, it was over 30/15 points higher than her normal. I asked a few questions about her symptoms.

That means, no inversion. We don't go upside down when there is risk of a stroke.
Abdominal release and standing sacral release will have to do for it. Not identical, not all inclusive, but as close as we can get.

Her liver profile wasn't encouraging.
Generalized swelling including her face
Severe headaches
Flashes of light and other visual disturbances

She did not have protein in her urine.

The headaches began 3 weeks earlier and were severe enough to deny her sleep. The doctor prescribed Promethazine.

She wondered if she were going into labor as she was showing early signs of possible latent labor. The warnings on Promethazine are not to take in labor in case it causes the baby to bleed. Bleeding in the brain can be fatal to newborns. How can she sleep then on the night she might or might not go into labor? Second time moms may experience several nights like this.

Yet now she couldn't sleep and if she didn't take the Promethazine she was up all night. She had nightmares when she took it. She was anxious during the day. I noticed that was a side effect as well as the nightmares.

The medical plan was to see if she could stay pregnant long enough for the baby's lungs to mature before she had a siezure, her ration worsened, or her blood pressure went up 3 more points.

I introduced Jess to the Brewer Diet immediately. As we spoke, her husband made her a high protein meal.
She was seeing the doctor in the morning. I asked her to eat 50 grams of her 100 gram daily goal of protein before seeing the doctor.

The next day she was normal enough to remain home. She felt somewhat better. We talked again the day after that 36 hours after starting the high protein, salt-to-taste, 3 quarts of water, leafy greens and more good food diet designed by Dr. Tom Brewer some decades ago. This diet has been a Bradley Method Childbirth  Class recommendation and a home birth midwife recommendation since the 80s. Babies end up big and healthy.

Reduce sugar, white flours, etc. and eat close to the farm, so to speak, to avoid large sugary babies. We love 'em but for a VBAC mama it'll be easier through those ischial spines, since this mama needed strategies, and her baby would have good size and good health from good food.

36 hours later she said her headaches, swelling and flashes of light were gone. She still hasn't had her baby yet, so we are hoping for improving health and spontaneous and safe birthing!

Yesterday.
Sarah Longacre of Blooma.com asked me to come down and talk with some of the relatively fresh doulas. Expecting Spinning Babies topics they may have been a little put out to have a lecture on blood pressure, Brewer style via Gail Tully.

Success has happened so far for every one of the mothers I've counseled who followed the Brewer Diet but one that we also had to involve homeopathic advice from a professional. The stories are dramatic. Read it yourself,
http://www.therealblueribbonbaby.com/

There are wonderful complimentary modalities, alternate modalities, for hypertensive disorders when given by the expert practitioner. The Brewer Diet has saved lives and let babies grow to full gestational potential. Check it out.

LAST UPDATE! Jess Tate (in the story above) called me while I was grocery shopping. She is now at 38 weeks and feeling much better. The headaches have not returned and her swelling is gone. Her blood pressure at the doctor's visit was 108/60. She continues to eat 100 grams of protein a day and wonders about her contractions. More questions about her contractions show they last 1-2 hours just before dinner time! She's hungry and Baby's hungry, so to speak. I suggested a snack about 4 pm so her body has the energy to wait for her husband's arrival at their 6:30 supper together. Now that her blood pressure is normal, I asked her to ask her provider if there is any more a medical reason not to do forward-leaning inversion. We'll see.  But I don't think her contractions are due to a fetal position, but rather a late afternoon need for a protein snack. 

Monday, January 11, 2016

Walk proud after birth! Mama, you can Strut!

The timing was perfect, the product was something she could get behind, the deal was done!
Then I heard about it and here is a product-based blog post to tell you about Mama Strut.


Tammy Ryan was contacted by Jill Bigelow of Pelv-ICE right about the time she was enamored  with the pelvic floor during her training to come on the Spinning Babies Approved Trainer team.  Jill approached Tammy to promote their new Mama Strut postpartum recovery aid. She loved it. When Tammy told me about it, in my private thoughts, I was like,
"Someone designed a pair of shorts to hold an ice cube? What is the mom doing out of bed that early, anyway?"  Well, when I saw the actual pair of shorts, I was very impressed. Jill put so much quality and creativeness into her product. And the support panel aspect in itself offers powerful postpartum comfort. Actually, for the mom who has to get out of bed early, perhaps to walk to the nursery, Mama Strut will add a health safety advantage.  I knew I would feel good telling others about it, too!

So, Tammy and I put together a little video Q and A about Mama Strut.

Spinning Babies asks, What is MamaStrut? 




The visual on the pants is hard to see, so I will include a photo from the Mama Strut Website.

These pants are actually a medical device! So you know I found them well stitched and well made.
See if your insurance carries the cost.
Now you can see how to put it on at https://vimeo.com/109742584

We are so impressed, we affiliated with Mama Strut, and asked Jill to have Mama Strut be a Spinning Babies Sponsor. So you can see the ad at the top of our website banner.

Contact Tammy Ryan, Director of Education and Sales, for MamaStrut.

There are exercises to protect your pelvic floor as well. Mama Strut is a super smart support tool but you will also want to stand, walk, Rest Smart and Move Smart for Postpartum as well. Moving will definitely feel better for weeks and months after birth. Buy Mama Strut from Spinning Babies Website and we'll both feel better. Thanks for reading this weeks Product Blog! 

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.