November 11, 1999
November 11, 1999
16 Recommendations from WHO * Questions to Ask Your Caregiver About Obstetric Tests & Technology * Prenatal Exercises * Perineal Massage * Birth Affirmations * Medications & Procedures Commonly Used During Childbirth * Exhale Pushing
16 Recommendations from the World Health Organization, based on the principle that each mother has a fundamental right to receive proper prenatal care; has a central role in all aspects of this care; including participation in the planning, carrying out and evaluation of the care; and that social, emotional and psychological factors are decisive in the understanding and implementation of proper prenatal care.
1. The whole community should be informed about the various procedures in birth care, to enable each woman to choose the type of birth care she prefers.
2. The training of professional midwives or birth attendants should be promoted. Care during normal pregnancy and birth, and following birth should be the duty of this profession.
3. Information about birth practices in hospitals (rates of cesarean sections, etc.) should be given to the public served by the hospitals.
4. There is no justification in any specific geographic region to have more than 10-15% cesarean section births. (The current US c-section rate is estimated to be about 23%.)
5. There is no evidence that a cesarean section is required after a previous transverse low segment c-section birth Vaginal deliveries after a cesarean (VBAC) should normally be encouraged wherever emergency surgical capacity is available.
6. There is no evidence that routine electronic fetal monitoring (EFM) during labor has a positive effect on the outcome of pregnancy.
7. There is no indication for pubic shaving or a pre-delivery enema.
8. Pregnant women should not be put in a lithotomy (flat on back) position during labor or delivery. They should be encouraged to walk during labor and each woman must freely decide which position to adopt during delivery.
9. The systematic use of episiotomy is not justified.
10. Birth should not be induced for convenience, and the induction of labor should be reserved for specific medical indications. No geographic region should have rates of induced labor over 10%.
11. During delivery, the routine administration of analgesic or anesthetic drugs, that are not specifically required to correct or prevent a complication in delivery, should be avoided.
12. Artificial early rupture of the membranes (AROM), as a routine process, is not scientifically justified.
13. The healthy newborn must remain with the mother, whenever both their conditions permit it. No process of observation of the healthy newborn justifies a separation from the mother.
14. The immediate beginning of breastfeeding should be promoted, even before the mother leaves the delivery room.
15. Obstetric care services that have critical attitudes towards technology and that have adopted an attitude of respect for the emotional, psychological and social aspects of birth should be identified. Such services should be encouraged and the processes that have led them to their position must be studied so that they can be used as models to foster similar attitudes in other centers and to influence obstetrical views nationwide.
16. Governments should consider developing regulations to permit the use of new birth technology only after adequate evaluation.
Is it necessary in my particular pregnancy? Will information about the genetic well-being of my baby increase my well-being in managing my pregnancy or making medical decisions?
What is your particular experience and complication rate with the procedure? Should I be referred to a fetal-medicine specialist?
How much will it cost? Will it be covered by my insurance?
What information does the test give? When will I hear the results? How reliable are the results?
Are there alternative procedures that are safer and yeild nearly as much information? Will the procedure hurt? What complications might I expect? Can my husband and I watch the procedure on the ultrasound screen?
Squatting - Instead of bending when you need to pick things up, squat. Squatting increases the outlet diameter of the pelvis. It helps to prepare the muscles in the back, belly and bottom. The farther apart your knees can go, the farther back your thighs can go. Thus, the wider to door is opened, the sooner and more comfortably your baby can come out during pushing! (I used this position A LOT while in labor.)
Pelvic Rocking - Involves lifting and relaxing your lower back rhythmically while on your hands and knees. When our backbones are parallel to the ground, our organs can fall freely forward where they belong. After doing several repetitions you should lie on your side with your top leg drawn up and let your uterus remain formard for a few minutes. It is also comfortable to relax in the "froggy" position for a while afterwards, your hips reclining against your heels, hands and arms making a pillow in front for your head. (I found that this exercise made me feel much more comfortable when things were feeling "squished" in my abdomen. I also used this in labor.)
Sleep Position - First off, let's dispell the myth that a mother can hurt her fetus by laying on it. It's actually the other way around, especially as the baby grows larger because sleeping on your back allows the baby to put a lot of pressure on mom's internal organs, spine, etc. Your baby is suspended in amniotic fluid, which acts as an equalizer of pressure (like hydraulics.) Any local pressure applied to a bag of water is immediately distributed equally and therefore harmlessly diminished.
When sleeping on your belly becomes uncomfortable for you, that's the time to find another sleeping position. The preferable position is laying on your left side with your top leg drawn up and supported by a pillow. (Husbands also make a good support for the raised leg!) This position allows the uterus to continue to fall freely forward while you sleep.
Legs-apart(Butterfly) Exercise
Kegels
Relaxation Practice
So, how do I do it?
You might want to try this in front of a full length mirror the first few times. Use massage oil, pure vegetable oil, or a water-soluble lubricant (like KY Jelly) on your fingers and thumbs and around your perineum.
With your legs spread, insert your thumbs into your vagina as deeply as you can. Press the perineal area down towards your rectum and towards the sides. Gently continue stretching until you feel a slight burn or tingling sensation. Hold this until the tingling subsides and massage the lower part of the vaginal canal back and forth. While you are massaging, hook your thumbs onto the sides and pull the tissues forward, simulating what your baby's head will do during the birth. Finally, massage the tissues between the thumb and forefinger back and forth for about a minute.
Don't be too vigorous or you could cause bruising or swelling in areas you don't want it! Make sure to avoid pressure on your urethra to avoid irritation or infection. And practice those Kegels too!
"All regional anesthetics reach the fetal circulation and consequently, the fetal brain within seconds or minutes of administration to the mother." This includes the drugs used in epidural, spinal, caudal, saddle or pudendal blocks or as a local infiltration for episiotomy.
"Wide experience with the use of epidural blocks also indicates that epidural block is associated with significantly longer labors, more use of oxytocin ("Pit drip"), rotational forceps deliveries, and markedly more postpartum bladder catheterization. It's well accepted that an episiotomy is almost unavoidable is regional anesthesia is in effect during delivery because the epidural block deprives the mother of her ability to bear down effectively and prolongs the expulsion of the baby."
"Most obstetricians quietly agree that epidural block also increases the rate of Cesarean section. An epidural block causes the pelvic musculatrue to become flaccid or limp, leading to dysfunction of th etrough of pelvic muscles that normally rotate the baby into the proper position."
"Oxytocin (Pitocin, Syntocinon) is a powerful synthetic hormone used to initiate labor or to stimulate contractions. The drug is frequently the physician's preferred method of speeding up labor, even though helping the laboring mother ot walk, stand or sit facilitates the normal progress of labor for the majority of women."
(Source for the above quotes - Drugs in Labor and Birth by Doris Haire, printed in Childbirth Educator/Spring 1987)
Tuning Into Your Body
It�s important that you work on this long before labor begins. Doing your Kegel exercises and practicing relaxation will help you to gain a general awareness of your perineum and will increase the muscle tone and blood supply to that area. Yoga may also help you to learn more about muscle control and relaxation-consciousness. There is no rush to push. Wait until the urge is irresistible and you will most likely be more productive than if you begin pushing before your body signals you to do so. When the urge to push comes, being able to release your pelvic floor is crucial. You can experience that feeling of release by paying attention every time you use the toilet. You can practice bearing down on the toilet when you release your pelvic floor muscles during a bowel movement. (It�s even easier to bear down once the baby is actually in the birth canal because you have something to push against.) Sometimes sitting on the toilet while you are in labor will help you to remember to relax your pelvic floor. (I didn�t think I�d want to sit on the toilet while in labor but actually spent some time there, including pretty much all of transition.) If you begin to feel the urge to push before you are fully dilated, or if labor seems to be moving too quickly, you can try a side-lying position or get up on all fours to try to slow things down.
Optimal Body Position
This is really important! In years past, women gave birth in mostly upright positions such as standing, squatting or sitting. In the 1700�s doctors began to insist women be on their backs to make it easier for THEM�not for the laboring mother. Pushing with the help of gravity makes much more sense and is much more efficient. There is no one �right� position to be in. You should simply do what feels best to you. Your main goals in selecting a position should be maintaining good blood circulation, setting up your body for breathing, and getting some help from our pal gravity. Keeping your back in a C-curve is very helpful. Some good positions include: squatting, reclining, up on all fours, propped at a 45 degree angle, kneeling, sitting on the toilet seat rim, knees pulled to chest, standing, tailor sitting, and/or side-lying with partner supporting top leg. Remember that you don�t have to stay in one position. If it doesn�t seem to be working for you, try something else.
Relaxation
The key to efficiently pushing your baby out is relaxing and coordinating your muscles instead of making a maximum effort to push. Relax your perineum totally as you did when practicing your Kegel exercises so that your pelvis opens for your baby. If your perineum is tight, it can contribute to pain, a slow second stage, and perineal tissue damage or tearing. Try not to brace your arms and legs in order to avoid tensing your muscles.
Breathing
Remember to breathe so that you and your baby both get plenty of oxygen! One productive way to exhale push is to take two deep relaxing breaths at the start of your contraction then take a third deep breath, tuck your chin, and then slowly grunt the air out while bulging your lower abdominal muscles around the uterus. It helps some women to think of pressing the baby down and out or smply letting go rather than pushing. Keep your lower body relaxed, push only as long as it is comfortable to do so and release the air slowly. Part your lips rather than pursing them and don�t be afraid to make noise! You don�t have to push through all of every contraction. Tune into your body and only bear down when, how and for as long as your body tells you to.
A Word About Valsalva Pushing
Valsalva pushing (or �purple pushing�) may work for some women but I feel it really isn�t the best option. This is where the woman is told to hold her breath and everyone around her counts �1-2-3-4-5-6-7-8-9-10� and yells �Push! Push!� Excessive breath-holding can cause a deficiency in oxygen reaching your baby and also changes in the mother�s blood pressure. If holding your breath feels correct and comfortable to you, try to do so only briefly (3-6 seconds) at the beginning of each push. This way the oxygen keeps flowing to your baby.
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