Labor & Birth: The Big Push…Let the Woman Lead

“Let the Woman Lead in the Dance of Birth”

Today I attended an in-service training for labor nurses and educators in our hospital maternity services (Yale-New Haven Hospital) concerning the new guidelines on second stage, or pushing, from AWHONN. These guidelines are being implemented on our labor and birth floor. This change comes not a moment too soon!

Not only are women telling us that they dislike the medicalization of birth, but also that they perceive potential dangers to them and their offspring inherent in some common in-hospital practices. One such practice is the use of the Valsalva maneuver, also called “directed” pushing, in which you hold your breath and bear down hard. Unfortunately, it causes hemodynamic problems, damages tissue and stresses mother and baby.

Our educator today, Louise Ward, RN, MSN, took us through the second edition of the AWHONN guidelines, with their focus on following the woman’s urges, helping her stay mobile and upright, and supporting her physically, emotionally, instructionally and psychologically. She covered laboring down, the process of allowing the mother to wait until she felt sufficient pressure or has the urge to begin pushing. She covered accommodating women with epidurals, helping them distinguish between pain and pressure. And, we discussed how to help women accept and focus on letting the baby emerge.

Many of the topics we covered were items I had learned about by reading the research studies that allowed AWHONN to develop these evidence-based guidelines. But, it was an exciting moment for me.  Many of the women that I work with in various prenatal classes tell me they want to give birth at the hospital because they want to be in a safe place in case of an emergency, but do not want to be subjected to much of the medical intervention they hear about. I agree. And so, I am glad to learn what our hospital is doing to bring the evidence – which my clients have read – into practice.

Our hydrotherapy tub is up and running…plumbing finally fixed! We are committed to letting the mother lead in pushing, to support breastfeeding and nurture new families. Next, we may even get back to intermittent auscultation! These things are happening in part because of consumer pressure and in part because of mandates to reduce the number of unnecessary, ineffective and costly medical procedures throughout the health care system.

I’m glad to see that evidence, mother’s instincts and financial pressures are all pointing toward the same solution…birth is primal behavior and works best when we follow the woman’s lead.

Pregnancy Exercise and Home Birth

The web is abuzz with news of the rising rate of home births. Increasingly women are electing to stay home for three major reasons: perceived safety, a desire to avoid medical interventions, and a previous negative hospital experience. There is also a lot of discussion about the need for more trained midwives, qualified to attend home births in low risk situations, as well as more midwives to attend in-hospital births. Some physicians are even complaining that the current insurance and liability situation forces them to practice defensive medicine, executing procedures and recording them to maintain a legal paper trail rather than care for their patients.

What is at the core of this issue? Several things leap to mind…

Defensive medicine is certainly a major component. Mandated medical procedures and frequent measurements during labor tend to interfere with the natural process. For example, in first stage labor, interruptions force women out of the parasympathetic state (brain alpha rhythm associated with the relaxation response) that helps promote the release of oxytocin and progress in labor.

Allowing the body to work is a very different kind of experience from what many women discover about birth in a hospital setting. In my experience, women who are aerobically fit do well in any labor setting. Women from my fitness classes have a very low rate of cesareans. Having your vitals checked and your contractions and fetal heart beat measured every hour or sometimes continuously cannot promote labor, although fitness seems to protect women to some degree. Of course, the argument for measurement is that if anything goes wrong that could have been detected through measurement, the practitioner will be blamed for malpractice. Thus, if 3 out of 4 cases of late decels leading to cesareans result from false positives in fetal monitoring, that has been seen as an acceptable rate within the medical community.

But, clearly, it is less acceptable to women, fit or not. Attempts are being made to alter the amount of monitoring in hospitals. The fact that it is perceived as an interference speaks to the problems with the method of measuring. In home births and even some midwife-attended hospital births, attendants listen to the fetal heart, a skill that – while it produces more accurate assessment – is rarely taught in medical schools any more.

Additional elements of defensive medicine are suspect, as well:  induction, denial of food and adequate fluid intake, poor communication to patients about the risks of procedures, and a system that views the mother as merely the medium through which the fetus is produced.

Another component is surely the psychological safety that women associate with their home environment over a hospital setting. Hospitals have attempted to circumvent this by creating labor and birth rooms that mimic a home environment and by offering tours of the labor and birth floor to help acclimate parents-to-be. But, it is also factors like not wanting medications that may flatten their emotional response to the birth experience, and the perception that drugs will be pushed on them in a hospital setting, that cause women to simply stay out of the hospital. Obs and midwives will even tell their patients to stay out of the hospital as long as possible if they want to avoid drugs and interventions. Certainly, in my work as a childbirth educator, I see a large part of my task as providing all the information they are requesting to couples in their decision-making process about their approach to the hospital.

One component I find particularly difficult is the standard approach to second stage labor in a hospital setting. To be clear, the notion of using the valsalva maneuver to push out a baby was invented by a man. It speeds up the process (which strikes me as a particularly male goal – apologies to the anti-sexist contingent), but creates more damage than following the body’s urges (reference here). During transition, the body shifts from the parasympathetic state to the sympathetic state. Pushing is aggressive; urges allow a woman to summon strength and direct her efforts. At the end of a long endurance event lasting many hours, a strength test is required. It is very different from the quiet stamina needed during dilation.

As information to this effect gets disseminated, I think women have come to recognize that they have greater trust in a female-based approach. More and more, we are hearing that educated women prefer laboring in water, movement, upright positions, drinking water, eating, gentle monitoring and being around people they trust, to what they have heard about or learned in previous births at the hospital.

Which brings me to a point:  Being present and enjoying birth requires not only a safe setting, but also body trust. Body trust is something one gains by having successful experiences with one’s body. I wonder if women who choose to birth at home tend to have positive self-images? And, most of all, I would be curious to know about the exercise practices of women who choose to birth at home. Any thoughts?

Pregnancy Exercise Safety Tip: Stay Hydrated

This is the second in a series on pregnancy exercise safety. The first article covered exercise guidelines and cautions for exercising moms-to-be and fitness instructors.

Pregnancy Exercise Safety Tip: Stay Hydrated

By Monique Nemarch, DTP® Master Teacher

As a Dancing Thru Pregnancy instructor, the safety of mother and baby must be your number one priority. This holds true whether your class consists of one mother or twelve.  Throughout your first few years as a DTP instructor you will develop a myriad of concerns, ranging from the welfare of your students to your own competence as a teacher: Will I be able to teach the floor work properly? Will I remember to remind the class to breathe? (Will I remember to breathe?) Does this aerobic dance work?  The class is so quiet – do they like me?

Now add safety questions to the mix, and this can all seem daunting to a new teacher.

Throughout my years as an instructor I’ve encountered many safety concerns, and as a result, I’ve developed shortcuts to help keep the members of my classes safe.

Some years ago I had a client who refused to take water breaks.  She would jog or march in place while the others took sips from their water bottles.  To single her out from her peers and publically insist that she stay hydrated might have led her to drop the class. I decided to explain to the whole class the importance of staying hydrated during times of exertion.

She still refused.

So, I had to resort to catching her before class and discreetly asking if we could talk in the hallway.  I proceeded to explain, very gently, how concerned I was with her not taking water breaks during class.  I noted that her workout would benefit from these water breaks; however, going without them might jeopardize her pregnancy.  I commiserated with her about forgetfulness during one’s pregnancy, and promised that there would always be a pitcher of water provided for the class lest someone should forget their water bottle.

I’m happy to report that this approach worked.  She started taking breaks, and when she forgot her water bottle she used the water set out for the class.

From this I learned to be proactive.  Assume that someone in your class will forget their water, and have a pitcher and cups at their disposal.  Your class will appreciate your thoughtfulness!

Mother’s Day for the Compassionate

Mother’s Day is an important day!  It is set aside because – let’s face it – without our mothers, none of us would be here. Not only do moms carry us inside their own bodies for those critical nine months, but once we are here our mom, or someone who can sub for our mom, is essential to our early survival.

For moms, moms-to-be and those with moms, here is something else to consider: Many presents celebrate motherhood. We can also give gifts that save mother’s lives, help them nurture their children, and improve the lives of families in our own countries and the developing world.

Here are a few groups to which you might want to consider giving this year. By donating to these organizations you can help improve the lives of mothers and children. Most will send a card or email message to the mom in whose honor you give the gift.

UNICEF Inspired Gifts.  You can choose gifts that improve education, water, health, nutrition, emergency care and other factors that affect the well-being of women and children.

White Ribbon Alliance for Safe Motherhood. You can advocate for every mother and every child in 152 nations when you give to this organization.

International Confederation of Midwives. This group exists to raise awareness of the global role of midwives in reducing maternal and newborn child mortality.

The Fistula Foundation. This group exists to raise awareness of and funding for fistula treatment, prevention and educational programs worldwide. Fistula is the devastating injury cause by untreated obstructed labor.

The Preeclampsia Foundation. This organization supports research to prevent and treat one of the most dangerous disorders of pregnancy, one that accounts for a large percentage of premature births and low birth weight infants. Having preeclampsia is also a risk factor for later heart disease for the mother.

March of Dimes. The “mother” of all charities for helping prevent and treat disorders and diseases that affect children.

Happy Mother’s Day to you and – hopefully – to all mothers everywhere!

One World Birth, Video Trailer

This is a must see…

http://www.youtube.com/watch?v=sCPZrK8C2ZY&feature=player_embedded

Pregnancy Exercise Safety

Included in this Blog

There are three sections to this blog. One is for moms-to-be, the second for pregnancy fitness teachers and personal trainers and the third includes specific contraindicated and adapted exercises.  All information presented is based on peer-review research and evidence collected over a 30 year period of working with this population. More information is available at http://dancingthrupregnancy.com.

1) Safety & Exercise Guidelines for Moms-To-Be

First and foremost, be safe. Trust your body. Make sure your teacher or trainer is certified by an established organization that specializes in pre/postnatal exercise, has worked under master teachers during her preparation, and can answer or get answers to your questions.

These are the safety principles that we suggest to our participants:

  • get proper screen­ing from your health care provider
  • pro­tect yourself
  • do not over­reach your abilities
  • you are respon­si­ble for your body (and its contents)

Squatting is an example of a standard pregnancy exercise used for childbirth preparation that must be adapted by each individual based on body proportions, flexibility, strength and comfort.

Second, make sure you are getting the most from your activity. Keep these findings in mind when choosing your workout routine:

  • Aerobics and strength training provide the greatest health benefits, reduce the risk for some interventions in labor, help shorten labor, and reduce recovery time
  • Cen­ter­ing helps to prevent injury; relaxation and deep breathing reduce stress; and mild stretching can relieve some discomforts
  • Avoid fatigue and over-training; do reg­u­lar exer­cise 3 — 5 times a week
  • Eat small meals many times a day (200–300 calo­ries every 2–3 hours)
  • Drink at least 8 cups of water every day
  • Avoid hot, humid places
  • Wear good shoes dur­ing aer­o­bic activities
  • BE CAREFUL!   LISTEN TO YOUR BODY!

If you experience any of the following symptoms, stop exercising and call your health care provider:

  • Sudden pelvic or vaginal pain
  • Excessive fatigue
  • Dizziness or shortness of breath
  • Leaking fluid or bleeding from the vagina
  • Regular contractions, 4 or more per hour
  • Increased heartbeat while resting
  • Sudden abnormal decrease in fetal movement (note: it is completely normal for baby’s movements to decrease slightly during exercise)

2) Safety & Exercise Guidelines for Teachers & Trainers

A principle of practice that increases in importance for fitness professionals working with pregnant women is having the knowledge and skills to articulate the rationale and safety guidelines for every movement she asks clients to perform.

This goal requires adherence to safety as the number one priority. Here is how we delineate safety and the procedures we require of our instructors for achieving safety in practice:

First priority:  safety [First, do no harm]

  • sometimes medical conditions preclude exercise
  • find an appropriate starting point for each individual
  • individual tolerances affect modification
  • general safety guidelines are physical
  • pregnant women also need psychological safety

Mind-Body Safety Procedures

Centering enhances movement efficiency and safety. Always begin with…

  • balanced, neutral posture
  • deep or rhythmic breathing
  • mindfulness
  • safe range of motion

Strength Training Cautions

  • avoid Valsalva maneuver
  • avoid free weights after mid pregnancy (open chain; control issue)
  • avoid supine after 1st trimester
  • avoid semi-recumbent 3rd trimester
  • keep in mind the common joint displacements, and nerve and blood vessel entrapment when designing specific exercises

Aerobics or Cardiovascular Conditioning Procedures

Monitor for safety..

  • take a pulse
  • assess perceived exertion (RPE)

Instructional style needs to be appropriate…

Walking steps with natural gestures can be done throughout pregnancy

Vigorous steps with large gestures are more intense, appropriate as fitness increases

The ability to create movement that will be safe and work for various levels of fitness and at different points in pregnancy is one of the most critical skills for pregnancy fitness instructors.

  • steps with leg gestures and/or arm gestures increase intensity
  • size affects intensity of movement
  • speed affects intensity of movement
  • jumping increases the ground force or impact on the joints
  • stepping up (e.g., step aerobics or stair climbing) increases intensity
  • some effort/shapes are ballistic and should be avoided
  • movement needs to be modified for each woman’s comfort

Venue Safety

  • Setting should provide physical and emotional safety
  • Equipment must be well-maintained

3) Contraindicated  and adapted exercises

Exercises for which case studies and research have shown that there are serious medical issues include the “down dog” position, resting on the back after the 4th month, and abdominal crunches and oblique exercises. Here is more information and adaptation suggestions:

Contraindicated: “Down Dog” requires that the pelvic floor and vaginal area are quite stretched, bringing porous blood vessels at the surface of the vagina close to air. There are records of air entering the blood stream in this position and moving to the heart as a fatal air embolism.

Adaptation: Use the child’s pose, with the seat down resting on the heels and the elbows on the ground, hands one on top of the other, and forehead resting on the hands. Keep the heart above the pelvis.

_________

Contraindicated: Resting on the back during relaxation.

Adaptation: Rest in the side-lying position. About 75% prefer the left side, 25% prefer the right side.

_________

Contraindicated: Abdominal crunches and oblique exercises can contribute to diastasis recti in some women. The transverse abdominal muscle is not always able to maintain vertical integrity at the linea alba, and thus there is tearing and/or plasticity of that central connective tissue.

Adaptation: Splinting with curl-downs, see positions below. By pressing the sides of the abdomen toward the center, women can continue to strengthen the transverse abdominals without the shearing forces that place lateral pressure on the linea alba.

Splint by crossing arms and pulling toward center

Or, splint by placing hands at sides and pressing toward center

Healthy Moms Having Healthy Babies – the Challenge in 2011

Welcome to 2011! We want to take this opportunity to say, once again, that our main goal here is to provide credible, evidence-based information on how to prepare for a healthy pregnancy and birth, recover quickly and begin your mothering experience in good health. Why? Because that is what you can do to help get your baby off to a healthy start in life.

Helping women be healthy during the childbearing period is our primary goal. Not everything is within your control, especially genetic factors. But your baby’s life is determined – in part – by your behavior before pregnancy, during pregnancy, during birth and in the early mothering stages. More and more, we are coming to understand that the environment within the uterus is largely affected by the mother’s behavior (exercise, nutrition, stress, breastfeeding and avoidance of risky behaviors such as smoking) and environmental exposures (toxins in chemicals, the air we breathe and food products).

We are recommitting to making up-to-date and well-documented information available through this blog. Now and then you will get a rant, but for the most part, we want to help people have terrific experiences during the childbearing period. Of course, since we are part of Dancing Thru Pregnancy and its Total Pregnancy Fitness and Mom-Baby Fitness programs, you will hear a lot about being fit before, during and after pregnancy BECAUSE fitness has more benefits for mom and baby than any other single factor!

Here are some of the well-documented findings about being fit during the childbearing period:

  • assists in healthy implantation and improves placental function
  • reduces the risk or severity of gestational diabetes
  • reduces the risk of preeclampsia
  • reduces the risk of prematurity and low birth weight
  • reduces the risk for childhood obesity
  • may reduce the risk of surgical (cesarean) birth
  • improves long term maternal heart health
  • reduces the risk of postpartum depression
  • increases the likelihood that a woman will be fit in mid life

You can find references for these findings on this blog, on our website (dancingthrupregnancy.com) or through the American College of Sports Medicine and other organizations listed in our blogroll.

Our secondary goal is adding to the effort to assure Safe Motherhood around the globe. We do this, in part, by supporting the White Ribbon Alliance for Safe Motherhood and helping sponsor projects that improve mother’s lives locally. We are also committed to spreading the word that improving the lives of women and children involves a reality change…namely that helping women plan their families, have healthy pregnancies and give birth in safety are more important human goals than wars and violence.

Please join us this year in this important endeavor.

Thank you.

Ann Cowlin, founder/director, DancingThruPregnancy.com, twitter@anncowlin