Physical Preparation for Birth

A recent research article on birth positioning [1] and a policy paper on reducing interventions in labor [2] reinforced my thinking that how we prepare women for labor and birth needs updating. As we learn more and more about the physiology of labor and birth [3], we are learning which practices are productive for a healthy birth and which practices work against birth.

Augmenting our knowledge and skills, as well as encouraging exercise components that improve outcomes truly prepare women for the intense challenges of giving birth. So here are some up and coming tips:

Hands and knees is mechanically efficient for mom’s body to “cradle” the fetus.

Why is this pregnant woman on her hands and knees?

Hands & knees can help low back pain in pregnancy & labor. It also reduces risk of injury to the pelvic floor during birth [1].

This position innervates transverse abdominal support of the abdomen. It opens SI joint via knee press effect. Practicing breathing, pelvic tilts, and modified planks in this position improves hands and knees endurance.

Why are these pregnant women squatting with partner support?

The most common reason given for practicing squats is that this action “opens the pelvic outlet.” This is true. But knowing how valuable kinesthesia is in executing challenging actions, I find that I must first teach women (and their partners) to sense where the target outlet is – between the sitsbones! This helps them learn to release the pelvic floor muscles and know where to focus their pushing efforts.

Also, having the support partner understand what is happening, as well as learning to support this action, is equally valuable to mom. It creates an important bonding and trusting activity. Explaining, illustrating with charts, and then teaching the ability to release, then bulge or distend the pelvic floor in the target area turns out to be one of the activities for which both partners are most grateful.

Why is this woman taking big strides and really moving out?

Aerobic fitness helps provide endurance in labor

Moving is a complicated neurological phenomenon and requires large afferent fiber pathways. The gate-control theory of pain states that movement deters other sensations that must travel up smaller pathways to reach our attention. Example: When you hit your elbow funny bone, you are likely to move around and rub the area, NOT sit and focus on the discomfort.

Labor is an endurance event, so if a mom is going to use movement (and gravity – another big helper) for 10 or 12 hours in labor, endurance fitness is a key preparation. Whether she jogs, swims, spins or dances, cardiovascular activity is possibly the most valuable exercise component she can acquire.

Some Quick Tips, based on recent research:

  • Encourage moms in early labor to stay out of the hospital as long as they can, unless they are given a significant medical reason to go in by their care provider. Once in the hospital, try to minimize the procedures that she must undergo [2]. The hospital or birthing center where she gives birth can, itself, be a factor in how she births [4].
  • If this is a healthy pregnancy, encourage her to eat in early labor and maintain her fluid intake throughout labor [5]. Endurance drinks can be useful to help maintain electrolyte balance during this long event.
  • Let her know she can ask to have hands-on support of her pelvic floor as the baby descends in pushing. Have her discuss this ahead of time with her care provider. This is another method that has been shown to reduce injury [6].
  • She can also ask to “labor down” rather than push for a few contractions after she is fully dilated, if she feels she needs to regroup once the head is through the cervix [7].
  • A good resource for positioning for birth and for recovery exercise is a Physical Therapist who has a PT certification in women’s health. For more information, go to PTPN.com or their Physiquality Blog.

REFERENCES

These references are worthy reading on our changing concepts of pregnancy, labor and birth practice. All of us who work with pregnant women are important influences in helping them gain skills and confidence to cope with this intensely physical, challenging experience.

  1. Zhang H et al. A randomised controlled trial in comparing maternal and neonatal outcomes between hands-and-knees delivery position and supine position in China. Midwifery July 2017 50:117-124. http://www.midwiferyjournal.com/article/S0266-6138(17)30236-X/abstract
  2. ACOG. Approaches to Limit Intervention During Labor and Birth. Committee Opinion Number 687, February 2017. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth
  3. Buckley SJ. Hormonal Physiology of Childbearing: Evidence and implications for Women, Babies, and Maternity Care. Childbirth Connection, 2015. PDF: http://www.nationalpartnership.org/research-library/maternal-health/hormonal-physiology-of-childbearing.pdf
  4. Shah NT. System Complexity and the Challenge of Too Much Medicine, Annual Meeting ACOG 2017. http://annualmeeting.acog.org/growing-c-section-rates-can-be-mitigated-by-counteracting-hospital-complexities/#.WRCbmxRaHFK
  5. ASA Press Release. Most healthy women would benefit from light meal during labor. Nov. 6, 2015. http://www.asahq.org/about-asa/newsroom/news-releases/2015/10/eating-a-light-meal-during-labor
  6. Leenskjold S, Hoi L, Pirhonen J. Manual protection of the perineum reduces the risk of obstetric anal sphincter ruptures. Dan Med J May 2015; 62(5). pii: A5075. https://www.ncbi.nlm.nih.gov/pubmed/?term=Leenskjold+S%2C+Hoi+L%2C+Pirhonen+J.+Manual+protection+of+the+perineum
  7. Brancato (Ozovek) RM, Church S, Stone PW. A Meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the second stage of labor, JOGNN 2008; 37(1):4-12. https://www.ncbi.nlm.nih.gov/pubmed/?term=Brancato+RM+A+Meta-analysis+of+passive+descent

About Pain and Birth

That Was Then…

As I became involved in the birthing field, one of the nurse-midwives with whom I was acquainted introduced me to Jung’s quotation: “There is no birth of consciousness without pain.” (Alternately, “There is no coming to consciousness without pain.”) It struck a deep chord in me.

At the time, I was going through a painful divorce and creating a new sense of self. As a dancer, I had long since learned that the acquisition of new movement and performance skills involved a painful relationship with one’s body and mind that results in a new identity: I am a person who can do this. At that time, I also had my first pregnancy loss – painful in every definition of the word. Even ideas required painful “births” in my educational process. “Aha!” was usually preceded by muddled difficulty in disciplining my thought processes.

So, when I first saw the saying, “There is no birth of consciousness without pain,” intertwined with a drawing of a woman literally giving birth, the truth of the image seemed obvious to me. It become hard-wired into my underlying assumptions about giving birth. The process itself combines intense noxious sensations with mid brain emotional input into what neural science calls pain. For years, this realization has driven what and how I teach: Being fit and educated in body/mind are the tools of enlightenment and self-empowerment.

…And This Is Now

A little while ago I came across a NY Times article “Profiting From Pain.” While the article concerns the huge increase in the legitimate opioid business – products, sales, hospitalizations, legal expenses and workplace cost – it restarted my thinking about a topic fermenting in my brain between That Was Then And This Is Now: The sense of entitlement to a pain-free existence. The idea that pain free is better than painful. And the selling of this idea for profit.

Where does this come from? Trying to obliterate pain has led to increased addiction, death and other adverse side effects. A new topic has shown up in women’s health discussions: Increasing use and overdose from prescription pain killers by women, including during pregnancy.

Could it be that human fear of pain is being used to generate financial profit? (the opium-is-the-opiate-of-the-masses model). Perhaps once the notion of palliative care reached a certain level of acceptance for the dying within the medical community, it began to spill over into other human conditions (the slippery-slope model). Or, perhaps we don’t want transparency at all (the denial model).

In the last few days, NPR has raised the question of whether the high cesarean birth rate is tied to the payment for procedure rather than outcome model? The recovery from cesarean is more painful than the recovery from vaginal birth, has adverse side-effects for mother and baby, and was originally designed for use only for the 15% +/- of real complications that arise in normal birth. So, how is it being sold to 35% of women in the U.S,? At one point, there was a serious discussion within the medical community that if women were afraid of the pain of birth and wanted a cesarean, a care provider should do one. No discussion of why it seems painful or how to deal with pain.

The Affordable Care Act aims to improve some of the cost issues in medical care by shifting the payment incentive away from procedures and on to outcome assessment. As a result, the cesarean rate and even such seemingly innocuous procedures as fetal monitoring are coming under scrutiny. If we truly want to do a service to the mothers-to-be in the ACA transition period and beyond, I think we must discuss the question of birth and pain. 

I can think of many questions that fall under this topic…Why do we call the intense phenomenon of birth “painful”? How do our genetics, behavior, training and thought-processes affect our experience of pain? What about the health care culture – has it focused on relieving pain at the expense of what we gain from working with pain short of trauma or imminent death? How do we prepare women for working with sensation without automatically labeling it pain? Is the “empowerment” often attributed to giving birth what is learned by going through the center of the “there is no birth of consciousness without pain” experience? These questions are just a start.

In closing…

Let me address the childbirth educators and pregnancy exercise instructors. This is our present challenge. In my work, I feel the necessity to make all pain management strategies understandable to my clients. I find that most of the women I see in classes must deal first with self-discovery before they can assess their commitment to the view of birth they carry in their minds. The images of birth we lay out for them to consider need to include an understanding that you cannot escape the work of birth. Being present – mindfulness – can be scary and intense but it is the medium by which our consciousness expands. Cardiovascular fitness and strength are the source of our endurance and power.