Monday, September 28, 2009
Breastfeeding Woes
Jill at The Unnecesarean.com blog is holding a Best of review. One of the posts that really struck me was Dou-La-La's story about breastfeeding her daughter. She faced many challenges but ultimately overcame them. It's an inspirational story, especially for me as I had breastfeeding struggles with my first and second child. It took me three kids to get it right!
Thursday, September 24, 2009
Birth Strategy Class
Our September class was full (and running over). We had a great evening with 13 couples participating in our newest effort to assist families in having the most optimtal birth possible. Register early to assure your spot in this VERY fun and informative class!
Sunday, September 20, 2009
D's Birth Story
D and her husband called me earlier in the night around 9pm. Her husband wanted to let me know what was going on. It sounded like D was in labor with her first baby!
I had met this couple initially in the office and seen them a couple times throughout the remainder of the pregnancy. D had initially expressed an interest in having an epidural for her labor. When I saw her again towards the end of the pregnancy, she told me that she wanted to wait awhile but then would get an epidural unless I would convince her to do otherwise. I didn't - I told her that she was the only one that could make that decision. I didn't see her again until she came in for labor.
When her husband called me, he said she was contracting regularly but could talk when she was having them and they were about every 5-6 minutes. It sounded like they could stay home for awhile still. She had been 2/80/-2 in the office that day when seeing Lylaine. I asked him about her plans for pain management and was she still planning an epidural. He told me not necessarily. Cool :)
I got the call from L&D about 1:30am that D and her family had arrived. She was 8-9/100/-1 and didn't want anything for pain. I got myself out of bed and headed in to the hospital as quickly as I could. When I arrived, she was coping beautifully with her contractions. Her husband was at her side for support as well as her parents. D tried the tub for a bit but then wanted to get out and lay down for awhile. She laid on her side, while I rubbed her back. Eventually her water broke - with a very loud pop and a tidal wave all over the bed! We got dry linens on the bed while D began to feel like she needed to push. I checked her to discover she was 10/100/+1 - and told D that she could push whenever she felt ready too. We were checking the baby's heartbeat intermittently and baby was doing wonderful.
D stayed in a side-lying position to push. After pushing for just over an hour she delivered a beautiful little girl over an intact perineum, weighing in at 6 pounds 14 ounces. Her control during crowning was amazing. Her and her husband did a fantastic job with natural childbirth!
Congrats guys!
(posted with D's permission)
I had met this couple initially in the office and seen them a couple times throughout the remainder of the pregnancy. D had initially expressed an interest in having an epidural for her labor. When I saw her again towards the end of the pregnancy, she told me that she wanted to wait awhile but then would get an epidural unless I would convince her to do otherwise. I didn't - I told her that she was the only one that could make that decision. I didn't see her again until she came in for labor.
When her husband called me, he said she was contracting regularly but could talk when she was having them and they were about every 5-6 minutes. It sounded like they could stay home for awhile still. She had been 2/80/-2 in the office that day when seeing Lylaine. I asked him about her plans for pain management and was she still planning an epidural. He told me not necessarily. Cool :)
I got the call from L&D about 1:30am that D and her family had arrived. She was 8-9/100/-1 and didn't want anything for pain. I got myself out of bed and headed in to the hospital as quickly as I could. When I arrived, she was coping beautifully with her contractions. Her husband was at her side for support as well as her parents. D tried the tub for a bit but then wanted to get out and lay down for awhile. She laid on her side, while I rubbed her back. Eventually her water broke - with a very loud pop and a tidal wave all over the bed! We got dry linens on the bed while D began to feel like she needed to push. I checked her to discover she was 10/100/+1 - and told D that she could push whenever she felt ready too. We were checking the baby's heartbeat intermittently and baby was doing wonderful.
D stayed in a side-lying position to push. After pushing for just over an hour she delivered a beautiful little girl over an intact perineum, weighing in at 6 pounds 14 ounces. Her control during crowning was amazing. Her and her husband did a fantastic job with natural childbirth!
Congrats guys!
(posted with D's permission)
Monday, September 14, 2009
Today show and poor reporting
Unfortunately, the blogosphere is ablaze about the piece, entitled Perils of Homebirth (originally titled Perils of Midwifery), by the Today show. This 'informative' piece tells viewers how homebirth is trendy and unsafe. The focus is on a couple who sadly experienced a stillbirth after a homebirth delivery. It's as if they are implying this would never happen otherwise, and certainly not in a hospital. No one speaks to the rising cesarean rate or the moratlity rates in this country. The Today show clearly does not believe that midwives are the answer to the current crisis in women's healthcare despite ample and sound evidence that says otherwise.
Here are links to other blogs talking about this issue, including ACNM's response.
Our Bodies Our Blogs
*Thanks to Kathy at Woman to Woman Childbirth Education for the code mec button!
Birth Symposium
Birth Symposium
“Building A Better Birth with Midwives and Doulas”
“Building A Better Birth with Midwives and Doulas”
Are you planning a family, pregnant or have you just given birth and need support? Come to the Birth Symposium at Bethany Womens Healthcare to learn about the clinical and support options available to you in the commu-nity. Meet with local Midwives and Doulas (labor support paraprofessionals) to explore options on how you can build a better birth and postpartum ex-perience. This will be an interactive day filled with pampering, comfort measure techniques for labor, information, demonstrations and 30 minute talks about topics surrounding the childbearing year. This is a FREE event and open to the public. Dads & significant others are encouraged to attend.
October 29th, 2009
10 a.m. to 3 p.m.
Bethany Womens Healthcare
3660 W. Bethany Home Rd.
Phoenix, AZ 85019
More info: 602-973-3200 / 602-931-7045
Monday, September 7, 2009
World Breastfeeding Challenge Phoenix, AZ
World Breastfeeding Challenge Phoenix
Saturday, October 3rd 2009
9:00 am-12:00 pm
6932 W. Pershing Avenue
(near Thunderbird/67th Avenue)
Peoria, AZ 85345
Breastfeeding Counts!
Join Phoenix families to celebrate breastfeeding!
*9am-11am: Support local
mom-owned businesses.
Enjoy kids music
and activities.
*11:15am: Be Counted!
Gather on a blanket with your breastfeeding children.
*11:30am: Raffle to Benefit
La Leche League of Arizona
Cash Donations Only Please
Local Businesses who will be on site:
*A Great Little Balloon Company*
*Arizona Diaper Company*
*Cuddlebug Cloth Diapers*
*Free Car Seat Safety Checks*
*Formula Fed America Documentary Director*
*Groovy Kids Music Party*
*Heaven Sent Doula Services*
*Herbal Jules Herbal Clinic*
*Inspired By Finn Amber Jewelry*
*Piggy Paint Natural Nail Polish*
*Lil Boy Blu Kids Clothing*
*Little Treasures and More*
*Modest Middles Nursing Wear*
*Shaklee Healthy Home Products*
*Sunshine Baby Slings*
Saturday, October 3rd 2009
9:00 am-12:00 pm
6932 W. Pershing Avenue
(near Thunderbird/67th Avenue)
Peoria, AZ 85345
Breastfeeding Counts!
Join Phoenix families to celebrate breastfeeding!
*9am-11am: Support local
mom-owned businesses.
Enjoy kids music
and activities.
*11:15am: Be Counted!
Gather on a blanket with your breastfeeding children.
*11:30am: Raffle to Benefit
La Leche League of Arizona
Cash Donations Only Please
Local Businesses who will be on site:
*A Great Little Balloon Company*
*Arizona Diaper Company*
*Cuddlebug Cloth Diapers*
*Free Car Seat Safety Checks*
*Formula Fed America Documentary Director*
*Groovy Kids Music Party*
*Heaven Sent Doula Services*
*Herbal Jules Herbal Clinic*
*Inspired By Finn Amber Jewelry*
*Piggy Paint Natural Nail Polish*
*Lil Boy Blu Kids Clothing*
*Little Treasures and More*
*Modest Middles Nursing Wear*
*Shaklee Healthy Home Products*
*Sunshine Baby Slings*
Why I Became a Midwife - Lylaine
OK. I admit it. My name is Lylaine and I’m a birth junkie.
SO….why did I become a midwife? Guided by the Universe, I guess…and numerous influential women. My entire career has centered on mothers and babies-starting with scrubbing delivery tables in the 1960’s while attending college. I can still picture Mrs. Dodge, the labor nurse in her starched nurses’ cap and white apron, who instructed me in proper cleaning of equipment after each birth (maybe why I feel compelled now to “tidy up” after births). And Mrs. Tidwell, the cherubic nursery nurse who let me rock babies when I wasn’t cleaning (maybe why I feel magnetically drawn to little babies). Next came along Mrs. Bonny, the maternity nursing instructor. She had a way of making each student feel important and confident. She instilled my life-long belief that birth is a miraculous event, a natural process, not an illness. Then while working as an RN in Labor and Delivery at Good Sam, Mrs. Thomas taught me to stay calm in the midst of crisis. There were many others who have contributed to my evolution as a midwife, especially Anne Marie Faxel and Nancy Bolles who were the first midwives I ever met. Joyce Roberts and Lorraine Guyette were marvelous mentors and always made time to “be with” student midwives. Kitty Ernst and Ruth Lubic are others that have inspired and motivated me to continue the advocacy and empowerment of women in pregnancy and birth. The sisterhood of midwives is a marvelous place to be, a network of like-minded souls sharing love and joy with families at such important times in their lives.
Working in Labor and Delivery as a nurse (for about 15 years) solidified my love affair (and fascination) with birth. What I saw in the first midwives I met (at Phoenix Memorial) was an opportunity to get to know women and their families and be “with women” at birth in a more related and deeper way.
Since becoming a midwife, I have learned most of what I know about birthing from women (and their babies). For each and every one of them, I am truly grateful. And to mothers yet to cross my path, I cherish the opportunity to be with each one as I continue to learn from my most profound teachers.
SO….why did I become a midwife? Guided by the Universe, I guess…and numerous influential women. My entire career has centered on mothers and babies-starting with scrubbing delivery tables in the 1960’s while attending college. I can still picture Mrs. Dodge, the labor nurse in her starched nurses’ cap and white apron, who instructed me in proper cleaning of equipment after each birth (maybe why I feel compelled now to “tidy up” after births). And Mrs. Tidwell, the cherubic nursery nurse who let me rock babies when I wasn’t cleaning (maybe why I feel magnetically drawn to little babies). Next came along Mrs. Bonny, the maternity nursing instructor. She had a way of making each student feel important and confident. She instilled my life-long belief that birth is a miraculous event, a natural process, not an illness. Then while working as an RN in Labor and Delivery at Good Sam, Mrs. Thomas taught me to stay calm in the midst of crisis. There were many others who have contributed to my evolution as a midwife, especially Anne Marie Faxel and Nancy Bolles who were the first midwives I ever met. Joyce Roberts and Lorraine Guyette were marvelous mentors and always made time to “be with” student midwives. Kitty Ernst and Ruth Lubic are others that have inspired and motivated me to continue the advocacy and empowerment of women in pregnancy and birth. The sisterhood of midwives is a marvelous place to be, a network of like-minded souls sharing love and joy with families at such important times in their lives.
Working in Labor and Delivery as a nurse (for about 15 years) solidified my love affair (and fascination) with birth. What I saw in the first midwives I met (at Phoenix Memorial) was an opportunity to get to know women and their families and be “with women” at birth in a more related and deeper way.
Since becoming a midwife, I have learned most of what I know about birthing from women (and their babies). For each and every one of them, I am truly grateful. And to mothers yet to cross my path, I cherish the opportunity to be with each one as I continue to learn from my most profound teachers.
Friday, September 4, 2009
Birth Physiology by Michel Odent
One of our favorite birth advocates, Michel Odent, has some wonderful wisdom and knowledge to share...Read on!
Lylaine
What are the basic needs of human mammals when they are giving birth? In spite of thousands of years of cultural interferences, it is possible today to rediscover such needs with the help of a small number of physiological concepts (Odent 2001).
BASIC MAMMALIAN NEEDS
Our current understanding of birth physiology is based on the adrenaline–oxytocin antagonism: when mammals release adrenaline they cannot release oxytocin. We use the word ‘adrenaline’ as a simplified way to refer to the ‘fight and flight system’. Such an antagonism has been understood for a long time and evaluated in relation to myometrial response (Zuspan 1962) and milk ejection response (Whittlestone 1954). The first data have been confirmed by clinical studies among humans (Lederman 1978). Today oxytocin is often presented as ‘the mirror image of adrenaline’. (Uvnas-Moberg 2003).
It is well known that mammals (including humans) release adrenaline in situations such as being scared, feeling observed, or being cold. We can therefore draw the preliminary conclusion that in order to give birth a woman needs to feel secure, without feeling observed, in a warm enough place.
Although the adrenaline-oxytocin antagonism is theoretically established, it is not well-digested knowledge. It disagrees with deep-rooted beliefs. It is still commonplace, in natural childbirth circles, to include recommendations based on the simplistic idea that walking and using the force of gravity will make labour easier. Finding these recommendations strange is not new. As early as 1833, William DeWees wrote that ‘the preposterous custom of obliging her (the labouring woman) to walk the floor with a view to increase the pains when tardy should be preremptorily forbidden’. Today scientific evidence tends to support De Wees’ point of view. Since the prerequisite for labour to establish itself properly is a low level of adrenaline, it is a good sign when a labouring woman does not feel the need to stand up and walk. During the first stage of an easy and fast birth, women are often passive, for example on all fours or lying down. To suggest any sort of muscular activity at that phase can be counter-productive, even cruel.
This belief that a woman in labour should walk can still influence medical circles as well. This is how we can explain the popularity of the term ‘walking epidural’ and also the publication of randomised controlled trials to evaluate the effect of walking on labour and delivery. Of course none of the studies could demonstrate any effect. It is significant that, in the most authoritative of these studies, 22% of the women who were assigned to walking stayed in bed.(Bloom 1998)
In natural childbirth circles, labouring women are also often compared with athletes who are advised to consume large amount of carbohydrates before starting extreme physical exertion, such as running a marathon. Authors of articles about nutrition during labour have suggested that we should learn from sports medicine. Many birth attendants are influenced by these comparisons and encourage women to eat food such as pasta at the onset of labour, and to drink something sweet when labour is established: ‘You need energy!’.
These ideas about nutrition are also in contradiction with our current understanding of the adrenaline-oxytocin antagonism. A low level of adrenaline and good progress in the first stage imply that the striated muscles are at rest. When a birth is as physiological as possible, the labouring woman has a tendency to be immobile during the first stage. When all the skeletal muscles are at rest, such as when the mother is lying on her side or is on all-fours, energy expended is insignificant, and the need for carbohydrates is minimal, insofar as glucose is the favourite fuel of skeletal muscles. The energy expenditure of the uterine muscle is insignificant. Smooth muscles are between 20 and 400 times more energy efficient than skeletal muscles. Furthermore they can easily use fatty acids (rather than glucose) as fuel. In practice there is no risk of fuel shortage for the smooth muscles. The observations by Paterson and colleagues are highly significant. They found that ketone levels were higher in women who had been starved for twelve hours before an elective caesarean under general anaesthesia than they were for women who had been in labour. This confirms that labouring women spend less energy than those who are only waiting for an operation without being in labour.
Comparing labouring women to marathon runners is misleading and potentially dangerous. The side effects of sugar during labour are well documented. There is evidence that when the mother has been given an infusion containing glucose, the risk of lactic acidosis in the fetus is increased and the intensity of jaundice in the neonate is greater (Kenepp et al 1982)..
These theoretical considerations are supported by what we can learn from observation. Mammals in general do not eat during the process of parturition. For several decades, either in a hospital or at home, I have learned from thousands of women who were neither encouraged nor discouraged to eat and drink in labour. Although there are always exceptions, it is possible to summarize several simple observations. The first point is that labour rarely starts when a pregnant woman is hungry. This makes sense since hunger tends to increase the level of catecholamines. Second, when labour is really well established, women do not feel the need to eat.
OVERCOMING THE SPECIFICALLY HUMAN HANDICAP
A specifically human handicap during the process of parturition is the huge development of the neocortex in our species. During the birth process (or during any sort of sexual experience) most inhibitions are related to neocortical activity. In general rational control of the procreative drives is a byproduct of human brain evolution.
The evolutionary process found a way of overcoming this vulnerability. Neocortical activity simply becomes reduced during the birth process. This had not been understood by the Pavlovian physiologists whose theories are, directly or indirectly, at the root of most current schools of ‘natural childbirth’. It is, on the other hand, easily interpreted by those who have the experience of undisturbed, unmanaged and “uncoached” births. When a woman is giving birth easily, without any interference, there is a time when she seems to cut herself off from our world. She becomes indifferent to what is happening around her. She tends to forget her plans and received ideas. She behaves in a way that would be considered unacceptable in the daily life of a civilized woman. When, for example, she dares to scream, or to swear, or to be impolite, it means that there is reduction in neocortical control. She can find herself in the most bizarre, unexpected, and often primitive, quadrupedal and typically mammalian postures. She seems to be “on another planet”. This reduction of neocortical activity is an essential aspect of birth physiology among humans. It implies that labouring women need to be protected against any sort of neocortical stimulation. We must remember the main stimulants of the human neocortex are, if we are to avoid such stimulations.
Language is a specifically human stimulant of the neocortex. When we communicate with language we process what we perceive with our neocortex. This implies, for example, that if there is a birth attendant, one of her main qualities is her capacity to keep a low profile and to remain silent, to avoid in particular asking precise questions. It will probably take a long time for people to realize that a birth attendant must remain as silent as possible. It is difficult to get rid of the after-effects of the Pavlovian theories. Velvovski and other Pavlovian theoreticians had understood the neocortical origins of inhibitions during human parturition. However, probably because they were not practitioners directly involved in childbirth, they ignored the reduction of neocortical control as an essential aspect of birth physiology in our species. They assumed that the practical objective should be to ‘recondition’ women in order to eliminate the inhibitions and to make childbirth painless. From their point of view labour pain is a conditioned reflex, and therefore cultural. Such theories lead to the concept of ‘verbal analgesia’. After visiting the Pavlovian theoreticians in Russia in 1951, Lamaze introduced their concepts in Western countries. This is how the birth attendants started to overuse language and became invasive guides, helpers and even ‘coaches’.
Light is another well-known stimulant of the human neocortex. Electroencephalographers know that the trace exploring neocortical activity is influenced by visual stimulation. We usually close the curtains and switch off the lights when we want to reduce the activity of our intellect in order to go to sleep. This implies that, from a physiological perspective, a dim light should in general facilitate the birth process. These are important considerations in the age of electricity, when we have the power to switch on a bright light simply by pressing a button. It is noticeable that as soon as a labouring woman is on ‘another planet’ she is spontaneously driven towards postures that tend to protect her against all sorts of visual stimulations. For example she may be on all fours, as if praying. Apart from reducing the back pain, this common posture (with many asymmetrical variants) has several positive effects, such as eliminating the main reason for fetal distress (no compression of the vena cava), influencing the process of rotation, and therefore minimizing the mechanical difficulties that characterize human parturition.
The perception of danger is another possible stimulant of the neocortex. Since in situations of danger it is an advantage to be alert and attentive, neocortical activity is an appropriate response. Analyzing such a situation is another way to consider the need to feel secure as basic during human parturition.
Understanding the solution the evolutionary process found in order to overcome the specifically human handicap in parturition appears today to be a necessary step towards rediscovering the basic needs of labouring women.
BASIC NEEDS DURING THE THIRD STAGE OF LABOUR
Provided there have been no major deviations from the physiological reference during the previous phases of labour, mother and baby share similar basic needs during the third stage. From a physiological perspective there is a key event between the birth of the baby and the delivery of the placenta. It is the high peak of oxytocin that human mothers have the capacity to release immediately after the birth, which is arguably the highest level of oxytocin a woman can reach during her whole life. (Nissen 1995) This peak of oxytocin is vital, since it is necessary for a safe and bloodless delivery of the placenta, and since oxytocin is the main component of the 'cocktail of love hormones' that is supposed to be released in the perinatal period.
Whatever the circumstances, a release of oxytocin is highly influenced by the environment. We must therefore look at the factors that can have a positive or negative effect at the beginning of the mother-newborn interaction. By mixing theoretical considerations and clinical observations we can identify two main groups of factors. At this phase of labour, the vulnerability of mothers to an inappropriate ambient temperature is well known. This is why shivering (a sign of adrenaline release) is a frequent physiological response to an insufficiently high room temperature. In fact, just after the birth of the baby, mothers never complain because the place is too hot, while nonverbally they often indicate that it is not warm enough. The concept of adrenaline-oxytocin antagonism, alongside clinical observation, must bring us to the conclusion that, as soon as the baby is born, the thermo-regulation of the mother must be at rest. In other words, maintaining an appropriate ambient temperature should be the first preoccupation.An undisturbed interaction between mother and newborn is another factor facilitating oxytocin release. During the third stage of labour an appropriate maternal hormonal balance is more easily obtained if, in an atmosphere of privacy, the mother can feel the skin-to-skin contact, can try to establish eye-to-eye contact, and can smell the odour of her baby…without any distractions. Eliminating any distractions is difficult: as soon as a baby is born, there is always an irrational need for activity around; there is always somebody who wants to do something or to say something. This need for activity has been ritualized in many societies. It is impossible to offer an exhaustive catalogue of all the possible ways to interfere with the mother-newborn intimacy. Let us imagine, for example, that a mother is still in such a state of consciousness that she has forgotten the rest of the world while discovering her baby; suddenly somebody appears with two clamps and a pair of scissors in order to cut the cord. This distraction is a dangerous interference with the physiological processes.
At the very time when we are starting to understand the importance of the third stage for the ‘development of the capacity to love’, we have to realize that this particular phase of labour has been dramatically disturbed by all cultural milieus via a great diversity of beliefs and rituals. Furthermore we have to realize that, in the age of the safe caesarean, this phase of labour can be purely and simply eliminated for the first time in the history of mankind.
References
**Bloom SL, McIntire DD et al (1998) Lack of effect of walking on labor and delivery. N Engl J Med; 339: 76-9
**Kenepp NB, Shelley WC et al (1982) Fetal and neonatal hazards of maternal hydration with 5% dextrose before caesarean section. Lancet ii:1150-52
**Lederman RP, Lederman E, Work B, McCann DS (1978) The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol to progress in labor. Am J Obstet Gynecol 132(5):495-500
**Nissen E, Lilja G, Widstrom AM, Uvnas-Moberg K (1995) Elevation of oxytocin levels early post partum in women. Acta Obstet Gynecol Scand 74:530-3
**Odent M (2001) New reasons and new ways to study birth physiology. International Journal of Gynecology and Obstetrics 75:S39-S45
**Uvnas Moberg K (2003) The oxytocin factor. Da Capo Press. Cambridge MA
**Wittlestone WG (1954) The effect of adrenaline on the ejection response of the sow. J Endocrin 10:167-172
**Zuspan FP, Cibils LA. Pose SV(1962) Myometrial and cardiovascular responses to alterations in plasma epinephrine and norepinephrine. Am J Obstet Gynecol 84(7):841-851
Lylaine
BIRTH PHYSIOLOGY:
AN OVERVIEW
AN OVERVIEW
by Michel Odent
What are the basic needs of human mammals when they are giving birth? In spite of thousands of years of cultural interferences, it is possible today to rediscover such needs with the help of a small number of physiological concepts (Odent 2001).
BASIC MAMMALIAN NEEDS
Our current understanding of birth physiology is based on the adrenaline–oxytocin antagonism: when mammals release adrenaline they cannot release oxytocin. We use the word ‘adrenaline’ as a simplified way to refer to the ‘fight and flight system’. Such an antagonism has been understood for a long time and evaluated in relation to myometrial response (Zuspan 1962) and milk ejection response (Whittlestone 1954). The first data have been confirmed by clinical studies among humans (Lederman 1978). Today oxytocin is often presented as ‘the mirror image of adrenaline’. (Uvnas-Moberg 2003).
It is well known that mammals (including humans) release adrenaline in situations such as being scared, feeling observed, or being cold. We can therefore draw the preliminary conclusion that in order to give birth a woman needs to feel secure, without feeling observed, in a warm enough place.
Although the adrenaline-oxytocin antagonism is theoretically established, it is not well-digested knowledge. It disagrees with deep-rooted beliefs. It is still commonplace, in natural childbirth circles, to include recommendations based on the simplistic idea that walking and using the force of gravity will make labour easier. Finding these recommendations strange is not new. As early as 1833, William DeWees wrote that ‘the preposterous custom of obliging her (the labouring woman) to walk the floor with a view to increase the pains when tardy should be preremptorily forbidden’. Today scientific evidence tends to support De Wees’ point of view. Since the prerequisite for labour to establish itself properly is a low level of adrenaline, it is a good sign when a labouring woman does not feel the need to stand up and walk. During the first stage of an easy and fast birth, women are often passive, for example on all fours or lying down. To suggest any sort of muscular activity at that phase can be counter-productive, even cruel.
This belief that a woman in labour should walk can still influence medical circles as well. This is how we can explain the popularity of the term ‘walking epidural’ and also the publication of randomised controlled trials to evaluate the effect of walking on labour and delivery. Of course none of the studies could demonstrate any effect. It is significant that, in the most authoritative of these studies, 22% of the women who were assigned to walking stayed in bed.(Bloom 1998)
In natural childbirth circles, labouring women are also often compared with athletes who are advised to consume large amount of carbohydrates before starting extreme physical exertion, such as running a marathon. Authors of articles about nutrition during labour have suggested that we should learn from sports medicine. Many birth attendants are influenced by these comparisons and encourage women to eat food such as pasta at the onset of labour, and to drink something sweet when labour is established: ‘You need energy!’.
These ideas about nutrition are also in contradiction with our current understanding of the adrenaline-oxytocin antagonism. A low level of adrenaline and good progress in the first stage imply that the striated muscles are at rest. When a birth is as physiological as possible, the labouring woman has a tendency to be immobile during the first stage. When all the skeletal muscles are at rest, such as when the mother is lying on her side or is on all-fours, energy expended is insignificant, and the need for carbohydrates is minimal, insofar as glucose is the favourite fuel of skeletal muscles. The energy expenditure of the uterine muscle is insignificant. Smooth muscles are between 20 and 400 times more energy efficient than skeletal muscles. Furthermore they can easily use fatty acids (rather than glucose) as fuel. In practice there is no risk of fuel shortage for the smooth muscles. The observations by Paterson and colleagues are highly significant. They found that ketone levels were higher in women who had been starved for twelve hours before an elective caesarean under general anaesthesia than they were for women who had been in labour. This confirms that labouring women spend less energy than those who are only waiting for an operation without being in labour.
Comparing labouring women to marathon runners is misleading and potentially dangerous. The side effects of sugar during labour are well documented. There is evidence that when the mother has been given an infusion containing glucose, the risk of lactic acidosis in the fetus is increased and the intensity of jaundice in the neonate is greater (Kenepp et al 1982)..
These theoretical considerations are supported by what we can learn from observation. Mammals in general do not eat during the process of parturition. For several decades, either in a hospital or at home, I have learned from thousands of women who were neither encouraged nor discouraged to eat and drink in labour. Although there are always exceptions, it is possible to summarize several simple observations. The first point is that labour rarely starts when a pregnant woman is hungry. This makes sense since hunger tends to increase the level of catecholamines. Second, when labour is really well established, women do not feel the need to eat.
OVERCOMING THE SPECIFICALLY HUMAN HANDICAP
A specifically human handicap during the process of parturition is the huge development of the neocortex in our species. During the birth process (or during any sort of sexual experience) most inhibitions are related to neocortical activity. In general rational control of the procreative drives is a byproduct of human brain evolution.
The evolutionary process found a way of overcoming this vulnerability. Neocortical activity simply becomes reduced during the birth process. This had not been understood by the Pavlovian physiologists whose theories are, directly or indirectly, at the root of most current schools of ‘natural childbirth’. It is, on the other hand, easily interpreted by those who have the experience of undisturbed, unmanaged and “uncoached” births. When a woman is giving birth easily, without any interference, there is a time when she seems to cut herself off from our world. She becomes indifferent to what is happening around her. She tends to forget her plans and received ideas. She behaves in a way that would be considered unacceptable in the daily life of a civilized woman. When, for example, she dares to scream, or to swear, or to be impolite, it means that there is reduction in neocortical control. She can find herself in the most bizarre, unexpected, and often primitive, quadrupedal and typically mammalian postures. She seems to be “on another planet”. This reduction of neocortical activity is an essential aspect of birth physiology among humans. It implies that labouring women need to be protected against any sort of neocortical stimulation. We must remember the main stimulants of the human neocortex are, if we are to avoid such stimulations.
Language is a specifically human stimulant of the neocortex. When we communicate with language we process what we perceive with our neocortex. This implies, for example, that if there is a birth attendant, one of her main qualities is her capacity to keep a low profile and to remain silent, to avoid in particular asking precise questions. It will probably take a long time for people to realize that a birth attendant must remain as silent as possible. It is difficult to get rid of the after-effects of the Pavlovian theories. Velvovski and other Pavlovian theoreticians had understood the neocortical origins of inhibitions during human parturition. However, probably because they were not practitioners directly involved in childbirth, they ignored the reduction of neocortical control as an essential aspect of birth physiology in our species. They assumed that the practical objective should be to ‘recondition’ women in order to eliminate the inhibitions and to make childbirth painless. From their point of view labour pain is a conditioned reflex, and therefore cultural. Such theories lead to the concept of ‘verbal analgesia’. After visiting the Pavlovian theoreticians in Russia in 1951, Lamaze introduced their concepts in Western countries. This is how the birth attendants started to overuse language and became invasive guides, helpers and even ‘coaches’.
Light is another well-known stimulant of the human neocortex. Electroencephalographers know that the trace exploring neocortical activity is influenced by visual stimulation. We usually close the curtains and switch off the lights when we want to reduce the activity of our intellect in order to go to sleep. This implies that, from a physiological perspective, a dim light should in general facilitate the birth process. These are important considerations in the age of electricity, when we have the power to switch on a bright light simply by pressing a button. It is noticeable that as soon as a labouring woman is on ‘another planet’ she is spontaneously driven towards postures that tend to protect her against all sorts of visual stimulations. For example she may be on all fours, as if praying. Apart from reducing the back pain, this common posture (with many asymmetrical variants) has several positive effects, such as eliminating the main reason for fetal distress (no compression of the vena cava), influencing the process of rotation, and therefore minimizing the mechanical difficulties that characterize human parturition.
Feeling observed is a situation associated with neocortical stimulation. When we feel observed, we tend in return to observe ourselves and to correct our attitude. This is another way to interpret the importance of privacy (i.e. not to feel observed) as a basic need during labour. Understanding the need for privacy makes us anticipate, for example, that there is a difference between a midwife staying in front of a labouring woman and watching her, and another one sitting in a corner. It might also make us anticipate that devices that are perceived by the labouring woman as observing tools (such as a camera or an electronic fetal monitor) should be introduced with extreme caution in a birthing place. The surprise produced by the results of randomized controlled trials comparing the effects on statistics of electronic fetal monitoring versus intermittent auscultation is a symptom of a lack of understanding of birth physiology. It might have been anticipated that the only fact that a labouring woman knows that her body functions are continuously monitored tends to stimulate her neocortex. Stimulating the neocortex risks making the labour longer, more difficult, and therefore more dangerous so that more babies must be rescued via the abdominal route. Photos in books for the general public and videos shown in conferences constitute proof that the need for privacy is not understood by the natural childbirth movements: it is commonplace to see a woman in labour surrounded by several people watching her.
The perception of danger is another possible stimulant of the neocortex. Since in situations of danger it is an advantage to be alert and attentive, neocortical activity is an appropriate response. Analyzing such a situation is another way to consider the need to feel secure as basic during human parturition.
Understanding the solution the evolutionary process found in order to overcome the specifically human handicap in parturition appears today to be a necessary step towards rediscovering the basic needs of labouring women.
BASIC NEEDS DURING THE THIRD STAGE OF LABOUR
Provided there have been no major deviations from the physiological reference during the previous phases of labour, mother and baby share similar basic needs during the third stage. From a physiological perspective there is a key event between the birth of the baby and the delivery of the placenta. It is the high peak of oxytocin that human mothers have the capacity to release immediately after the birth, which is arguably the highest level of oxytocin a woman can reach during her whole life. (Nissen 1995) This peak of oxytocin is vital, since it is necessary for a safe and bloodless delivery of the placenta, and since oxytocin is the main component of the 'cocktail of love hormones' that is supposed to be released in the perinatal period.
Whatever the circumstances, a release of oxytocin is highly influenced by the environment. We must therefore look at the factors that can have a positive or negative effect at the beginning of the mother-newborn interaction. By mixing theoretical considerations and clinical observations we can identify two main groups of factors. At this phase of labour, the vulnerability of mothers to an inappropriate ambient temperature is well known. This is why shivering (a sign of adrenaline release) is a frequent physiological response to an insufficiently high room temperature. In fact, just after the birth of the baby, mothers never complain because the place is too hot, while nonverbally they often indicate that it is not warm enough. The concept of adrenaline-oxytocin antagonism, alongside clinical observation, must bring us to the conclusion that, as soon as the baby is born, the thermo-regulation of the mother must be at rest. In other words, maintaining an appropriate ambient temperature should be the first preoccupation.An undisturbed interaction between mother and newborn is another factor facilitating oxytocin release. During the third stage of labour an appropriate maternal hormonal balance is more easily obtained if, in an atmosphere of privacy, the mother can feel the skin-to-skin contact, can try to establish eye-to-eye contact, and can smell the odour of her baby…without any distractions. Eliminating any distractions is difficult: as soon as a baby is born, there is always an irrational need for activity around; there is always somebody who wants to do something or to say something. This need for activity has been ritualized in many societies. It is impossible to offer an exhaustive catalogue of all the possible ways to interfere with the mother-newborn intimacy. Let us imagine, for example, that a mother is still in such a state of consciousness that she has forgotten the rest of the world while discovering her baby; suddenly somebody appears with two clamps and a pair of scissors in order to cut the cord. This distraction is a dangerous interference with the physiological processes.
At the very time when we are starting to understand the importance of the third stage for the ‘development of the capacity to love’, we have to realize that this particular phase of labour has been dramatically disturbed by all cultural milieus via a great diversity of beliefs and rituals. Furthermore we have to realize that, in the age of the safe caesarean, this phase of labour can be purely and simply eliminated for the first time in the history of mankind.
References
**Bloom SL, McIntire DD et al (1998) Lack of effect of walking on labor and delivery. N Engl J Med; 339: 76-9
**Kenepp NB, Shelley WC et al (1982) Fetal and neonatal hazards of maternal hydration with 5% dextrose before caesarean section. Lancet ii:1150-52
**Lederman RP, Lederman E, Work B, McCann DS (1978) The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol to progress in labor. Am J Obstet Gynecol 132(5):495-500
**Nissen E, Lilja G, Widstrom AM, Uvnas-Moberg K (1995) Elevation of oxytocin levels early post partum in women. Acta Obstet Gynecol Scand 74:530-3
**Odent M (2001) New reasons and new ways to study birth physiology. International Journal of Gynecology and Obstetrics 75:S39-S45
**Uvnas Moberg K (2003) The oxytocin factor. Da Capo Press. Cambridge MA
**Wittlestone WG (1954) The effect of adrenaline on the ejection response of the sow. J Endocrin 10:167-172
**Zuspan FP, Cibils LA. Pose SV(1962) Myometrial and cardiovascular responses to alterations in plasma epinephrine and norepinephrine. Am J Obstet Gynecol 84(7):841-851
Wednesday, September 2, 2009
Homebirth CNM
This CNM has started her own practice in Kansas City, MO. She spent part of her clinicals with us at Bethany last year so I can attest to her skills personally. She's sweet and a fantastic midwife - and that was as a student! You can contact her through her website...
Awakened Birthing
Tiffany
Awakened Birthing
Tiffany
Another fabulous birth
This young woman was having her second baby and showed up to the hospital almost in transition! She had natural childbirth with her first and wanted to do the same with this one.
When I arrived, she was just getting out of the tub. She wasn't feeling too comfortable in there, with her back hurting. She stood in the bathroom for a while with her boyfriend to lean on. Eventually she came out and stood by the bedside, with her mother on one side and her boyfriend on the other. I asked her what she wanted to do and made some suggestions, as she wasn't really sure what or where she wanted to be! She didn't like the idea of hands and knees, and really just wanted to lay down. She requested to be checked as well. She was 9cms with a very stretchy, soft cervix. That's the kinda cervix that tends to slip away if momma starts to do some grunty pushes. I figured it wouldn't be long.
She didn't want to be touched and I think her boyfriend's feelings were a little hurt. I explained to him this was a normal part of birth and some women were a little irritable at the end - nothing he should take personally!
After about a half hour had gone by, she told me she felt like she needed to push. I said go ahead but she seemed really nervous about doing that without me checking her. I waited a bit and she spontaneously started bearing down...she couldn't help herself. She asked me to check her. Of course, she was 10cms and the baby was at a +2 station. The bag of waters was still intact. I told her she could have the baby whenever she was ready. She wanted me to put my gloves on. I told her I would when she showed me the baby :)
Which she did, in about 2 more contractions. I could see the bag, with clear fluid in it and the baby with lots of hair! I threw my gloves on and got ready to catch. I did rupture the membranes once the head was crowning - just made a tiny little hole. She pushed the baby out with great control over an intact perineum. The baby went up onto her chest, while we waited for the cord to stop pulsating.
Tiffany
When I arrived, she was just getting out of the tub. She wasn't feeling too comfortable in there, with her back hurting. She stood in the bathroom for a while with her boyfriend to lean on. Eventually she came out and stood by the bedside, with her mother on one side and her boyfriend on the other. I asked her what she wanted to do and made some suggestions, as she wasn't really sure what or where she wanted to be! She didn't like the idea of hands and knees, and really just wanted to lay down. She requested to be checked as well. She was 9cms with a very stretchy, soft cervix. That's the kinda cervix that tends to slip away if momma starts to do some grunty pushes. I figured it wouldn't be long.
She didn't want to be touched and I think her boyfriend's feelings were a little hurt. I explained to him this was a normal part of birth and some women were a little irritable at the end - nothing he should take personally!
After about a half hour had gone by, she told me she felt like she needed to push. I said go ahead but she seemed really nervous about doing that without me checking her. I waited a bit and she spontaneously started bearing down...she couldn't help herself. She asked me to check her. Of course, she was 10cms and the baby was at a +2 station. The bag of waters was still intact. I told her she could have the baby whenever she was ready. She wanted me to put my gloves on. I told her I would when she showed me the baby :)
Which she did, in about 2 more contractions. I could see the bag, with clear fluid in it and the baby with lots of hair! I threw my gloves on and got ready to catch. I did rupture the membranes once the head was crowning - just made a tiny little hole. She pushed the baby out with great control over an intact perineum. The baby went up onto her chest, while we waited for the cord to stop pulsating.
Tiffany
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