Diversity in Focus - Interview with Judith Nylander - Doula
Preterm labor is sometimes a cry for help-a cry from the baby or a cry from the mother. Sometimes a woman is doing too much, and the baby shouts, "Hey mom, take a rest!" In these situations, bed rest is probably a good idea. But the most important thing we are missing in these cries for help is the absolute necessity for the mom and baby to be pampered. Pregnant women should be treated with the utmost respect and valued for the incredible job they are doing growing their babies. Our culture doesn't recognize this, sadly. Pregnant women should receive the highest quality and most delicious foods-especially toward the end of pregnancy. Massage should be a weekly routine, as well as competent, woman-centered prenatal care, which includes care with a chiropractor and/or a cranial sacral therapist. Her dreams should be listened to and her fears addressed.
Where can women get this type of care? Doula? Grandma? Sister? Partner? Neighbors? Friends? Co-workers? The answer is, all of these people. Our society has a duty to its future citizens to create an environment that fosters optimal growth.
Besides the fact that tocolytics have many side effects, the worse thing they offer is a false sense of security. I am not judging women who have taken them to stop preterm labor. What I mean is, the idea that a pill will fix a problem like this is insulting to the woman, and most important, ignores the real reason for the cry. It covers up the issue instead of getting to the root.
- Ruth Shepard Trode, Minneapolis, MN
Back labor is most often caused by the baby presenting in a posterior position. This means that the baby's spine and the hardest part of the head are against the mother's spine; this can cause intense lower back pain and pressure, during and possibly between contractions, and sometimes even during pregnancy. Since the baby's head is not as well-applied to the cervix, this position sometimes delays the onset of labor, or leads to hours or days of what are known as "turning contractions" or prodromal labor (aka false labor). It may also lengthen the dilation and/or pushing phases of labor significantly.
A skilled care-provider will often detect this variation of the baby's position before labor, but other times it is not discovered until labor has begun. Sometimes slow labor due to posterior presentation leads to a diagnosis of "failure to progress" or "cephalopelvic disproportion" since a larger diameter of the baby's head is working to fit through the pelvis. The baby may rotate to an easier position during labor; about 5% of posterior babies do not rotate and are born in a face-forward position, often called "sunny-side up".
The best way to handle posterior presentation is through prevention. It is usually much easier to rotate the baby before labor has begun. During pregnancy, regardless of your baby's position, sit in upright or forward-leaning positions, such as on a birth/exercise ball, leaning on a straight-back chair that has been turned backwards, or cross-legged on the floor ("tailor sitting"). A back support called the Nada Chair can help you sit this way comfortably for longer periods of time. When standing or walking, avoid the "sway-back" silhouette by tucking your pelvis forward. Avoid reclining on a couch or chair and leaning on your tailbone; this can cause your baby to assume a posterior position. You can do the cat/cow yoga exercise, also know as the pelvic rock; on hands and knees, first arch your back up and tuck your head down, then bring your head up and make your back straight.
Gravity can help you avoid or change posterior position; when you are on hands and knees, since your baby's spine and head are the heaviest parts they often sink toward to floor and into an anterior position. You can also lean forward over a birth ball if you cannot lean on your wrists or arms. Midwife Jean Sutton suggests using a Swedish chair. These are backless, with a place for you to tuck your legs under.
Some babies remain posterior when the mother sleeps in the same position each night. Try sleeping on your side, top leg bent and drawn up with pillows under the knee. Don't recline to rest. Lie on your side or sit on a birth ball, leaning forward into something soft. If your baby's head has already engaged (moved deep into the pelvis) you might try kneeling with your face and chest on the bed - the knee/chest position - to help the baby move up a little before you start the other exercises. This may give the baby a little more room to turn around. After this, try climbing stairs. In addition, always visualize your baby's back facing the forward part of your uterus, and ask your baby to help.
Some women have successfully rotated posterior babies by using moxabustion (burning mugwort, the same technique used for breech turning; ask your midwife or doula for help). The homeopathic remedy pulsatilla may also help; ask a homeopathist or herbalist.
During labor, all of the above suggestions can help your baby rotate and be born more easily. Showering or bathing in a tub may help relieve back labor. If in the shower, direct the jets to your lower back; in a tub, the deeper the better. Massage and counterpressure can help. Ask someone to apply pressure with the heels of their hands on either side of your tailbone. In addition to all of your comfort measures, a midwife or doula may be able to use a rebozo - a long piece of fabric - to help the baby turn, or may use a technique called the "double hip squeeze" to help make room for your baby's head. Spend time on hands and knees, maybe while swaying and circling your hips. Try climbing stairs or doing lunges with one foot up on a low chair, alternating sides (try the right side first). You can also use a technique called the abdominal lift. Place your hands under your belly down by your pubic bone and lift your abdomen with your hands. This is especially effective during a contraction - it can tuck your baby's head into your pelvis. Try to avoid amniotomy (artificial rupture of membranes, or "breaking the bag of waters") because this may fix the baby in a posterior position and make it more difficult for the baby to rotate.
Your birth partner, midwife and/or doula can really help with physical support and verbal encouragement (tell her how well she's doing, and focus on the positive!). Be sure to eat and drink; if you are facing a long labor you will need the extra energy and fluids. Above all, relax your bottom and belly and rest between contractions. The most important thing you can do is focus on relaxing and releasing your baby, and your most effective tools are your sense of humor and good attitude.
In addition, there are other resources you can use to help your baby assume an optimal position. Midwife Gail Tully has developed a technique called Spinning Babies, with these and other suggestions - see www.spinningbabies.com. Books you may want to consult include Active Birth by Janet Balaskas, Optimal Foetal Positioning by Jean Sutton, and Penny Simkin's Labor Progress Handbook.
Remember that if all of your efforts to help the baby rotate do not work, babies can and do come out anyway! Some babies may just need to be born this way. Relaxation, patience and persistence, and above all a courageous positive attitude will take you a long way. With support, encouragement, and trust in birth, you can do it.
The use of warm water during labor is a great comfort measure. It is safe, widely available, inexpensive, and effective. Warm water immersion in labor can diminish stress hormones, catacholamines, which increase pain and slow labor. It also directly reduces pain by increasing the body's production of natural pain relievers (endorphins), can ease involuntary muscular tension, and enhance relaxation during and between contractions. It can also lower blood pressure within minutes and increase the efficiency of uterine contractions. In addition, use of a larger tub increases mobility so that it is easier for a woman to change position to aid the progress of labor, especially when she is becoming tired. Birth into water can reduce the incidence and severity of perineal tearing. The water encourages relaxation of the pelvic floor and provides natural support to the perineum.
Waterbirth may have benefits for the baby as well, and often provides a gentler transition to life outside the womb. Many pregnant women are drawn to water, especially during labor, and women all over the world give birth in labor tubs, tide pools or natural springs. The advantage of tubs specifically designed for birth is that they are portable, heated, and large enough to accommodate movement and a variety of labor positions.
Some hospitals now offer waterbirth and/or labor tubs. Rented tubs can be used in the hospital or at home, and might be just what you need for a more comfortable labor. Some women choosing hospital birth use rented labor tubs at home, often with the services of a doula, to help them comfortably stay home longer. This enables them to enter the hospital when labor is well established, which can often help them avoid unwanted interventions. A bathtub or shower can also provide pain relief and relaxation, and should be available wherever you choose to give birth.
There are some practical considerations to using water as a comfort measure. If a woman is using it for pain relief or reduction of blood pressure and edema, it is important to have enough depth to be fully immersed. Her whole body should be under the surface. Less water than this will still be helpful, but not as effective. Be sure to use water that is close to body temperature, 98 to 100 degrees Fahrenheit. If it is too cold she could become chilled and waste energy shivering--energy better used for labor! For this reason, have plenty of towels and blankets handy, since many women will be in and out of the tub several times during labor. If the water is too warm she may become overheated, flushed and dizzy; if this happens she can simply leave the tub for a while and have someone add cold water. In any labor it is important to keep drinking liquids, but especially while in the tub, to avoid dehydration. Have a non-slip surface-bathmat or similar item-nearby for when the mother gets out, and a person or two ready to assist if necessary.
A woman can use the pool whenever she wants. However, if a mother chooses to get into the water in early labor, before her contractions are strong and close together, the water may relax her enough to slow or stop the labor altogether. That is why some care providers limit the use of the pool until labor is established and the dilation of the cervix is a least 5 centimeters. (The tub is ideal to have at home for women who experience lots of preparatory or "false" labor, since it can sometimes help her get some rest.) But some women have found that entering the pool helps them relax enough to really get labor going! It can sometimes be helpful to wait until active labor so the mother has something in reserve for when labor becomes more difficult. According to Barbara Harper of Waterbirth International, the first hour of relaxation in the pool is usually the best and can sometimes help a woman achieve complete dilation even in that short amount of time.
For many women the question of safety needs to be addressed. There are no known hazards to laboring in water, whether or not the bag of waters has broken, and waterbirth is completely safe as well, as long as some basic precautions are used. First, there are several factors that prevent the baby from beginning to breathe underwater after birth. The water temperature is close to that of the amniotic fluid in the womb, so there is no shock of a temperature change. The baby is also receiving oxygen from the umbilical cord just as it has for the previous nine months. In addition, the baby has an autonomic reflex, called the dive reflex, which prevents it from inhaling any substance that is in the throat and causes it instead to swallow. (This reflex disappears after about six months.) There is a complex chain reaction of hormones and chemicals that cause the breathing process to begin; just know that it is impossible for a newborn to breathe until up in the air. The baby should not be left under the water for an extended period of time (longer than half a minute). There are several waterbirth videos that show babies under water longer than this, who do just fine since the placenta is till supplying the baby with oxygen, but it can't be predicted when the placenta will begin to separate and stop the flow of oxygen. The safest approach is to remove the baby unhurriedly, face down so that water drains from the nose and mouth.
A note about waterbirth: the use of water during labor always works best when there is no expectation that the birth will happen in the tub. Although the water can be a valuable tool, some women need more assistance from gravity or find that contractions slow down in the tub. The best approach is to be flexible. Michel Odent, French waterbirth expert and author of Birth Reborn, says that "The baby can be born underwater when there are suddenly irresistibly powerful contractions and the mother does not feel like getting out of the pool; it should not be the objective…Often women need to get out of the pool for the very last contractions, at a phase when paradoxically a short rush of adrenaline can help. Women who are prisoners of the project of giving birth under water may be tempted to stay too long in the bath."
There are several ways to use pools during labor. Many homebirth midwives are experienced with and enthusiastic about waterbirth. Tubs can be rented for home use, whether the birth will happen there or in the hospital; some hospitals are also receptive to allowing use of rented tubs, but this changes often so ask your care provider. The emphasis on technology and monitoring in hospitals sometimes makes this a controversial request, but be persistent. Abbott Northwestern in Minneapolis has a hydrotherapy tub available for labor, but will ask you to get out for the birth; waterbirth options and a tub are available at St. Joseph's in St. Paul, Woodwinds Health Campus in Woodbury, Ridgeview in Waconia, Lakeview in Stillwater, and Hennepin County Medical Center midwife unit in Minneapolis. Labor tubs can be rented from Waterbirth Resources at 612-822-3263. As this option becomes well known and more women request it, expect more hospitals to offer water immersion for labor and birth.
Although vaginal breech birth is possible, it is preferable for safety reasons that the baby be born headfirst. Here are some things to try to encourage your baby to assume a vertex (head-down) position.
Moxabustion - Burning mugwort-moxa sticks outside of the little toe. Keep close enough to the skin to feel hot but not close enough to burn yourself.
Homeopathy - consult a licensed Homeopath for possible remedies.
Have your partner or a friend speak to the baby through a toilet paper tube placed down by the cervix. Be relaxed, friendly and gently encouraging. A warm voice and loving words might make the baby want to hear more and get closer to the sound.
Breech tilt exercises - Lay on a board, one end on the floor and the other on a couch, or propped up by lots of pillows, head down and with your pelvis up at a 45 degree angle, for 10 to 15 minutes twice a day (or more often if you can) until the baby turns head down.
Visualization-See in your mind's eye your baby's heavy head slowly and gently surrendering to gravity and sinking down towards your cervix. Imagine that your baby has already changed position and is head down, ready to be born.
Talk to your baby - Tell her or him all about your situation and request that she/he change position. You could say how much more comfortable it might be to have his head cradled by your pelvis and going with gravity, how much safer you would feel with her head down, or anything else that comes to mind.
Talk to yourself! It's possible a mother holds her baby close to her heart due to fears of birth or parenthood, feelings about safety of the world the baby will be born into, or other emotional reasons. Explore why you might feel a need for your baby to be breech.
Chiropractic adjustment - Some chiropractors are familiar with the Webster maneuver, which can encourage a breech baby to turn. Find one who knows this technique.
External version - If the above methods don't work, you may wish to try having your birth practitioner turn the baby manually to a cephalic presentation. This is accomplished by feeling or using ultrasound to determine the way it would be easiest for the baby to turn, then applying gentle pressure hand-over-hand, externally on the belly. The relaxation of the mother is the key to the safety and efficacy of this method, so practice deep breathing and any relaxation techniques you know before, during, and after the procedure. Most practitioners will administer terbutaline, a drug that relaxes uterine muscle, to the mother; discuss the risks of this drug with your care provider. Version is more successful if performed before 37 weeks, but babies can return to the breech position. If done after this time, there is greater chance that the baby will not turn, but if he or she does, then is more likely to stay head-down. Unlike the above methods, there are some slight statistical risks associated with this procedure: again, discuss with your care provider.
All of the above methods may be used together. When the baby turns, do lots of walking to help her/his head settle in your pelvis. Posture is important, so sit upright in straight-backed chairs or on a birth ball whenever possible until the birth.
If None of the Breech-Turning Methods Works
It can be difficult to find a doctor or certified nurse-midwife who will attend a vaginal breech, but they are out there. Some homebirth midwives, known as traditional, empirical or direct-entry midwives, are experienced with vaginal breech births and will attend them.
Some women opt for a cesarean. Should this be the case for you, it is an option that you go into labor on your own before surgery. Natural labor is good for babies. It prepares the baby to be born and helps him or her withstand the stress of birth, and prevents prematurity. Some babies even turn head-down during labor.
Whatever you choose to do and whatever the results of your choices, remember that you did the best you could at the time. Your baby and your body have wisdom of their own, and though it isn't always possible to know the reasons why some things happen, there are always reasons. Only you know what is best for you and your baby. If a particular choice just feels right or wrong, it may be - let your intuition be a guide. The best choices are made from love, not fear. So make yours from an open heart, and best wishes!
Doulas cradle the twins of Support and Vision. We support the mother within her current views and needs. We also keep a vision of what is possible in a community with healthy birth practices. This can, at times, be a delicate lullaby. Obstetrics has swaddled our culture with the fear of impending emergency. Fewer American women are dying in childbirth. American women are better fed in general, and water and hygiene have improved over the last century. Antibiotics and blood replacement improve outcomes for women who get into danger. Yet women seem to be more afraid of birth today than in the 70's and 80's when the natural childbirth movement saw a small but well publicized surge.
Taking our cues from evidence based studies and the midwifery model, doulas see birth as an emergence. The maiden emerges into mother. The girl into woman. The mystery into the known. The dream baby into the greeted child. We are concerned with that emergence. Support is a powerful antidote for fear. Courage is the cure. In our caring for a mother, we hear her fears as much as we see her strengths. Re-framing the culture of fear around birth, we seek to help the mother see her potential in her own emergence through birth.
We present her with healthy visions of birth. Yet at the same time, we can not push her beyond her awareness. If we do so, we we will force ourselves further away from her goals for a healthy birth, and also from her as she moves toward her goal.
Consider a common scenario: the doctor suggests a routine "convenience" induction. By the third trimester, she has established her pace, coping methods, and support. Her birth attendent, doctor or midwife, is part of her support system and she trusts them. The mother may stumble emotionally in her path to her goal; she may accept the induction with ease or with grief. In this example there are no specific medical indications, only cultural ones.
We, as up-to-date doulas, may feel an urge to educate the mother about the pros and cons of routine induction. Perhaps we do this in an appropriate way. The mother is somewhat open, but she also wants to protect her baby from the emergency the obstetrician is warning her may happen. We feel some hope for avoiding unnecessary meddling, but we also are frustrated because of the mother's response to fear tactics. So we educate a little more. We get the mother's attention, but she feels drawn into the induction.
Gradually, our education borders on persuasion. At this point the mother may feel an uncomfortable pressure coming from the doula. If we continue trying to persuade her, it is felt as an "agenda." She will feel the need to reduce her emotional connection to the doula in order to sustain equilibrium in her relationship with her medical provider. If she also wishes to avoid the induction, the doctor steps up the fear tactics. She dares not rebel.
Pulled between to perspectives the mother will choose her medical provider who she has entrusted with her health and reduce her trust in the doula just to reduce her stress in dealing with the difference in viewpoints. Even if she grieves or resents the induction, she will still feel forced to align with the medical provider. This may not be apparent to the doula until active labor when the reduced reliance on the doula is now not enough to get the mother past her fear of increasing labor pain.
For the doula, revealing an agenda has compromised our closeness to the mother and we are at a disadvantage in helping her obtain her goal -even if we were "right" about the statistical chance that an un-indicated induction would decrease the well-being of mother and baby! Why? Because the mother has to be more loyal to her doctor than to her doula. She seeks the doctor's medical advice and care in an emergency and the doctor has just presented an impending emergency.
There comes a time when a doula's advice could disempower. Disempowerment always follows a breakdown in trust. Communication fails when trust is weakening. The doula has to dare to work her strengths of supporting the mother where she is, not rescuing her from where she might go.
To cradle a mother's empowerment, we must also nurture the birthing community. Over the years the Childbirth collective has nurtured the birth community through Parent Topic Nights, the newsletter, and setting standards for and nurturing new doulas and each other. Other community groups such as International Cesarean Awareness Network, Minnesotans for Midwifery, International Childbirth Education Association, and many more groups and individuals have played a role in nurturing healthy birth images.
But how do we get a healthy image of birth into the monopolistic institution of mechanized birth, the hospital? Of course, dedicated nurses, nurse-midwives, and doctors struggle to enlighten and improve obstetric practice. But realistically, in 40 years what changes have we seen? Women may be conscious at the time of birth, but with soaring rates of epidurals as the norm, how aware of birth are new mothers today? Cesarean rates are inching back up, VBAC rates are slipping, certain doctors are proclaiming surgery as the natural evolution of birth, and we're little closer to keeping newborns and mothers together than 20 years ago, in spite of overwhelming encouragement from top pediatricians and psychologists. It will take something more than the internal actions of the clockwork itself to change the time.
The doula introduces change by keeping the Vision of Birth. We go with the mother's flow while we are with her. But community activism is also the domain of the doula. We clarify our vision with continuing education. We read and participate in doula discussions. And we bring our vision to the medical community as an external motivator.
Change can bring resistance. Change can bring anger. Unfortunately, anger and resistance temporarily slow down the changes we seek, but the reactions show that we have the attention of the established medical community.
We must remember, support is the opposite of management. Why work to introduce improved management practices? This is not the strength of the doula. We're not into management! Let's go in the direction of support and we'll find ourselves moving beyond fruitless debate. We offer love and support, and love follows love. Believe me, those left out will see our modeling and seek to come closer themselves. Ask the doulas who actually go into the hospital doula programs to tell you about significant improvements in practices since their programs started. There are nurses and doctors happy to use the support of an external agent to help alter the status quo.
We can carry the vision to the birth practitioners, educating not only the parents before birth, but the nurses and doctors as well. Providing loving support is attractive. It's contagious. Not our insistence, but the smiles of the mothers and the health of the babies will convert. It takes all of us on working on many levels:
• The gentle persuasion of Love modeled
To cradle our birthing culture in loving arms, let's be aware of our strengths as doulas. Let's set a course, not only with our scope of practice but with where we are willing to go with our efforts. Keeping our eyes on the goal doesn't mean we have to push against what we dislike. It means nurturing what we believe in and know. Let us honor the gravity of our commitment to healthy birth with the love needed by one and all.
Blessings to all in the Nativity of New Birth.
A German study published in the American Academy of Pediatrics' journal found that breastfeeding protects infants from Sudden Infant Death Syndrome (SIDS). Any amount of breastfeeding was found to be protective. The study included 333 cases of SIDS and 998 age-matched controls from 1998-2001.
Researchers adjusted for the confounding effect of socioeconomic status (less likelihood of engaging in smoking or intoxicated co-sleeping), to meet criticism of prior studies. They speculated that because maternal acquired immunoglobulin G is low in early infancy and the baby does not yet produce large amounts of its own immunoglobulin, breast milk (which contains immunoglobulin and cytokines) may help prevent infections that are believed to contribute to SIDS. In addition, breastfed babies are more easily aroused than those fed formula. The researchers recommended that all SIDS-prevention campaigns include promotion of breastfeeding for the first six months of life.
The American College of Obstetricians and Gynecologists (ACOG) is now pushing for the American Medical Association (AMA) to lobby Congress for a law banning out of hospital birth.
Despite a statement by ACOG, regarding a patient's right to informed consent and informed refusal, it seems that more and more decisions and "recommendations" made by ACOG, are moving further away from that basic tenet. This is resulting in thousands of women being stripped of their basic right to choose safe maternity care based on balanced informed consent or informed refusal.
Not all ACOG members are happy with the current situation. Dr. Fischbein, a California physician stated, "ACOG's little 'guideline' paper on vaginal birth after Cesarean (VBAC) in 2004 where the word readily was changed to immediately has had the chilling effect of doing away with VBAC options at hundreds if not more hospitals. Not due to patient safety, or the ideal of giving true informed consent but really, let's be honest, to fear of litigation. I have seen how patients have become counseled by obstetricians at facilities where VBAC has been banned. They are clearly given a skewed view of the risks of VBAC but rarely told of the risks of multiple surgeries. If a hospital cannot handle an emergency c/section for VBACs - and most emergencies are for fetal bradycardia, hemorrhage (i.e. abruption) or shoulder dystocia, not for ruptured uteri - then how can they do obstetrics at all?” Indeed.
ACOG needs to defend their position in encouraging the AMA to lobby Congress for yet another?restriction on the freedom of choice that belongs to all women and their families. Those choices include midwifery care and the right to give birth wherever best fits their needs and desires.
Today's Midwives are well trained professionals and are required to have obstetrical backup. Interestingly, in the countries that have the lowest maternal and infant mortality rates the vast majority of pregnancies and births are managed by midwives.
The U.S. spends more money on maternity care than any other country in the world. Yet, we rank somewhere below 32nd (NOT 1st) in maternal and infant safety. Our maternal mortality rate is on the rise, as well a premature birth, epidemic rates of labor induction and Cesarean Section. Knowing this, ACOG needs to turn it's attention on reversing this alarming and shameful trend by welcoming the superb care that midwives provide and then, taking a long hard look at -- what is it, that Singapore, Sweden, Japan, Hong Kong, Iceland, France, Finland, Norway, The Czech Republic, Germany, Switzerland, Spain, Israel and TWENTY-NINE other countries are doing so much better than us?