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

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."

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 (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. 

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.