Thursday, August 25, 2016

40 weeks, lots of fluid, baby not engaged

Congratulations on your baby, beautiful Mama!

You've made it to 40 weeks and have much reason to be proud!
But you're doctor has expressed a concern that the baby's head is not yet in the pelvis.

Julie checks to see if her baby's head is in the pelvis and finds that is not.

This baby is engaged and then some. 0 station, shown here where the  "0" sits between two arrows, shows the middle of the pelvis. When the top of baby gets to "0" Station, the baby is considered "fully engaged."

Forehead over public bone. 

Some phrases for a full term baby that hasn't moved down into the pelvis are, 
  • Still high 
  • Floating 
  • Not engaged
  • Unengaged
  • And, sometimes I talk about the head that is "overlapping" the pubic bone
  • This last is often because baby's forehead extends beyond the pubic bone (occiput posterior)

this is an answer to an email. Read on for the personal experience: 

You've mention that the doctor thinks your baby may not be engaged because of the amount of fluid. Additional reasons (above) a baby is not engaged due to fetal position,
soft tissue issues or pelvic alignment, or a more unusual reason of size.
Checking for the baby's head. Is it deeper than the pubic bone or does it overlap?
The engaged head is deep inside and can be hard for a mother to find.
The unengaged head of a posterior baby will overlap the pubic bone.

I am guessing this is your first baby since you didn't mention another pregnancy.
When I was a practicing midwife, I noticed that many first pregnancies often begin labor at 41 weeks and 2 days. Expecting baby to come at 40 weeks is all very round and tidy, but not particularly likely.

To prepare for a good chance of you starting labor on your own about 41 weeks and 1 day to 41 and an half weeks, having a pelvic alignment session with a myofascial body worker and chiropractor is a reassuring idea. 

If cesarean is an option for you, then timing becomes a variable. It is too easy to slide into a decision that once you accept a cesarean to get things over with. Rather, hold that thought for the appropriate time. My personal opinion, based on Dr. Michel Odent's descriptions in his book, Cesarean, is that if a cesarean is needed to do it after labor begins on its own.
But it is approximately 50% likely that if you begin labor with baby still high that labor will bring baby lower. There are several studies showing that statistic. I've found some easy-to-do techniques 
helps baby get lower into the pelvis. Many women find these help labor to speed up but also EASE up! A fantastic combination!

 Spinning Babies Quick Reference download teaches you what to do to if baby stays high, but I'll give you a quick version of the quick version here:

Adding balance, alignment, and mobility now will help success for you once contractions begin.
After contractions begin and are predictably regular and coming 4-5 minutes apart, doing ten Abdominal lift and tucks will often engage baby's head in the pelvis. It's important to open the top of the pelvis when lifting the belly. See the instructions. Do ten in a row the best you can. These don't work unless you are having a contraction!

When finished with that you should feel pressure on the cervix and not on the back (or less so on the back as before).
Only after trying that and waiting an hour or two to see how labor goes (if given that time in the situation) then try Walcher's Open the Brim

Sometimes, though there is a bit of a risk of malposition from breaking the bag of waters. In 30 years, I have not found it necessary at the low-risk, normal births I attended. 

For women with truly high levels of amniotic fluid, doing a slow leak release of the waters brings baby down. Preceding this intervention with balance first may help the mother's muscles be softer and more symmetrical for baby to drop lower in the pelvis. The resistance of shortened or unconsciously held muscles will reduce.  

I notice a cesarean is less likely if the epidural or the rupture of membranes is done after 5 cm dilation. The data collection on that is not great. But it is clear in the studies that epidural is associated with more posterior babies than no epidural. If an epidural is planned, timing it after active labor has rotated baby to occiput anterior may offer the best chance at vaginal birth. It's not an either or issue, but there is an issue with how babies rotate after some epidurals. You take a chance. 

Getting baby on the cervix with the above plan will help baby onto the cervix and then dilation will be steady as long as rotation is equally easy for baby. 

Nature will engage most babies. Supporting nature means reducing the effects of living in gravity. It's not about right or wrong. It's more about having experienced a number of events or a single key event while living in gravity! A sudden stop during a twist or a previous sprained ankle are two such events that SOMETIMES effects pelvic alignment and thereby baby's path through the pelvis.

Again, balance makes rotation easier for baby
Rotation makes engagement more successful. 

It is quite likely labor will begin spontaneously
When labor starts about half of babies come into the pelvis with no other action needed.  Baby will come down with engagement. It is also fairly likely that doing these activities will help a slow labor or a labor that hurts more than one with which you can cope. (Mindfulness, breathing, and relaxation techniques are excellent.)  Adding balance means helping release what is tight or twisted or support what is loose. Often supporting what is loose is done by releasing some muscle or ligament across the body from the loose area. 

Beginning labor has many benefits
Preparing baby for breathing air is one benefit. Awakening areas of the mind to maternal intuition is reportabley another. Knowing your body can start labor has a satisfaction in itself that is missed by some women who never get the chance. 

Decision Time
Whatever you and your doctor decide, whatever course you choose, you can aid your chance of a vaginal birth by activities before and during childbirth to make room for your baby. Easier birth for babies means easier birth for you.

Sunday, August 21, 2016

The New Face of America's Breech Experts

Many hospital systems have taken to denying their doctors give vaginal breech birth care for families carrying breech babies. These are physicians who've devoted their lives to giving excellent obstetrical care. I believe they have a right to provide that care. I believe midwives who obtain the added expertise also have the right to provide breech birth care. Each caring for the communities of women who choose them to do so.

Today I met with Leslie, Jason, and their two children. They are a family for whom I kept watch while they gave birth to their second breech baby and second home birth. Their midwives invited me to come along for the added security to the safety of the birth that my experience would bring. Without the supportive midwives, Leslie would have had a high chance of being cut open against her will.

On Friday, Sept. 23rd, Leslie will talk on the Breech Panel at the Spinning Babies 2016 World Confluence about their surprise breech followed 3 years later with a planned home breech birth.

In the previous blog posting I talked about skilled doctors loosing their right to attend to breech birthing families because their medical institutions administrative decisions. Likely the fear of legal costs was cited but peer pressure is at the root. The majority of doctors won't assist breech births because its more controllable and less skill to do a cesarean. You can train surgical skills more readily than the complexity of breech birth.

There are few doctors left who offer breech care in this country. Most, like Dr. Brad Bootstaylor, above, have been forced to stop at their hospitals make policies against breech birth.

Midwives, like those in California, are also being denied the right to practice their profession fully. Some midwives taking policy roles are giving up the right of breech birth for their sister midwives. They themselves are not interested in attending breech births. The status of breech skill teaching is extremely poor in general in this country. Therefore, without real understanding, breech birth can be scary to the providers. The risks increase when skills decrease.

So who is left to care for families, women and babies who like to keep their heads up? Drum roll, please...

I'd like to introduce you to the new American Breech Expert:  The first responder. Fireman, paramedic, police, even a taxi driver now has as much chance of catching a breech baby as the average obstetrician.

This South Carolina Firefighter, with less exposure to breech birth than a midwifery student, is the new face of Breech Competency. He did what he had to do to serve this baby and her family - and likely on a half-a-day's worth of childbirth training. With or without high level skills, what care this firefighter could muster is denied everyday to highly trained doctors and midwives of our nation.

America squanders the skills of the few remaining maternity care experts in breech. Canada has their experts teaching the next generation of maternity care providers, in case you were wondering what else our wise elders might be doing.  Policy and politics may intend to leave the catching of breech babies to the men and women who won't challenge the justification of the OR. No medical system expects all babies born in the hands of paramedics to actually live. They are out in the wilderness, so to speak, facing the unfathomable. They will not be found wanting, for they are willing to show up.

These American Heroes do not shirk their responsibilities but rather face them without the full training that would be achieved by a doctor or midwife if it were not denied to them, perhaps even at the very hospital where the firefighter brings in the mother and newborn from an unplanned out-of-hospital birth.

Be assured, the course of modern maternity will not divert from finding the highest cesarean rate sustainable up to the point where maternal mortality upsets the membership. Oh, did you think I meant to say, up to the point where the maternal mortality rate begins to rise?

No, that rate is between 10-15% cesareans, according to the World Health Organization. Whereas, our society accepts a 34% rate. Some would like it lower, and even our Public Health officials cringe at our current rate knowing women are dying to reduce litigation for the obstetrical profession, for courts still think that if a cesarean was done the best care possible was given.

Physiological breech birth is the best care for over half of women with breech positioned babies. Our nation has to catch up and learn the possibilities of gentle breech birth.

Banning Breech in Atlanta

Dr. Brad Bootstaylor of in Atlanta, GA is someone I highly admire. He is a leader in the Atlanta birth movement. I've been to his office, he blew my mind.    He  was unethically restricted from providing care to birthing women having natural childbirth for their breech babies.

"Dr. B" has the skills, he has the intent, and the community of birthing families choose him. This is reason enough for the medical policy makers to shut him down.
This means that yet another bearer of the treasury of birth skills has been denied his God-given and self-determined path to the skills necessary for the preservation of the Human Right of birth for those coming bottom first. Here is the notice:

To our amazement and disappointment, See Baby Midwifery was advised by DeKalb Medical on 8/17/16 (yesterday) that we can no longer support birth options for mothers to include VBAC, water birth and vaginal breech deliveries.
This sudden and unexpected lack of support brings great concern to us and our community.
Temporarily, all VBAC eligible patients will be birthing at Emory Midtown with Brad Bootstaylor, MD.

Hospitals around the nation short-sightedly make the same Human Rights violation. In my area, Dr. Denny Hartung was blocked and in Los Angles, Dr. Ronald Wu faces the same.

September 7th there will be a Demonstration on Wednesday, Sept. 7th at 11 am, at Glendale Adventist Medical Center. 

The FaceBook event page says,
Last week, Glendale Adventist Medical Center created a policy outright banning vaginal breech birth...

GAMC is fortunate to have one of the most skilled breech practitioners in the country. Dr. Wu is an honored physician who has assisted women with vaginal breech birth for more than 40 years. And while this policy appears to affect the entire obstetric department, the reality is, it’s directed at this one specific provider, making it seem punitive and unnecessary.

We are concerned that this change seems to be motivated by political and perceived financial concerns instead of what is in the best interest of mothers and babies.

This is a policy that forces women into cesarean sections without respect to patient autonomy in decision-making and their legal right to informed consent and refusal.

We believe there is much evidence to support VBB that was not considered by those involved in this decision. Basing a policy on flawed information and perceived but not actual liability is an erroneous precedent.

A couple of people have spoken to the hospitals CEO about this matter without resolve. ImprovingBirth, in collaboration with a group of Los Angeles area providers and a couple of their celebrity clients have sent a letter to their board of directors requesting a meeting which we are less than confident will actually happen.

We will rally to bring awareness to this unethical policy and we hope you will join us.

Next blog post, I'll introduce the new US Breech Expert carrying this responsibility denied to Dr.s Wu and Bootstaylor. 

Monday, August 1, 2016

Face Presentation

Some of us like to face the music, face the facts, turn to the light, face life full on...
The baby who is coming face first, or face presentation, most often is born fine in this position.
There may be a little slow down after ten centimeters which can be helped by standing in a shower, moving and swaying, each a variation for comfort while standing through contractions.

From book of Smellie, 1800s

Face presentation is not the same as posterior presentation. But a face presentation can be occiput posterior with the chin anterior.
You may see more face presentations among premature babies, large babies, babies without skull development (anencephaly) or in women with small pelvis and large baby. Abundant amniotic fluid may allow for a face presentation, and those are the medical list. I would add that a twist in the lower uterine segment such as may also make a posterior or even a breech baby more likely may alternatively lead to face presentation.  A fall or jolt during or long before pregnancy may be examples of events that can cause such a twist. 
Face presentations occur from about 1/500–to 1/1,250 term births depending on who you ask. Duff and Benedetti wrote about face presentations in the 1980s.

The chin is the landmark of the face presentation, unlike a flexed baby whose occiput is the landmark.
  • Left Mento-Anterior (LMA), Left Mento-Posterior (LMP), Left Mento-Transverse (LMT);
  • Right Mento-Anterior (RMA), Right Mento-Posterior (RMP), Right Mento-Transverse (RMT)
Baby's whose chins are posterior are aiming their chin over the perineum. If contractions are slowing then there may not be the strength of momentum to bring the baby through the perineum since the chin is not sweeping the perineum open. There isn't enough pressure. The back of baby's head may not be fitting through the pubic arch on the front side. 

I was at one birth like this. The chin was on the perineum and 5 contractions didn't move baby forward and the little face was quite red and swollen. During this time, the mother tried squatting, hands and knees, and pushing on her back. (She squatted on the OR table in the hospital with 8 staff ready for a cesarean.) near and an episiotomy was necessary and then baby literally fell out. It was the first episiotomy I had seen. The cesarean was avoided and the baby born. The mother would not have needed an episiotomy with a flexed head. This was her first baby, and baby weighed 8 and 1/2 pounds, or a bit more than 4000 grams.

This position is considered impossible in the text books. All things vary, and some babies do and some babies don't follow the text book. 

What to do about a face presentation.

Some midwives have told me that in labor, 
they have inverted the mother just as in a forward-leaning inversion and then
shook her buttocks with their hands or using a rebozo. I call this a tootsie roll wrap and find it jiggles the buttocks quite well. This both relaxes the mother's deep muscles after a few minutes, and works baby back out of the pelvis. The oncoming contractions help keep baby head down. 

I am not sure that this would be wise in pregnancy without contractions!
Women can not invert if they have high blood pressure. 

Helping women into a parasympathetic state, or a more deeply relaxed state can help, and jiggling accomplishes this as well as other body work techniques. 

Balance is the key. The baby is not likely to be in this position if the surrounding supportive tissues are symmetrical. There are many roads to Balance. Balance the mother and the baby may flex. 

FYI, F. L. I. is Knee high

How high the couch? Inverting safely

Anisa asked, "Can anyone guide me about Forward-leaning inversion? What should be the height of the couch from which we are going to lean downwards."

The answer is within...
Or, rather on you? It's the height of your knee. Since women come in different heights, I'd suggest you see if your couch or bed is about the level of your knee.

The height of the couch approximately matches the height of the knee of the person who will invert.

A couch slightly higher than the knee is fine for a fit mother.
A lower surface may be better for someone with weak shoulders or more weight than average.

The steps to the forward-leaning inversion are at Spinning Babies website.
Don't invert if you have high blood pressure or other risks of stroke.

Tuck the chin and don't lean on your head.
This helps the connective tissue have room to "unwind".

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.