Less Intervention Leads to Less Complication in Birth

Recent research on the physiological processes at work in labor and birth are leading to conclusions that there should be as little intervention as possible in this process.

There is advice coming from prenatal care providers and researchers in the field telling us that some established practices need to change. For example, eating during early labor and continual drinking of clear fluids (even with electrolytes) are now recommended to help ward off uterine fatigue. It is a bag of muscles, after all!

Some recommendations have been less universally adopted than others by various birth professionals. For example, there is evidence that hand-held manual fetoscopes used to occasionally assess the fetal heart provide more accurate assessment than continuous electronic monitoring. Not all prenatal care providers are trained in manual fetal heart monitoring, so adoption is likely to take time in some areas.

To help readers learn about the specific practices that can help reduce intervention in labor, we have found and excellent summary to be the Childbirth Connection Fact Sheet – New Professional Recommendations to Limit Labor and Birth Interventions: What Pregnant Women Need to Know. It is brief, clear and concrete. Link to the fact sheet here.

One of the most interesting recent findings is that admission to the hospital at less than 4 cm dilation is a risk factor for increased intervention and cesarean birth. The abstract of the research, with a link to the full text, can be found through PubMed here.

We strongly recommend these two references.

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

To Kegel or Not to Kegel? That is the Question!

Every few years, the Kegel exercises come under attack. Practicing Kegels is often cited as the cause of difficulty during the pushing stage of birth, due to bearing down against contracted rather than relaxed pelvic floor muscles. This increases resistance to fetal movement, potentially damaging soft tissue, as well as stressing maternal cardiac reserve and the fetal heart. So, a call goes out to stop doing Kegels. But, Kegels were invented for a reason, and contracting the pelvic floor during birth is not it.

So, to kegel or not to kegel? Two things help us understand how to answer the question of whether or not – and when – to do Kegels. One is history (ever a useful tool) and the other is identifying the anatomy and physiological functions of the female pelvic floor.

1) History

Hands and knees is mechanically efficient for mom's body to "cradle" the fetus.

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

 

First thing, a quick peek at evolution. The pelvic floor did not originally support the contents of the abdomen. Starting out as 4-legged creatures, our pelvic floor originally served more as the back door.

Sacrum & Coccyx at top. Pubis at bottom. Evolution position.

Sacrum & Coccyx at top. Pubis at bottom. Evolution position.

Thus, the opening and closing of outlets were primary functions, and support of abdominal contents was largely a job for the Transverse Abdominals.

We could rock into an upright posture (squatting or sitting on our “sitsbones”), allowing gravity to assist in downward emptying of abdominal contents. When we relax our skeletal muscles, the involuntary muscles and neuro-motor emptying pathways proceed unfettered.

Squatting

Squatting

Once we discovered we could stand on our feet and still reach much of the fruit in the trees, a fast transition to upright (in evolutionary terms) placed strain on movement and support in the pelvis, spine and hip joints. Reviewing all the details involved in the ensuing adaptations is another story for another day. Suffice it to say, supporting the abdominal contents was not included in the original design of the pelvic “floor.”

Fast forward to the end of the 19th Century when birth began moving into a clinical setting and women were routinely placed on their back for labor and birth.

Pubis at top. Sacrum and coccyx at bottom. Supine position.

Pubis at top. Sacrum and coccyx at bottom. Supine position.

Yes, this slowed down the process and made it more painful. Thus, the next steps emerge in the early 20th Century: “Twilight Sleep” and increased forceps birth.

For a good understanding of this era, I recommend the following 1916 article:

  • Haultain FWN and Swift BH. The Morphine-Hyoscine method of painless childbirth or so-called “Twilight Sleep,” British Medical Journal, 1916 Oct 14;2(2911):513-5. Full text here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2354830/pdf/brmedj07070-0003.pdf

  • The reader can also learn more about Twilight Sleep and its adaptations in the U.S. by entering “twilight sleep childbirth” into the PubMed search field.

Next: Urinary incontinence! Or, the reason Kegels were invented.

So, what was the product of placing women on their backs, putting them into a semi-conscious state, amnesia of events, and sometimes dragging the baby out of the vagina with forceps? Likely, increasing incidence of pelvic floor dysfunction. However, additional factors also influence maternal pelvic floor outcomes, including the Valsalva maneuver during pushing, and instrumental birth. Who invented “pushing” anyway? Male doctors.

  • For more on such matters, I recommend the reader examine Sheila Kitzinger’s work. She is a renowned British anthropologist who studied, wrote and spoke on global birth customs throughout her life.

Pushing, or bearing down, occurs naturally during coughing, sneezing, emesis, forced exhalation (as when a tennis player grunts while hitting a ball), urination, defecation and – when occurring without analgesia – parturition (birth). Identifying the “best” way to push remains illusive. What is the goal? Speed, damage control, fetal outcome? The Cochrane Library concludes only that maternal preferences and medical imperatives should guide the method of pushing.

  • Lemos A et al. Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev. 2015 Oct 9;10:CD009124. doi:10.1002/14651858.CD009124.pub2.

And, what about organ prolapse? How does that figure in here? Is weakness in the pelvic floor muscles a cause? It is becoming more clear that, even in the absence of trauma, genetic factors play a significant role in the occurrence and severity of pelvic floor dysfunction. There is great variability in how connective tissues respond to stress and stretching. A good recent account of one possible gene avenue is this article:

  • He K, Niu G, Gao J, Liu JX, Qu H. MicroRNA-92 expression may be associated with reduced estrogen receptor β1 mRNA levels in cervical portion of uterosacral ligaments in women with pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol. 2016 Mar;198:94-9. doi: 10.1016/j.ejogrb.2016.01.007. Epub 2016 Jan 11.

In the early-mid 20th Century, much less was understood about how genetics, physical training, postural sway and practice protocols might affect these matters. In 1948, Dr. Arnold Kegel, an American gynecologist, published on a non-surgical method of toning the pelvic floor in order to help women control incontinence following childbirth. By exercising the pubococcygeus muscles (PC muscles or sphincters) of the pelvic floor, he found that women could reduce their likelihood of experiencing bladder problems after pregnancy and birth. Here are the two publications that give rise to calling these exercises “Kegels.”

  • Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol. 1948 Aug;56(2):238-48.
  • Kegel AH. The nonsurgical treatment of genital relaxation; use of the perineometer as an aid in restoring anatomic and functional structure. Ann West Med Surg. 1948 May;2(5):213-6.

Keep these factors in mind: The experiments leading to publication included measurement of the strength of contraction of these muscles. Several devices (balls, cones and devices that read muscle strength) were developed to provide tactile aid in contracting and releasing the PC or sphincter muscles, and continue to be used today by physiotherapists. These actions are aimed at squeezing the detrusor (or urinary flow mechanism) to prevent incontinence with weak or relaxed sphincters.

What about the issue of organ prolapse? How does that tie in? Over time, the term “Kegel” has also come to refer to tightening the levator muscles (the sling-like muscles that lift the pelvic floor). This action is the opposite of what happens when bearing down. Which nicely brings us to the second topic:

2) Anatomy and Functions of the Female Pelvic Floor

There are three rings of muscles and four muscle actions that govern the opening and closing of the bony structures and soft tissue of the pelvic floor. The overall bony shape of the pelvic floor is similar to a baseball diamond, as seen in the first graphic.

Pelvic outlets, lithotomy position.

Pelvic outlets, lithotomy position.

 

The three rings are – from outside to in:

  1. Gluteals, transverse perineals and ischiocavernous that create two triangles of the pyramidal bony structure and create a rigid fence when contracted or a mobile structure when released. The deep rotators, including piriformis, and the pyramidalis also function to close the pelvic outlet.
  2. Levator and diaphragm muscle that lift and close the pelvic floor and/or support the contents of the abdomen by contracting when the woman is vertical.
  3. Sphincter muscles that squeeze and release the three orifices: urethra, vagina and anus, closing and opening these outlets.

The four muscle actions are:

  1. Contraction – tightening the muscle as in strength training. Can be done to shorten muscle (concentric) or as muscle extends (eccentric). Muscles can shorten approximately half their resting or relaxed length. Contracting muscle against resistance increases cardiovasculature and improves delivery of nutrients and oxygen, as well as improving innervation and awareness of motion.
  2. Release/Relaxation – letting go of contraction, allowing muscle to rest, relax or be stretched.
  3. Stretching – muscles can be lengthened approximately a third of their resting length by applying leverage to the bony structures the muscle controls. Stretching is also affected by genetic factors regarding elasticity of the connective tissue within and attaching to muscle and bone.
  4. Bulging or Distending – Some muscles can extend beyond their stretching range by pressure from the diaphragm, often termed “bearing down.” Both the Transverse Abdominals (TA) and pelvic floor muscles do this during parturition (efforts to expel the baby). The TA tighten in a distending position to assist in the emptying of the abdominal contents and the pelvic floor extends beyond the bony structure defined by the sit bones (ischial tubersoities) on either side of the vagina. To get a sense of how this occurs, I recommend two things: first, cough hard enough that you can sense the action of TA and pelvic floor; second, next time you take a poop, sense how your body is working. It is the same for parturition, although the target is the vagina rather than the anus and the voluntary assisting effort needed is much more intense. Two practices help prevent damage to the pelvic floor. One is following the urge to push and the other is to “labor down” when their is no urge, when the mother needs to rest a bit during pushing. Avoiding, as much as possible, the Valsalva maneuver (holding the breath while pushing) reduces strain on maternal cardiac reserve and the fetal heart.

An excellent way to get a sense of how the pelvic floor functions in birth is to view the 1974 Brazilian film, Birth in the Squatting Position. Here is the link:

https://www.youtube.com/watch?v=ZHHHcIZEi9U&oref=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DZHHHcIZEi9U&has_verified=1

So, do we do Kegels? Yes, but we also release/relax, stretch and learn the coordination of bulging/distending these muscles. After birth and as we age, we also do them as a method of recovery and because we are upright animals who have to support the contents of the abdomen. Learning to sit in an anatomically neutral position in a chair and many other healthy postural habits – not to mention understanding our genetic factors regarding elasticity – will also help us maintain a healthy pelvic floor. But these ideas are another story for another day.

 

In Labor? Eat for Endurance!!

For 30 years I have been reminding my pregnancy exercise and childbirth education classes – not to mention anesthesiologists – that the uterus is a bag of muscle, and that muscles need two things to function well: oxygen and sugar. To contract, muscles burn sugar in the presence of oxygen. Oxygen is renewed by regular, paced breathing. Sugar, on the other hand, has to be supplied first by glycogen at the muscle site, then by circulating blood glucose, optimally provided every few hours by food.

The amount of glycogen that rests at the muscle site in case the muscles need it for quick action lasts about 20 minutes at most. After that, during physical activity, the body will begin to break down fat to provide blood glucose. But. that also has time limits and acid begins to accumulate. Ultimately, nutrition of some kind is the only way that any ultra endurance activity ensures that adequate sugar is continuously supplied to the muscle. Without adequate energy, muscles do not work well.  Without nutrition, acid builds up.

For many decades, there has been a ban on food and water during labor once a laboring mom is in the hospital due to the risk of aspiration – inhaling food or water into the lungs. At last, anesthesiologists have looked at the risk of aspiration in labor and discovered that there has been only one case recorded between 2006 and 2013 associated with labor and birth. Logical conclusion: withholding food and water during the endurance event known as labor is not a great idea. Kudos to the researchers at Memorial University, St. John’s, Newfoundland, Canada, who suggest a change in practice. Yes, there are factors that might over-ride this conclusion, including obesity and preeclampsia, but for most healthy women, eating lightly in labor is a good thing.

Read the American Society of Anesthesiologists press release on this topic here: https://www.asahq.org/about-asa/newsroom/news-releases/2015/10/eating-a-light-meal-during-labor

 

DTP Offspring Guest Blog – Ebony Knight & Powerful Pioneers

Doula Ebony Knights became a Dancing Thru Pregnancy teacher in 2014 through the Healthy Start Brooklyn program. Together with her husband, Ebony runs Powerful Pioneers, a program to empower women, seniors and young adults through special workshops, activities and services.

Ebony 8DTP: Tell us about your work as a DTP teacher and a Doula.

EK: We start our class greeting each other, introducing ourselves to newcomers and start off with warm ups, stretching, etc. I have incorporated a Caribbean dance workout, which is a simple dance routine that gave us the opportunity to perform at BMS on stage out doors recently.

Ebony 9Ebony 4After we dance we relax and visualize and end with a discussion (sharing our thoughts and experiences to encourage each other).

To find out more about Ebony’s Doula service, click on this link, then click on the title:
Ebony doula

DTP: What do you most enjoy about your work?

EK: I truly enjoy what I do and was inspired when you traveled so far to teach such an amazing class. Also I have enjoyed getting a chance to meet these lovely ladies; my most committed and dedicated moms have recently had their babies. Some of these moms come back to visit and surprise me. Ebony 6

DTP: Tell us more about Powerful Pioneers and your activities.

EK: My husband and I have an organization called Powerful Pioneers and our mission is to empower women, seniors and children by offering workshops such as vegetarian cooking classes, dance, health education, drama classes and women and youth empowerment workshops.  You are welcome to visit our website to see what we do. If you happen to know any moms or organizations that would like to partner with us or utilize any of our services feel free to share.

Healthy Pregnancy & Birth Essentials – Be Fit! Be Prepared!

Moving relieves stress.

Moving relieves stress.

Do you want a healthy pregnancy, labor, birth and early mothering experience?

This post is designed to provide basic information about achieving this goal. As with any life situation, there are things you can do to help achieve the best outcome of your pregnancy. Some things will be outside your control. Your baby will have blue eyes or brown hair or attached ear lobes depending on genetic factors. But many things are in your control. If you are fit and eat well you will help your baby’s development.

Circumstances can also play a role. For example, where you live can impact how much you walk or whether you are exposed to second-hand smoke. Sometimes you can change these things, but not always. We have put together just the basics, the things you CAN do to help yourself have a healthy pregnancy and birth!

  1. PRENATAL CARE – Repeated studies show that women who have regular health care started early in pregnancy have the best outcomes.
  2. AIR & FOOD – Your muscles need oxygen and blood sugar in order to achieve activities of daily living (ADL), fitness activities, labor, birth, and caring for a newborn. Muscles – including the uterus – need these two essentials in order to this work. Therefore you must do these things:
    • Breathe deeply to strengthen your breathing apparatus.
    • Eat in a way that is balanced (carbs, fats & proteins in every meal or snack) and colorful (fresh fruit & veggies) to train your body to
      Fresh fruit provides vitamins & minerals!!

      Fresh fruit provides vitamins & minerals!!

      produce an even supply of blood sugar and provide needed vitamins & minerals. You need 200 – 300 calories every 2 – 3 hours, depending on your size. Prenatal vitamins are your backup safety mechanism. Eat real food, not edible food-like products (example: potatoes, not potato chips).

    • Drink fluids (primarily water) and eat protein to maintain an adequate blood volume. Blood delivers oxygen and sugar to your muscles, placenta and baby. Pregnancy increases needed blood volume by about 40%. More if you exercise regularly.
    • You don’t need other items, especially things that are dangerous, like alcohol, cigarettes and drugs. Continue safe sex.
  3. PHYSICAL FITNESS – Pregnancy, labor, birth and parenting are ENDURANCE events. Strength, flexibility and mindfulness will help, but only if you have stamina to tolerate the stress to your cardiovascular and respiratory systems.
    Aerobic Dancing improves stamina while having fun!

    Aerobic Dancing improves stamina while having fun!

    • Cardiovascular conditioning or aerobics is the cornerstone of fitness. Make sure to get 20 – 30 minutes of moderate to vigorous aerobic activity 3 or 4 days a week. Find a qualified prenatal aerobic fitness teacher. If you are more than 26 weeks pregnant, start very, very slowly.
    • Core, shoulders, hips, pelvic floor – these areas need adequate strength training and gentle flexibility for range of motion.
    • Relaxation practice has been shown to help reduce the active phase of labor.
    • Mindfulness can be a big help in birth if you have adequate endurance and are not in oxygen debt, out of blood sugar, dehydrated or too tired.
    • Find classes here: DTP Take-a-Class
  4. EDUCATION – Be sure these items are included in your childbirth education course:
    • Landmarks of labor & birth progress
    • Sensations at various points in labor
    • Physical skills that promote labor progress and help achieve a healthy birth

      Learn the benefits "skin-to-skin" after birth.

      Learn the benefits “skin-to-skin” after birth.

    • Pain Management techniques to help you deal with the intensity of birth
    • How to maintain oxygen and sugar supply in labor before going to the hospital and while in the hospital
    • Standard hospital procedures (so you can decide when to go to the hospital)
    • Complications that can lead to medical interventions, including surgery
  5. GET SUPPORT – Make sure you will have continuous support for your labor and birth
    • Spouses, partners, and female family members can be helpful if they accompany you to your Childbirth Education class and know how to help you during the process.
    • A Doula is a great option for support because they are trained to guide a mom and family through the birth process.
  6. POSTPARTUM ACTIVITY WITH BABY – This is a great way to get in shape after birth.
    • Early General Fitness in the first few weeks: walk with the baby in a stroller or carrier, work on kegels and suck in your belly.
    • After 4 – 8 weeks you will be ready to join a Mom-Baby fitness group!
Birth begins the bond or unique love between mother and child.

Birth begins the bond or unique love between mother and child.

About Dancing

“When a normal, healthy child is born, usually in the father’s compound, the women perform the nkwa to rejoice. Then…they sing and dance their way to the compounds of the mother’s kin to inform them of the joyous event through the dance-play, gathering additional dancers as it moves from compound to compound. In this nkwa, in which only married women who have given birth perform, the dancers highlight procreative body parts, birth exercises and child care gestures.” – page 164, Hanna JL, To Dance is Human: a theory of non-verbal communication, 1979. Rev. ed. 1987.

From its inception in 1979, Dancing Thru Pregnancy® has been inspired by this passage from Judith Lynne Hanna’s amazing text, in which she describes how the Ubakala of Nigeria “announce” the birth of a child. The dance serves a dual purpose – it tells of the birth, but it also teaches the uninitiated how pregnancy and birth occur. For the dancers it also serves as a catharsis.

As a professional dancer, I long ago recognized the transformative power of dance to make experiences accessible.Molly and Miri Through Hanna’s writing we see how dance is itself one of the earliest and most profound ways in which common human experiences are taught and learned. Contemporary culture often removes this type of learning from our environment. Employing dance to help women approach birth has always struck me as an obvious first choice in preparing women for the physical, emotional, identity-forming and joyful process of birth.

In the intervening years, science and technology have reinforced our understanding of how this non-verbal learning happens. A most excellent discussion of mirror neurons appears in Acharya and Shukla’s article, Mirror Neurons: Enigma of the metaphysical modular brain, J Nat Sci Biol Med. 2012 Jul-Dec; 3(2): 118–124. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3510904/. Mirror neurons are key to how empathy and understanding of experience are produced when people view movement and gesture. The mere perception of an action sets off a low level firing of the neural pathway that executes the actions we are seeing. The authors provide a thorough grounding in the history of how we have come to recognize that mirror neurons exist and how they work.

There are more arenas in which dance also shines as a preparation. Appropriately choreographed, dance enables excellent physical fitness and includes all the elements of physical activity that research demonstrates are effective for optimal health in pregnancy and coping with the rigors of birth. From the perspective of exercise physiology, labor is an ultra-distance endurance event, followed by a strength test (birth), a long physical recovery period and 18 years or more of sleep deprivation. And, further, such a preparation aids the mother in achieving a physiologic birth as described in Buckley’s “Hormonal Physiology of Childbearing: Evidence and implications for women, babies, and maternity care.” This recent groundbreaking article describes how labor, birth and breastfeeding are promoted through hormonal actions, as well as why some technological advances in childbirth are working against these processes.

DTP at YH 12:13Achieving cardiovascular endurance (aerobic fitness) is essential. There are so many benefits of aerobic fitness that a full recitation and hundreds of citations will not fit in a blog. Our teacher training aerobic component takes several days, even for experienced fitness pros. But, to summarize: cardiovascular fitness improves implantation, enhances nutrient and oxygen delivery, reduces the incidence or severity of some pregnancy disorders, reduces the risk of fetal distress, reduces stress on maternal cardiac reserve while pushing, reduces the risk of cesarean, hastens recovery, helps maintain a healthy weight, alleviates anxiety, builds body-image confidence (Cochrane) and enhances long term maternal and fetal health. The two forms of cardio or aerobic activity most often cited for effectiveness are running and aerobic dancing.

Two other elements of dance that are useful for pregnant, birthing and parenting moms are strength and flexibility. There are Elongemany movement actions derived from numerous dance forms that promote both power and elasticity in the muscles, connective tissue and skeletal structure. Some effective positions, movements and skills are shared with other disciplines: Traditional childbirth preparation, weight training, gymnastics, physical therapy, yoga, t’ai chi, pilates, boot camp, plyometrics, proprioceptor neuromuscular facilitation (PNF) techniques, Feldenkrais, Alexander, somatic therapies, posture training, etc.

This letter I received recently from a (not pregnant) ballet student willing to share her experience is a clear reminder of how a well-designed dance class accomplishes enhancement of strength and flexibility, along with confidence about working with one’s body:

“Hi Ann,

I just wanted to let you know that I lifted weights at the gym last night… It had been at least 6 months since I had lifted weights at all, and so I figured I’d need to start at a relatively low weight and I’d be really sore the next day regardless. I was very surprised to find that I could easily lift the maximum weight I’ve ever lifted, which was the weight I used to lift at a time when I was lifting weights routinely several times a week. Every muscle group was strong. And today I am not sore at all. This is all to say that I am shocked at how much strength I’ve gained from ballet. I had no idea that just lifting my limbs against gravity could be so effective.

Thank you so much for having a class for beginner adults, and for your patience with all of us! I’m 42 years old at this point, and started ballet because I had noticed my core strength, flexibility and balance starting to really decline…I am so thrilled with the results from ballet even though I have such a long way to go!!! Plus it’s really fun. How I wish I would have discovered ballet in my 20s or 30s, since I didn’t learn it as a child!

Glenda G. Callender, MD FACS

An additional arena in which dance shines is in building mind-body skills. Dancing relies on centering – aligning with gravity to produce the greatest efficiency for movement (balance) along with breathing as a component of movement. Centering also reduces the load on the nervous system and allows the brain to modulate into the parasympathetic nervous system state, also known as the relaxation response (autogenic training, hypnosis, meditation, progressive relaxation), the zone (athletes’ term), mindfulness (big in research presently), the trophotropic response (the scientific term) or the alpha state (the current fad term). Dancers sometimes refer to this as tuning in to the unconscious. The actual coordination of motions, such as pushing, is primarily unconscious. The conscious piece is keeping a clear image of the goal, while allowing the body to work. This is the skill that allows the birthing mother to follow her body’s urges, flowing with the labor rather than trying to control what is going on. It gives her access to the cathartic nature of birth as a dance.

Centering 2:08Align

Breathe

Focus on the breath

Sense the movement within

Then, allow the body to dance…

A part of the dance experience I truly enjoy is a phenomenon known as muscle bonding. When a group does vigorous physical activity together – dancing together, a sports team, a drill team – a special kind of bond forms. Part of the euphoria is this muscle bonding experience.  Those of us whose interest lies in understanding the mechanics of such things have a pretty good idea how this works – some of which is laid out in this blog and the reading links. But, that is not the wonder of it. The wdancing_overview from backonder of it is what the Ubakala women experience moving together to announce the birth of a child.

When I am dancing with my pregnant ladies and we are in the grove with our modified hip hop routine, we are smiling at each other and feeling completely alive. We are breathing hard and working hard, but we are strong. My hope is always that when she senses that labor and birth are starting, a mom-to-be can get in that groove with the baby and support person. Birth as a dance.

No blog on pregnancy or birth is complete without a caveat. Every pregnancy and birth is unique. Sometimes things go wrong. But, mostly they go right! And, moms can optimize the experience. One of the greatest dangers to pregnancy and birth is sedentary behavior. Regular, vigorous, strength-inducing, flexibility gaining, mindfulness, relaxation muscle bonding fun is available. Check our U.S. and International Find-a-Class listing. If there is nothing near you, start something!

Dispelling Myths on Pregnancy Exercise

At regular intervals, it becomes necessary to dispel two persistent myths that are often perpetuated by well-meaning care providers. Both of them were debunked long ago, in research literature that is readily available and about which I have written a great deal, including in my chapters on Women and Exercise (editions 3 & 4) and Health Promotion in Varney’s Midwifery (edition 5), in posts on the DTP website, on my Twitter feed (@anncowlin), on DTP’s Facebook page and in a textbook.

DTP_mover1_pregnantThe more common myth is that pregnant women should never let their pulse get over 140 beats per minute. But, more on that one at another time. That was an ACOG guess in 1985 that long ago (1994) was rescinded.

The other is that pregnant women should never begin a new exercise regimen, but only modify (i.e., reduce) what they are already doing. What brings me to write this blog after a blog break (to respond to our expanding pre/postnatal fitness teacher training program) is that this evening I was told the latter myth was promoted by a CNM at a recent nearby conference. A childbirth education colleague alerted me to this occurrence and also to the happy response by an unknown person in the audience, who chose to differ with the midwife, citing Dancing Thru Pregnancy® as her example!! Thank you to this responder.

Let me address – yet again – the issue of whether it is safe for pregnant women to begin an exercise regimen after they become pregnant. The caveat I offer at the outset is that doing so should be under the supervision of a knowledgeable certified pre/postnatal fitness specialist. Within the profession, the resolution of this question is generally agreed to be the Cochrane Review conducted in 2002, which found that aerobic fitness can be improved or maintained in pregnancy. Improvement requires increasing the level of aerobic challenge. More recently, researchers concluded “….pregnant women benefit from regular physical activity the same way as non pregnant subjects…” and that “…[t]he adoption or continuation of a sedentary lifestyle during pregnancy may contribute to the development of certain disorders such as hypertension, maternal and childhood obesity, gestational diabetes, dyspnoea, and pre-eclampsia.” (Melzer et al. Physical activity and pregnancy: cardiovascular adaptations, recommendations and pregnancy outcomes. Sports Med. 2010 Jun 1;40(6):493-507. 

Put another way, the female is not put together to be sedentary in pregnancy. It is only in recent decades that this is an option. Until the mid 20th Century, activities of daily living required physical fitness, and obesity was rare, along with sedentary behavior. In the last few decades, those who are knowledgeable about the interactions of pregnancy and exercise, and who have the experience of teaching movement to this population, have come to understand how to present activities that improve the factors that improve maternal and fetal outcomes.

Those who are extremely well-versed in the field all agree that cardiovascular (aerobic) fitness during the 6 – 12 month pre-pregnancy period may be the greatest pregnancy enhancement a woman can have. Why? Because endothelial function is greatly enhanced, oxidative stress is reduced, and vascularity is increased by aerobic fitness, and these capacities underly healthy implantation and placental development (see Research Updates 2001-2005, Winter 2005 and Winter 2004 and Update on Immune Function). Barring that, beginning early in pregnancy is helpful because placental development is still underway. Barring that, mild to moderate aerobic activity introduced by 25-30 weeks will produce cardiovascular enhancement by the time of labor. My caveat goes here, too.

All conditions mediated by inflammation are a problem in pregnancy. Physical fitness is a major preventive strategy for inflammation, and pregnancy does not stand in the way.

 

 

Ina May’s Guide to Childbirth – book review

Ina May’s Guide to Childbirth by Ina May Gaskin.

NY; Bantam, 2003.

The physiology of birth is complicated and still not well understood. Our subjective experiences of birth are richly textured. Personal accounts spill over with combinations of intense sensations, strong emotions, vague impressions and fine details. What is astonishing about Ina May’s Guide to Childbirth is how exquisitely she traffics in the language of an internal landscape to describe and explain this complex process. She truly captures the uniqueness and universality of birth. I am adding this book to the list of recommendations I give my clients, as well as suggesting it to other teachers.

Devoting nearly the first third of the book to positive first-hand birth stories provides a substantial grounding. Many times I found myself thinking: Yes! That woman is describing this or that essential bit of wisdom I want to impart to my clients. Let me point out one example.

On pages 24 and 25, one of narrators describes 3 slices of her experience. First, she got advice not to read or learn too much and not to make a plan because the more details she had in mind, the less likely she would get what she wanted. Too much reading would interfere with her ability to go with her body, she was told.

Second, she describes her experience of being in a tub and how she needed a lot of reassurance because she was both scared and aware of the great power in her body. The physiological phenomena occurring in her brain and motor systems indeed would be described as these subjective states of being. She definitely perceived what was happening.

Third, she describes turning from looking at things during a contraction to listening because looking made her think, while listening allowed her to feel and be instinctive, which felt better than thinking and was not so overwhelming. Thus, she was going with her body. We see her process in this narrative.

The stories all got me thinking about whether I am telling my clients too much or too little! One of my teaching goals is to insure that clients distinguish between strategy and tactics. Example:  In the case of the story above, the strategy was to go with her body. The tactics she used were to not get too much information so she did not have too many expectations and to use sound rather than vision as her way of connecting inner and outer reality.

As a teacher, I see my job as insuring that my clients who might hear this story do not think that they must use sound rather than vision in order to go with their bodies, but rather that this was a piece of the process for this woman to reach her objective. It might work, but it might not. To get this across to clients, I tell stories about births in which I have been present when opposite tactics accomplished the same strategy or where the same tactic led to different outcomes.

The multitude of stories she presents in part I allow part II – the textbook part – to come to life. Whether she is discussing stages of labor, pain or release, she calls up stories and because the reader is already receptive to the notion of examples, the illustrations help the reader grasp whatever point she is making about the process.

However, the complex physiologic sequence of birth, including its variation from woman to woman, is less well served – in part because there is still so much to be learned about how birth happens, and in part because the birth community in general (whether having had professional or academic training) is not as well versed in normal physiology as it could be.

Let me focus on two issues: One is pain/pleasure and the other is hormones/behavior. Regarding pain/pleasure, Ina May makes a lot of important points, among them that how we experience an intensely sensational experience depends to a great degree on our preparation and that different women have different pain/pleasure experiences during birth. What she doesn’t tell us, though (and I suspect because it’s not common knowledge), is that some of the factors that control how we experience sensations are beyond our control. We experience pain/pleasure through a series of sensations, mental foci and behaviors such as breathing and muscle release. These nerve impulses are forwarded throughout the brain, some sensations taking on emotional content – some terrifying and others ecstatic – depending on the neural pattern. This is the basis of both the fear/tension/pain syndrome and the orgasmic pattern. But the precise pattern is dependent on genetics, as well as environment and behavioral training.

Some individuals become aware of sensations at a very low neurological threshold; others do not. Some individuals quickly find sensation of which they are aware to be uncomfortable or emotionally intolerable; others do not. Some people need comfort measures for their discomfort soon; some later, or not at all. Tolerance of what finally becomes pain or pleasure (or just a sense of stretching or motion through space) is also variable from person to person. Thus, the point at which we start has both biological and psychosocial determinants within this already variable process. In describing the variation in how women experience pain and pleasure in labor, Ina May is great at giving us examples and identifying psychosocial or cultural variations identified in research, but not so enlightening on the biology of why and how. This may or may not matter to the reader.

The issue of hormones that govern the vicious cycle we call labor is much less well understood. We have a pretty good concept of how prostaglandins, oxytocin and endorphins are stimulated and affect the process, and Ina May describes these in accessible ways. But while adrenaline is thought to inhibit early release of oxytocin, there has been little discussion of its importance in the pushing or ejection phase (she does cite Michel Odent’s notion that adrenaline might play a part in the ejection reflex when a labor is slowing down). But, there is little recognition outside of the physiology field that what happens in transition is our energy system shifting to a sympathetic [adrenal] source to give us more power to push. That’s why contractions change, why some women have a rest period between, and why – back in the day – we used to say to a woman having difficulty culling up her resources to push that she could get mad! Going through the effort and discomfort is key to inducing the rush of beta-endorphins. We know this, in a scientific way, from research that tells us runners who listen to music (relaxing and dissociative) experience lower rates of beta-endorphins at the end of the run than runners who do not listen to music, but work through the effort and discomfort they experience (stress inducing).

One of the things that makes Ina May’s book so valuable, in my mind, is the discussion near the end about midwifery, statistical support for natural birth and enumeration of the risks associated with surgical birth that are often glossed over when a family experiences dystocia. There are many elements within the birthing community striving to create an accessible spectrum of choices for birth. Let’s face it, birthing at home for low risk women, seamless transport alternatives, birthing centers attached to medical facilities, and readily available medical options when emergencies arise, would be a wonderful future. Birth attendants with universal acceptance, variable but rigorous training, and delineated scopes of practice would be ideal. Whether we get there remains to be seen, but I am glad Ina May exists, has her track record and is being listened to in this effort.

Pregnany & Parenting Coaching

Looking through incoming emails, tweets, fb notifications and e-newsletters that inhabit my inbox more and more, I noticed something interesting:  Lifestyle Coaches for people entering the pregnancy and parenting pathway. After some investigation, I found a plethora (many, many) web business/sites that offer services on everything from getting pregnant to getting your kid into college.

There are sites by enduring public health organizations that cover the range of conception, pregnancy, birth and early parenting issues – such sites as those by the Mayo Clinic, the March of Dimes, and WebMD – starting with how to get pregnant. You can also find business sites for these range of topics – such as The Bump and BabyCenter.

In addition, there are individualized sites that cover coaching for one or more parts of the process. Sites specialize in getting pregnant, being pregnant, giving birth, caring for a newborn, finding childcare, finding early childhood education, how to talk to toddlers, what to do with children of all ages, how to get them ready for school, how to encourage them in school and so on. Some specialize in a combination of two or more of these topics. Some started out specializing in one topic and are moving along as the owners or writers evolve in their lives.

I realize that this is an outgrowth of the “mommy bloggers.” Many computer literate women found blogging a way to deal with the life-changing event of having a child. For some, the internet became a means of making a living while staying home. Realizing that there was a large audience in this realm, the mommy entrepreneurs evolved…and, not all of them are mommies.

We are beginning to see the next generation:  pregnancy and parenting life coaches – individuals who may or may not have professional backgrounds in one of these areas, but are learning to turn their own experiences into businesses that help – or purport to help – others along this part of life’s path. Where does the impetus for this come from? Is it just that the internet makes a new business model possible? What else might be happening here?

For some time, I have thought that young persons entering parenthood these days are at a distinct disadvantage. Bearing and raising children is not easy or cheap. It requires a network of support and advice that used to be present in the extended family. But, we leave home and are much more mobile these days. We may live in Texas, but our baby’s grandparents live in Oregon or Brazil or Turkey. I asked my own exercise, childbirth education, and parenting clients about this. I found that many were in the classes precisely because they felt they had no firsthand experience or knowledge about what it was like to hold, feed or change a baby, let alone be prepared for birth and the sleep deprivation that followed. I also found mommy bloggers and entrepreneurs who found the impetus for their new work sprang from these issues in their own lives.

So, over the next series of blogs, I will be writing about some of these sites and services…both the professional organizations and the new mom entrepreneurs who have turned a difficult life transition into a way of simultaneously helping others while putting food on their tables. It looks to be an interesting journey and I hope you will follow along! I will get the next blog up in a few days, as soon as I am in the next location with internet access. My office is temporarily in the hurricane blackout zone of CT, but they promise me service soon. The first topic:  How to get pregnant!