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Preparing For Labor

Big doesn't have to be too big for you. You never know till you try

Big doesn’t have to mean too big for you. How else can you explain super small boned, petite moms that vaginally deliver 11lb babies over intact perineums with no problems for mom or baby?

Until you try labor and delivery- really try it- you have no way of knowing. This is actually the American College of OB/Gyns' philosophy. They do not believe that c-sections should be scheduled for suspected large babies. This is because big might not be too big. The only way to know if your baby will fit in your body is a good trial of labor and delivery.
So, if your Dr. has decided that your baby is too big or you are too small to vaginally birth baby then you should ask what research they are following.

I know that a lot of moms get freaked out about babies size. And yes, there are plenty of babies nowadays that are technically defined as "macromasic." (Greater than 8lb8oz) Maybe a result of genetics, poor diet choices in pregnancy, GD, not smoking in pregnancy, growth hormones in dairy products...lots of reasons. But, many of these moms are also having vaginal births.

A big baby doesn't automatically mean a complicated labor or delivery. Many moms have said that their larger babies were their easier births. Many 2nd+ moms that might have had perineal damage with #1 might assume it was b/c of baby's size. However, they have no tears or anything for their even larger babies.

How labor is managed, how the delivery is managed, how the perineum is managed and the position of baby all play LARGE roles in the outcome of the birth.

Here's this CPD (Cephalopelvic Disproportion) can play our. Remember that CPD is real BUT only about 3% of moms really and truly have this. The rest are probably the mismanagement of labor or a malpositioned baby.

One very valid reason for having a cesarean section to deliver your baby is called cephalopelvic disproportion or CPD. What it means is that your baby is too big to fit through your pelvis in a vaginal delivery.
One very valid reason for having a cesarean section to deliver your baby is called cephalopelvic disproportion or CPD. What it means is that your baby is too big to fit through your pelvis in a vaginal delivery. However, this term is often given for cesareans that could have resulted in a vaginal delivery with a little more patience.


Here is the typical scenario of a woman who ends up with a c-section for CPD. She goes to the hospital in labor or has her labor induced and she doesn't progress according to the charts physicians follow in their medical practices, which in part is dilating one centimeter per hour. Since physicians rarely are patient and wait for women to birth on their own they will end up doing a c-section claiming the baby was too big to be born vaginally.


However, there is no certain way to ever know this is fact and the woman is left with the impression she is unable to deliver a baby vaginally because the baby was either large or had a large head circumference. If she is fortunate enough she will have a VBAC, vaginal birth after cesarean, next time, and birth a baby just as large as the one who was delivered by cesarean.


If pushing goes on for too long the physician will also make the call that the baby is too big to fit through the pelvis. Sometimes pushing becomes difficult with an epidural administered or if the laboring woman is not allowed freedom in her movement and the baby does not descend into the birth canal properly.


Unfortunately the woman ends up believing that her baby really would not have been born vaginally because the physician gives her the reason for CPD.


Another common comment by physicians is that a woman who had a c-section for CPD has hips that are too small to deliver a baby vaginally. Again, it is unfortunate that women will believe this and not question the knowledge given. In actuality, it is the pelvic inlet where the baby passes through that is the real determiner of whether or not a baby will be born vaginally. The pelvic wings of the exterior hip along with extra padding, which gives the visual effect that the hips may be too small, really has nothing to do with the realities of delivering a baby vaginally.


Once CPD is diagnosed in a woman's chart in her pregnancy history it can be difficult to overcome and a source of tension between mother and care provider. When another pregnancy comes along and the woman wants to choose a VBAC, CPD is considered a red flag and one that will cause a physician to be discouraged from agreeing with a VBAC. They will worry needlessly that the same thing will occur and try to scare the woman into choosing a repeat c-section saying that it would be worse to labor and then have a surgically-born baby rather than just schedule a repeat c-section.


It really is up to the woman in deciding how she will approach another birth, but bearing in mind the truth of CPD and its implications will make an informed choice more easily obtained.


http://ri.essortment.com/cephalopelvicd_rcam.htm


Q: My doctor told me my pelvis is too small to vaginally deliver a baby over eight pounds. Is this true?
A: No, the pelvis and the baby's head are not fixed bone structures. During labor the pelvis opens, allowing room for the baby, whose head molds to fit. The pelvis will actually open up 33% larger than it's pre-pregnant size with a squatting position. There are several factors that contribute to this. First a hormone called relaxin is released during the latter part of pregnancy which soften the ligaments and cartilage surrounding the pelvis. Also different positions assumed during labor will change the dimensions of the pelvis such as walking, climbing stairs and squatting. This combined with the flexibility of the baby's head gives ample room for babies to move through the pelvis. The baby's head is made up of five plates that are connected with soft tissues that allow it to mold during the birth process as the baby travels through the pelvis. These bones return to their pre-birth state within hours of birth.
http://www.ican-online.org/resources/faqs.htm


I have just heard so many discouraging things lately around the boards from moms who really and truly believe that their baby is too big. But, they will never really know that. They have no proof of that.



If you already think that the baby is going to be too big, that can really affect the outcome
-If labor stalls or is slow (which is OK!! ) and someone hints that it is probably because the baby is too big for your body then you will probably believe them. No effort will be made on any front to work on position. ***Stalled labor between 5-7cm is often a result of a malpositioned baby!**
-If delivery is taking a while, you are more inclined to face an intervention if the thought is already in everyone's mind that the baby will be big.
-If size hadn't been brought up then that could change the outcome.

Inducing for size (Henci Goer):
http://www.parentspl.....ru/articles/0,10335,243385_234322,00.html

Baby Hasn’t Dropped yet- Should I be worried?
http://childbirth.org/AskANurse/laboring/laboring9.html

Myth of needing a c-section based on mom’s height and weight:
http://www.childbirth.org/AskACBE/labor/labor1.html

My Dr. doesn’t think I can vaginally deliver a baby b/c of size concerns:
http://www.ican-online.org/resources/faqs.htm

U/S estimates should not be used for determining induction: for estimates between 4000g-4500g, C-section Risk did NOT decrease
http://www.ncbi.nlm......&dopt=Abstract&list_uids=97314122

Pelvis sizes:
http://www.birthlove.com/free/gloria.html

Short Women And Big Babies
http://transitiontoparenthood.com/ttp/foreducators/shortwomen.htm

What is cephalopelvic disproportion?
http://ri.essortment.com/cephalopelvicd_rcam.htm

Narrow Pelvis
http://www.storknet.com/cubbies/childbirth/exdb1.htm



Anything can happen. So much comes down to baby's position, the careprovider you have chosen and your attidue/beliefs about birth.

Each pregnancy and birth is as unique as the child that is born. Having a tough delivery with #1 (especially if shoulder dystocia was present) doesn't doom you to that same fate. In fact, research has shown that SD is not a reason to induce for size in future pregnancies. Babies of all sizes cna get stuck.

You never know till you try.

What can you do to have a safer, easier birth even if baby is larger? I'll post that next.


Malpositioned are often the source of FTP and CPD diagnosis. They can mimic CPD by making a long, slow, labor and a harder delivery. A malpositioned baby is a correctable situation though. If FTP starts to cross your Dr.'s lips in labor, ask if there are positioning things you can try before a c-section. If there is no distress then there should be no reason to at least try, right? It's the only way you'll know.

A malpositioned baby can make birth more complicated so it is to your advantage to get the baby in the proper anterior position.

A malpositioned baby can make for a slower labor. Your body might be contracting at full steam but the contractions have to work overtime because ideally your body wants the baby to turn. So your contractions are working on changing the cervix, lowering the baby and helping baby to rotate.

In a posterior labor you will probably have a lot more back pressure and pain during the contractions. Sometimes that is all you feel- your back- and you only feel a tightening in the front.

A traditional hosptal birth can increase the chances of a longer, more complicated labor so definetly know your options and know what affect things can have on you and a vaginal birth.

1. Laboring in bed makes it really hard for the baby to turn. Ideally with a posterior baby you would try positions like hands and knees or leaning over things. These will shift the weight of the baby around and help them to be able to move.

2. Having your water broken can force the baby into the pelvis at that angle or an even worse angle. The baby can almost get wedged there. A lot of babies that are dubbed "too big" were just malpositioned. Avoiding having your water broken can really up your chances or success.

3. Those 2 above things can also factor into the pain part. Laboring in bed with a posterior baby hurts. All that pressure is in your back and the added pressure just intensifies the contractions. Your body knows better than to lay in bed that is why it is screaming at you to get up. The amniotic sac forms a cushion from the intensity from the contractions for both you and baby. Staying out of bed and keeping the amniotic sac in tact can make things easier, less painful and increase your odds of a vaginal birth.

4. Patience is a virtue that is often lacking in a lot of births today. Labor hurts so even if we know that pitocin or having your water broken might make the birth more complicated, it is appealing none the less because it means that maybe you can get the birth done with sooner. Unfortunately, your body might know better and you might not get the result you were hoping for. Like I said before, a posterior birth is slow for a reason. Rather than intervening with pitocin or AROM, try 15 minutes of getting out of bed and getting on your hands and knees or something. It might make all the difference in the world.

5. Just as a warning, epidurals are not always effective as they normally would be with a posterior baby involved. You will still have a lot of pressure on your back. When the epidural is in place you might lose some of your valuable assets- mainly the ability to get out of bed and change positions.

Prevent malposition with different stretches and exercises:
Back Labor and Optimal Fetal Positioning:
http://www.motherspirit.net/articles/pregnancy/preventpost.htm

Optimal Fetal Positioning
http://www.homebirth.org.uk/ofp.htm

Ok, so I covered the role of baby's position in labor and what you can do about that.

That leaves how your labor is managed, how delivery is managed and how the perineum is managed.

We'll talk about labor now....


If all is well there shouldn't be a time limit placed on you and the baby.

Barring an unusual set of complications, once labor starts I should end with a baby.

The textbook average first labor is about 12-16 hours. Second labors are usually 10-12 hours. Each birth after that tends to get shorter. Especially with regards to the pushing phase.

Some Dr.s and midwives practice "Active Management." A while back someone decided that labor should progress at a certain rate. Anything slower than that was abnormal and needed to be "fixed." These carepoviders follow the "Friedman Curve." This means that, on average (depends if you are a first time mom or not) that your labor should progress one cm per hour during active labor. If your birth isn・t progressing at this rate then they will often want to intervene with pitocin or breaking your water.

Does your Dr. or midwife adhere to this? It would be a good idea to ask! Some Dr.s will do a c-section automatically after 12 hours; it has happened to moms on this board in the past. That is shorter than the average first labor.

Here is a recent study about the validity of the Friedman curve in birth:
"RESULTS: Our average labor curve differs markedly from the Friedman curve. The cervix dilated substantially slower in the active phase. It took approximately 5.5 hours from 4 cm to 10 cm, compared with 2.5 hours under the Friedman curve. We observed no deceleration phase. Before 7 cm, no perceivable change in cervical dilation for more than 2 hour was not uncommon. The 5th percentiles of rate of cervical dilation were all below 1 cm per hour. The 95th percentile of time interval for fetal descent from station +1/3 to +2/3 was 3 hours at the second stage. CONCLUSION: Our results suggest that the pattern of labor progression in contemporary practice differs significantly from the Friedman curve. The diagnostic criteria for protraction and arrest disorders of labor may be too stringent in nulliparous women."
http://www.ncbi.nlm......&list_uids=12388957&dopt=Abstract


The American College of OB/Gyns does nor subscribe to the active management model of care, especially if mom and baby are well. In fact, in their book "Planning your Pregnancy and Birth" they discuss that if all is well in the pushing stage that moms should be given as much time as they need- there shouldn't be a set time limit before hand.

Feeling like you are on the clock to produce can be really stressful and can actually halt your labor. Stress hormones can supress oxytocin.

Also, an implication is made that your body must be broken if it isn't following this predetermined schedule. That can actually really make a lasting impact on how a woman views herself. The odds are very good that if given a chance that a woman・s labor will progress and she will be able to have a healthy, successful vaginal delivery. Planting seeds of doubt that something is wrong (like the baby is too big) can eat away at a successful labor.

Pitocin and breaking the amniotic sac may also cause problems. Every intervention can set off a domino effect that can ultimately affect the end result.
Pitocin- Synthetic from of body・s natural oxytocin. Unlike natural oxytocin, the dosage is not perfectly designed for your body and labor. Some labors are meant to be fast while others are meant to be slow. Some babies come at 38 weeks others are ready at 42 weeks (still term).
Risks:
-Fetal distress caused by the contractions being too strong- hyperstimultaion of the uterus (blood flow to baby can be compromised as a result of the compression)
-Contractions that give mom and baby no breaks and increase the desire for pain meds (which have their own pros and cons)
-A contraction that doesn・t end (tetanic contraction)- they have medicine that can end it though
-Increased risk of c-section due to fetal distress along with the other interventions that are common in an induced labor
-Increased risk of postpartum bleeding
-Baby may be born premature if the due dates aren・t right

Artificial Rupture of Membranes (aka amniotomy, AROM or breaking your water)- This protective cushion serves many important functions for you and baby. Sometimes Dr.s or midwives do this as a matter of routine which just might not be right in every situation. Also, the popular wisdom that it speeds up labor isn・t always the case.
Risks:-The fluid acts as a cushion for baby. It keeps the cord from getting compressed. Cord compression can reduce the blood and oxygen flow to baby.
-The fluid makes the contractions easier on mom and baby. Having your water broken can really intensify labor contractions.
-A lot of caregivers put you on the c-section clock to deliver. If labor doesn・t pick up then other interventions (like pitocin) might be necessary. 24 hours is the norm though it might be longer or shorter depending on mom and baby・s condition and signs of infection.
-The fluid protects the baby from infection. Frequent internal exams after AROM increases the risk.
-Fetal malpresentation- If baby wasn't engaged the AROM can push them into the pelvis at a bad angle (posterior, sideways). This can lengthen labor and make delivery more difficult
-Rare but possible is cord prolapse (the cord comes out before the baby). This is an emergency situation.

So, while these interventions were designed to aid a woman and help her have a nice, quick delivery, they actually set up greater challenges than time. Sometimes Pitocin and AROM are so casually mentioned and only the benefit is told to mom. And I am willing to bet that a lot of moms deep into active labor would willingly accept anything that would get labor done sooner. If the risks were more known then there might not be such a desire to reach for these options first.

There really are other options but they just aren't offered very often. Walking, eating, drinking, position change, support and encouragement can do just as much to help labor progress as pitocin or AROM could. They are a great first option if labor is slow or not progressing at the ideal rate. Remember these in your labor. If they say they want to speed things us with one of those 2, ask why. Ask if there are alternatives. Ask what would happen if you didn・t do either. Ask if there is a reason they want to speed things up. Are you ok? Is the baby ok?

My labor was very pokey. But my ds was posterior. I wouldn't have gotten far if I was stuck in bed with pitocin. I needed to get up and change his position before things would progress. But, my CNM did suggest pitocin after I had been at 5cm for a few hours. I asked her if I had other options. She told me to drink some juice and go for a walk. Much better for me. But, I was still miffed that she suggested pitocin and I accused her of being just like a Dr.. She said that if she were a typical Dr. she would have called in orders for pitocin to the nurse from the comfort of the staff lounge. They wouldn't have been there discussing it with me. (Generalizations, I know, but that is how the conversation took place). 20 hours after my water broke and labor started, my ds was born. No worse for the wear. APGARs of 8 and 9.


" What is Active Management of Labor? And is it successful?
Active Management of Labor (AML) was started in Dublin in 1968. It was started to help a mother's labor be efficient. This is achieved with a medical model of birth, including amniotomy (Artificial Rupture of Membranes), and pitocin augmentation.

AML has many components in Dublin. I will start with explaining their approach and then explain the American approach.

In Dublin, a woman is given classes that guarantee that she will be able to diagnose her own labor (Labor is defined as completely effaced, having painful contraction 7-10 minutes apart, or having you water broken.). When she arrives at the maternity ward she is given a student midwife who performs no clinical skills (making her a doula), that stays by the woman's side throughout labor. The midwife in charge of her care makes sure that she is progressing at the rate of 1-2 cms per hour. If not her water will be broken (if not previous done), and then she will be hooked up to pitocin (which is given at a quicker infusion, reaching maximum dose before we normally would here in the US). They will also guarantee the birth will take 12 hours or less.

98% of women delivered in 12 hours of beginning AML, and 40% were by reaching four hours. They had a cesarean rate of 5%. They had an epidural rate of 15%. They also had no apparent difference in the condition of the baby.

Sounds to good to be true? Well, this is what the Americans have done with it. First of all, they have no standard prenatal education, nor guide to define labor. In Dublin, if you are completely effaced your cervix is more likely to be receptive to pitocin, that is not a standard of American AML. We also don't provide the doula, which has been previously shown to help reduce the epidural and cesarean rates. So, AML is not the same here in the United States."
http://www.childbirth.org/articles/pit.html#aml

From the World Health Organization:
"There is no question that the clocks have been quickened. The definition of the normal upper limit to labor has been reduced from 36 hours in the 1950s to 24 hours in the 1960s to 12 hours in 1972 when active management was introduced. In describing active management, one of its practitioners says: "Twelve hours is considered the maximum safe duration of spontaneous labor and cesarean section is performed unless delivery is imminent at that time" (O'Herlihy). All of these time limits were arbitrarily based on clinical concerns and not on scientific evidence. Putting a stop watch to labor, as is done in active management, precipitates many problems. When to start the stop watch and declare the race on is difficult and subjective. "The final component of active management is taking care to diagnose labor only when progressive dilatation or effacement of the cervix is observed. This has never been evaluated by a randomized trial, and the "diagnosis" of labor is fraught with all the difficulties of trying to categorize a continuous variable" (Thornton and Lilford 1994).

Each labor is unique and idiosyncratic and frequently may not follow the linear thinking of the partogram which does not take into consideration such variations as the woman's normal biorhythms or the woman's natural need to occasionally "take a break" from the enormous effort of labor.....
"There have been no randomized trials of the total package of active management or of the use of strict diagnostic criteria alone, but trials of early amniotomy, early oxytocin, and these interventions combined do not suggest that these interventions are effective in reducing rates of cesarean sections or operative vaginal deliveries. In contrast, the provision of continuous professional support in labor seems to reduce both types of operative delivery, although the effects on cesarean section are confined to those settings where non-professional companions are not normally present in labor. Delivery units should endeavor to provide continuous professional support in labor, but routine use of amniotomy and early oxytocin is not recommended" (Thornton and Lilford 1994)."
http://www.acegraphics.com.au/articles/wagner01.html

"The Thinking Womans Guide to a Better Birth
Chapter 7 The Slow Labor: Patience Is a Virtue"
http://members.efn.org/~djz/birth/betterbirth/7.html#active


http://www.hencigoer.com/betterbirth/lit/

Just something to think about.

Delivery...

The ACOG does not believe in setting time limits on the delivery of baby if all is well. They acknowledge that a first time mom can easily take 3+ hours to push baby out, especially if she has an epidural.

There are some myths that it is dangerous to push for a long time. If mom and baby are doing well then that is not true. There are also options to pushing as soon as you hit 10cm anyway. I'll discuss that in a second.

Setting time limits sets up a lot of pressure on mom to perform and that can make things even harder.

There should be no timer that goes off after X time telling them to do an episiotomy to speed things up (BTW- this has been found to, at most statistically, speed up delivery by 5 contractions!) nor should they reach for the vacuum or forceps. Barring fetal distress, the ACOG does not recommend any of those practices. I know that some moms just get tired and don't care anymore- they just want the baby out. However, there could be long term consequences for that impatience.

There are also better options to a slow delivery instead of episiotomies, vacuums or forceps. The most valuable thing is this:
If you do have an epidural (it could work if you don't but it'll be harder) consider the newest trend, "Passive Pushing." Your contractions will naturally work to push the baby out. Some care providers are now encouraging moms to let their bodies do almost all the work and allowing mom to rest. Mom then just gives the final few pushes. This gives the perineum more time to stretch naturally and it conseves strength.
"Pushing with an epidural
If you use an epidural, you may be encouraged to rest until you have the sensation to push. Women who receive epidural anesthesia for labor may have difficulty pushing, especially if the strength of the anesthetic numbs the sensation to bear down. The practice of "delayed pushing" is currently being studied in women using epidurals as an alternative to routine pushing at 10 centimeters."
http://babies.sutterhealth.org/laboranddelivery/ld_ftm.html
And:
http://articles.findarticles.com/p/articles/mi_m0CYD/is_6_38/ai_99376501

It may be valuable or necessary to turn off an epidural during the pushing stage so mom is more efficient. This should always be an option to try before intervening otherwise.

Pretty much any position is better than lying down for birth from a biological standpoint!!! But, probably 90+% of moms birth that way. Why? There are so many better options. You can birth standing up (though more effective is probably squatting). Not to be gross but pushing out a baby is an awful lot like having a bowel movement and for that there are toilets. They are at a good height and help moms really use good leverage and the muscles that they have been building for years. Since most moms wouldn't want to push over a toilet there are birthing chairs- same principal of a toilet but no water or bowl, just a place for the Dr. or midwife to be able to help.

There really are many better positions. Most any good birth book will tell you them and explain why they are good. I'll post a link that has that info. But, 2 good books are "The Birth Book" by Dr. Sears and "Pregnancy, Childbirth and the Newborn" by Penny Simkin. I would highly recommend picking them up and reading them with your partner. It sounds like there might be a lot more unfounded birth beliefs that should get nipped in the bud. "The Thinking Woman's Guide to a Better Birth" by Henci Goer can really help to dispell a lot of inaccurate birth beliefs- even just about what probably how all of your friends and family gave birth (mainly the role of interventions).

What’s wrong with the lithotomy position?
There is a book called "The Complete Book of Pregnancy and Childbirth" by Sheila Kitzinger that gives a great history of the lithotomy position for birth. I'll summarize though it might be worth a trip to the library or bookstore to read it.

In France in (I believe) the 1800s one of the King Louis liked to watch the birth so he requested that his women deliver this way. Well, the lower classes of citizens very much wanted to do what the nobility was doing so the craze caught on.

Nowadays it is used for several reasons. We see it on TV all the time and believe that is what you are supposed to do. 80-90% of moms choose an epidural and don't have the benefit of leg power most of the time so they are stuck in bed (though there are many other options, unfortunately they often aren't suggested). Midcentury to the not so distant past moms were knocked out for birth and babies were pulled out with forceps; the lithotomy position was the best for that.

This article explains the disadvantages of birthing lying down very well. If you check out most birth books or do a google search for the lithotomy position, you are going to run into almost all negatives. the few positives you see...well, I would want to know the source and really think about it.

"The lithotomy position, with a mother flat on her back and her feet in stirrups, was once the standard position in hospitals for women to give birth and in some hospitals it still is. Current obstetrical practices during second stage were developed with the attendant, rather than the birthing mother, in mind. Lithotomy was believed to be the ideal position for doctors to deliver the baby while sitting or standing in attendance. The doctor had easy access to watch, to help with delivery if needed, and to intervene when he or she felt it necessary.

Who it wasn't ideal for was the mother who has to push her baby uphill against the force of gravity when lying on her back. The common lack of progress despite the mother's strong efforts often led to a forceps delivery of the baby. With the mother's perineum stretched by the positioning of the stirrups, tearing was much more common. Doctors started to believe that episiotomies were needed to "protect" the mother's perineum because of the large number of tears they observed in this position and the difficulty women had in pushing their babies out while lying prone. Episiotomies became the norm and were easy to do for the doctor because of the access to her perineum. Today episiotomies rates are plummeting as this research confirms that the side effects of unnecessarily cutting the perineum are long lasting and avoidable in most circumstances. Women revolted against the lithotomy position and other routine obstetrical practices in the late 1960's and the semi-sitting posture is now seen in almost all hospital birthing rooms. But is this position any better for mother and baby?

Time had it that almost all women pushed in the position she felt most comfortable. For most, that was a squat or in a kneeling, standing, or forward leaning position. Native American women traditionally kneeled, leaned forward and grasped a tipi pole or tree. In southern Africa, the woman may kneel, legs wide apart, with her heels supporting her perineum. In central Africa and Columbia, women grasp the branch of a tree which is laid horizontally between two other trees (or stakes set in the ground), bending her knees into a squatting position as she pushes. An alternative is a vertical stake driven firmly into the earth.1

In many cultures a woman sits on another's lap or squats between her husband's or another woman's thighs. Birth stools and chairs evolved from lap-sitting and squatting positions. Birth stools are low, simple with a cutout that enabled a woman to squat with support. As time went on, in Europe stools became more elaborate, with low backs on them. This immediately reduced pelvic mobility.2 These chairs became increasingly elaborate, especially as doctors took over childbirth, and became more and more complicated while at the same time making it harder and harder for a woman to move.

The next development was to tip the woman onto her back on a narrow table with her legs raised. The mother was even strapped to the bed with knotted bandages, metal restrainers, cuffs and straps. This was seen as a "protective measure" for the mother due to the use of hallucinogenic Twilight Sleep, which was routinely given to all labouring mothers. The newest innovation is the birthing beds that assume many positions and come apart during the pushing stage to assume an upright sitting position with various handles and foot rests for the mother's use.

Virtually all women today who birth in a hospital setting use these birthing beds. Although they allow a more physiologically superior position to lithotomy in terms of the mother's participation and comfort level, they still are inferior to traditional positions assumed by mothers in response to their body's signals.

During a very long labour in the 1880's, Dr. Campbell in Georgia decided to use forceps, "but just then in one of the violent pains, she raised herself up in bed and assumed a squatting position when the most magic effect was produced. It seemed to aid in completing delivery in the most remarkable manner, as the head advanced rapidly, and she soon expelled the child by what appeared to be one prolonged attack of pain. In subsequent parturition, labor appeared extremely painful and retarded in the same manner; I allowed her to take the same position, as I had remembered her former labor, and she was delivered at once, squatting."3

How is this possible? To understand, we need to understand the pelvis and how it moves during birth. The pelvis is made up of four independently movable bones, the left and right ilia separated in the front of the pelvis by the pubis symphysis, the sacrum attached to the ilia at the sacro-iliac joints, and the coccyx or tailbone located at the base of the sacrum. They are connected by cartilage and ligaments that are softened during pregnancy by a hormone called relaxin. This softening allows increased movement between the bones, allowing optimal passage of the baby through the pelvis.

When a mother is in an upright or forward leaning position, the angles and internal dimensions can change dramatically to allow the baby to maneuver through the pelvis. "The relationship of the pelvic brim to the lumbar spine changes, allowing the foetal head to enter the pelvis. The ischial spines (the narrowest part of the pelvis) are no longer level, allowing the foetal head to pass through them with ease. The ligaments connecting the sacrum to the ilia are more flexible (due to the effects of relaxin) which allows them to lift up about 1-2 cm straightening the posterior pelvic wall." When a woman is in a forward leaning or upright position, the sacrum can be seen clearly as the baby moves through the pelvis, lifting the sacrum and coccyx out of the way. "If a woman is in a well supported squat, standing and leaning forwards or kneeling and leaning forward with her arms clutching onto something higher than her waist, she will instinctively arch her back and 'throw' her pelvis out at this stage."4 Dr. Michel Odent calls this the 'Foetal Ejection Reflex'.

When a woman is in a lithotomy or semi-sitting position, the Foetal Ejection Reflex is impaired and the increased pain caused by the sacrum's inability to move as the baby descends can be intolerable. For anyone who has seen women giving birth, the inability of the mother to "keep her bottom down" on the bed is common as the baby moves past the sacrum. What is worse is the inability for the baby's head to move past the impacted sacrum or the now narrowed pelvic outlet due to the tailbone being forced inwards. This is more common when epidural anaesthesia impairs the mother's ability to feel her baby's descent and, according to Dr. Todd Gastaldo DC, will decrease the pelvic outlet by 30%.

The coccyx is designed to move out of the way as the baby's head descends. Sitting on the coccyx during birth restricts the pelvic outlet and can also lead to dislocation of the coccyx.5 It can also cause an increased length of labour, make delivery more difficult and slow or arrest descent.6 These may develop into oxygen deprivation for the baby, causing distress or worse. If it isn't resolved, forceps/vacuum assisted delivery is turned to as a solution. The uses of these instruments typically incur damage to the baby's fragile head and neck muscles and nerves. The alternative is caesarean delivery, a major abdominal surgical procedure to extract the baby, which brings its own risks into play for the mother.

Semi-sitting and lithotomy pushing positions can also result in another serious problem of shoulder dystocia. Dr. Jason Gardosi MD FRCS MRCOG from the Queen's Medical Centre in Nottingham, UK explains, "The anterio-posterior (outlet) diameter is reduced in recumbent (semi-sitting) and lithotomy positions where the weight is taken on the sacrum. The sacrum is capable of rotational movement through an axis at the upper part of the sacro-iliac joint." He goes on to add, "Many so called 'shoulder dystocias' are just difficult deliveries caused by a recumbent position. Apart from the sacrum being pushed upward, reducing the AP diameter, it is difficult to allow lateral flexion when the presenting shoulder abuts on the mattress." Dr. Todd Gastaldo adds, "And when the shoulders get REALLY stuck, MDs pull REALLY hard. Could this bizarre MD behavior account for at least SOME of the unexplained cerebral palsy, brachial plexus palsy, low APGAR scores, etc.? How about some of the unexplained DEATHS?" (Emphasis the doctor's) Good questions which need to be addressed with maneuvers beyond the McRoberts Position, placing the mother flat on her back with her knees pulled up and back, simulating an upside-down squatting position. This is the standard position women are placed in when shoulder dystocia is suspected. If women were allowed to birth in positions they assumed naturally, the Gaskin Maneuver, moving to a hands and knees position, would easily be done and thus far has been proven to be the most successful position for resolving shoulder dystocia.

The solution? Simple. Allow the mother to assume a position she feels most comfortable in, which in almost all cases does not involve a lying down or semi-sitting position on a bed. It is extremely rare that a woman will spontaneously assume a lying or leaning back position during second stage,7 the very position most women are expected to assume in a hospital situation. At the same time, obstetrical practices of frequent and/or continuous monitoring with stationary fetal monitors combined with the many interventions and medications used routinely interfere with the body's natural response to labour. If a woman is unable to assume a naturally active position like a squat, kneeling, or other forward-leaning positions (i.e. hands and knees), then avoiding sacral and coccyx impairing positions like lithotomy and semi-sitting would be wise and only make common sense. Sidelying is an excellent alternative when the situation warrants it, like when a mother has an epidural."

http://www.storknet.com/cubbies/childbirth/pushingpositions.htm


Dad can still be totally involved even if he isn't standing there counting to 10 and holding your foot on the stirrup.

This link explains the advantages of other positions as well as illustrations:
http://transitiontoparenthood.com/ttp/parented/pain/positions.htm


Good link:
http://www.obgyn.net/displayarticle.asp?page=/women/articles/reviews/review007

Final note- I am sure that a lot of moms have success in this position- especially 2nd+ moms. But, it doesn't mean that they couldn't have gone even better in another position. I pushed on my side for 2/3 of the time b/c it felt right. However, against my better judgement and prior discussion with my midwife, I ended up pushing on my back. I had a 2.5 degree tear. Maybe that wouldn't have happened if I was in a dif't position.

Something I often hear on the boards is that mom needed a big episiotomy or tore a bunch because baby was so big. That might be a bit of a leap. More likely it had to do with how the perineum was managed as well as the delivery.

Like I said before, delivering on your back is one of the worst delivery positions. It applies uneven pressure to the perineum and stretches the skin more taut than in many other positions. Simply avoiding this position could save your perineum.

Choosing a careprovider that doesn't put time limits on the delivery is another thing mom can do. I can't even count the # of moms who come back with their birth stories and say that they pushed for an hour or less and weren't making progress so the cp did an episiotomy or used an instrument to deliver baby. That just bothers me a lot. Given plenty of time- and opprotunity to try different things- many moms could be spared these invasive proceedures.

If the perineum is respected by your care provider then you should feel good that they will do their best to minimize damage. There are questions you can, and should, ask at your next appointment.
Find out how often your Dr. performs episiotomies.
-The answer should be less than 25% and ideally less than 15%.
-The answer should be "I try to avoid an episiotomy unless the baby has to come out immediately. I prefer to do perineal massage and a controlled pushing phase." The American College of OB/Gyns does not recommend episiotomies as a matter of routine or to prevent tearing (it is widely known that an episiotomy can cause you to tear more than if you just tore. The analogy is that a pair of jeans that already has a hole in them is easier to tear than a pair of jeans that is still intact).

What reasons do they perform episiotomies?

What preventative measures do they do to help avoid an episiotomy or tearing?

Will they pressure you to an episiotomy if it looks like you are going to tear.
-Discuss this before you are in labor and pushing b/c when you are pushing you will be too preoccupied to make rational, well thought out decisions that can have a profound effective on your future births, your urinary and fecal continence and your sex life.
-You hear of Dr.s and nurses recommending cuts in labor so it is very good to be clear ahead of time what your preferences are. You are the one who will have to recover, not them.

Their attitude towards episiotomies can tell you a lot about their birth attitude.
-Will they rush you throughout your birth? If pushing is "taking too long" but you and baby are well, will they still recommend an episiotomy? How often do they augment labor with pitocin or breaking the water? Are they willing to let nature take its course if you and the baby are well?
-How much do they respect you? Do they want to help you have an easier recovery?
-Are they cool with letting you labor and deliver in positions that are best for you even if they are less than ideal for them? Squatting and all 4s are so much better than being on your back and they know that. It is a lot easier for them though if you are on your back and legs in stirrups.

Are they patient, laid back in a low risk healthy birth, respectful and up to date with current ACOG recommendations?


What else can you to to help keep your perineum in tact?
-Kegels!! At least 5 sets of 10 per day!! These will help you to know how to control those muscles so that you can effectively relax them when you push. They will also help speed up recovery.

-Stay upright during the pushing phase (squatting) b/c that will help the baby descend. You can deliver like that or change to another position for your last pushes. Other positions like sidelying can be beneficial.

-Try a variety of pushing positions if your progress slows. Hands and knees, side lying, use a birthing bar...More advice:
http://askdrsears.com/html/1/T010900.asp#T010911

-Start doing perineal massage before your edd. Insist that warm compresses be applied during delivery to help stretch the skin.

-If you have an epidural, ask them to turn it down/ off so that you can feel what you are doing.

-Push only when you have the urge. Sometimes a woman dilates to 10cm and could start pushing but doesn't actually have the urge. Some call this the "rest and be grateful" stage. Don't feel pressured to push.
"The importance of waiting
It is important to wait for the natural urge to bear down before starting active pushing. You are often encouraged to push by "holding your breath and push as hard and as long as you can." Research has suggested that a woman's spontaneous urge to push occurs three-to-five times during a contraction while the woman is exhaling and bearing down."
http://babies.sutterhealth.org/laboranddelivery/ld_ftm.html


-Along the lines of the last tip...If you do have an epidural (it could work if you don't but it'll be harder) consider the newest trend, "Passive Pushing." Your contractions will naturally work to push the baby out. Some care providers are now encouraging moms to let their bodies do almost all the work and allowing mom to rest. Mom then just gives the final few pushes. This gives the perineum more time to stretch naturally and it conseves strength.
"Pushing with an epidural
If you use an epidural, you may be encouraged to rest until you have the sensation to push. Women who receive epidural anesthesia for labor may have difficulty pushing, especially if the strength of the anesthetic numbs the sensation to bear down. The practice of "delayed pushing" is currently being studied in women using epidurals as an alternative to routine pushing at 10 centimeters."
http://babies.sutterhealth.org/laboranddelivery/ld_ftm.html
And:
http://articles.findarticles.com/p/articles/mi_m0CYD/is_6_38/ai_99376501


-Also, when you do push, push when it feels right. There is no scientific reason to hold each push for 10 seconds. 6-7 seconds is actually more beneficial and scientific. Ask that no one count or shout commands at you unless you need them to.

-Don't pull your legs back into your chest. Some nurses ad Dr.s are really fond of this position b/c it is convenient for them. Not so kind to your though and that is what matters!The askdrsears.com website has some additional tips on pushing that might be worth a read.

Perineal Massage
Here is an article that explains the technique:
HYPERLINK "http://www.babycenter.com/expert/1955.html" \t "_blank"
http://www.babycenter.com/expert/1955.html

Remember to do those Kegels!!
( HYPERLINK "http://www.babycenter.com/refcap/baby/physrecovery/1154885.html" \t "_blank"
http://www.babycenter.com/refcap/baby/physrecovery/1154885.html )



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