Monday, December 13, 2010


The other day while waiting for my daughter's ballet class to finish up, I began chatting with a woman who was also waiting. During our chat, it came up that I am a doula. "A do-what?" this middle-aged Ukranian woman asked me.
Though the term doula is becoming more and more well-known, this is a question that I hear often. And I've noticed that older women tend to not understand the necessity of my role as do the younger women. And not knowing much about birth in the Ukraine, I was not really sure what this woman would think about the work I do.
"Are you more for the emotional support, then?" this woman asked me when I tried to describe my role at a birth.
"Yes! Exactly!" I responded.
This opened the door for this women to share her own experience, as often is the case when talk of my profession comes up.
I love that women feel that they can trust me to be a sounding board for them as they describe in great detail a part of their lives that is so intimate, and so personal. I love to listen and gain more insight into the beauty and pain of womanhood.
This woman told me of her first birth, thirty years ago at a Soviet hospital in what is now the Ukraine. She told me how she had no idea what was happening to her, that no one had explained how the baby would come out of her, and that no one bothered to inform her at the hospital. She told me how she was left alone to experience pain after pain, not knowing if she was dying. She asked me if I tell women what to expect before they go into labor. I assured her that this was a large part of my role as a doula, and that I teach entire class series on what to expect through my childbirth classes. "This is good," she told me. "Women need to know. And they need someone with them to help them through it. What you are doing, it is a very good thing."
I think that it is important for us, as birth workers, to hear not only the good stories of birth, but be reminded of the bad stories, and how our efforts must continue - that history must continue to change so that all women can experience birth in a safe and satisfying way.

Monday, September 20, 2010

OFP, part 4 - Putting Optimal Fetal Positioning into Practice


What is Optimal Fetal Positioning? Optimal fetal positioning is the act of manipulating a mother’s body through movement in order to alter the fetus’s position into one that is favorable to moving through the mother’s pelvis.
In the previous blog post, I explained why the left occipital anterior (LOA) position is the most favorable for a baby to start in during labor. While this is true for the majority of labors, I’d like to refer back to the first blog post on the various pelvis shapes among women, and explore how this may not be true in all cases.
Because the gynecoid pelvis is the most common shape – one that 50% of women possess – this is the pelvis that is mainly referred to in OFP discussions. But, what if you have one of the other three types of pelvises? Optimal fetal positioning may then look different for you. While the general thought is that OFP is trying to get the baby into the LOA position, variations in the pelvic shape will change what is the optimal position for the baby.
I will reiterate here: the optimal position for the baby is whichever position the baby most easily fits through the pelvis. So, in the case of the anthropoid or android pelvis, the shape of these pelvises makes it much more likely for a baby to be in the posterior position. While a labor where the occipital bone of the baby is pressing against the mother’s sacrum may not sound ideal to the mother, if it’s the place that baby best fits through, it’s the best position in which the baby should be.


*POSTURE In the last blog post, I brought up one of the best things a pregnant woman can do to encourage OFP, and that deals with her posture.
I would say that the majority of “failure to progress” babies are due to malpositioning, and that the majority of the malpositioning is due to our modern lifestyles. Instead of walking for travel, we slouch in our cars. We do not sit cross-legged on the floor, nor do we squat, we lounge on sofas and in easy chairs. The majority of our work is done while seated, and the majority of us sit poorly.
So, watch your posture! Get a birth ball to sit on during the day. Tailor sit at home. Take breaks from sitting and do pelvic rocks. Spend a good 10 minutes when you get home from work just leaning over your kitchen countertop and moving your hipsThese positions will move the uterus forward, and help the baby to rotate into an anterior position. These postures will encourage flexibility in the pelvic joints which will enable them to open up to make more room for the baby.

*BODY WORK Some of us may need more help than just normal posturing to get our babies to move into more favorable positions.
Perhaps you had a bad fall when you were a kid. Maybe you were in a car accident. Or you played soccer and made the same one-sided twisting motion over and over again. All of these things can affect the pelvis alignment and uterine ligaments.
When the pelvis is bumped out of alignment, or the uterine ligaments are tighter on one side of the uterus, there’s going to be a twist in the uterus. While a slight twist or misalignment may seem like a minimal problem from the outside, everything is magnified on the inside. A slight twist outside turns into a large twist on the inside, making rotation more difficult for the baby.
Chiropractic care is wonderful for dealing with these bone and ligament issues. Mayan Abdominal Massage is another form of body work that helps get the uterus into better alignment.

*MOVEMENT What happens when you sit the same way, walk the same way, move the same way over and over again? Your body becomes rigid and tight, only allowing certain movements to take place. In pregnancy and birth, we want the body to be able to open up, the pelvis to open and move, the ligaments stretch. So, to help a baby be able to move, you need to move! Certain movements are more helpful during pregnancy and for optimal fetal positioning than others.

- squatting – opens up the pelvis, stretches your leg muscles, gets baby into alignment.

- tailor sitting – this stretches out the legs, opens the pelvis, moves the uterus forward and aligns your body.

- pelvic rocking – this helps get the baby out of the pelvis to allow it to move into a more optimal position, loosens the joints and ligaments of the pelvis and uterus and tones the abdominal and back muscles..

- forward lean – this helps to counter all the leaning back we do during the day. Lean against a table, a counter and while you lean move your bottom around to loosen up the hips!

- hip shimmy – this is where, as mom leans forward (over a birth ball or a table or a bed) her partner comes up behind her, grabs each side of her hips and shimmies them back and forth. This helps to loosen up the pelvis and the uterus, gets baby moving around and feels good to mom

- dancing – dancing is one of the most fun ways of helping to get a baby positioned correctly! Last year when I attended a Zumba class with a friend, one of the dance instructors leading the class was 8 months pregnant. While her movements may have not been as mobile or precise as the other instructors, I couldn’t take my eyes off of her! The whole time I watched her I was thinking how great these movements were for her pelvis and uterus, and what a wonderful gift she was giving her baby through movement and flexibility!

* SIFTING Sifting is a technique that has been used by Mexican midwives for centuries. It involves wrapping a rebozo (“shawl”) under the bottom or belly of a pregnant mother, and shifting the shawl back and forth while raising the mother’s body slightly off the floor. This takes some arm strength, so have someone strong apply this technique! If you do not have a traditional shawl, a towel or sheet, or any longer piece of material, will work. This technique is similar to the hip shimmy in that it helps to loosen up the pelvis and uterus. It loosens ligaments and muscles, gets the baby moving, and can really help to rotate a baby. Whether or not sifting should be done on the woman’s belly or bottom depends on the position of her baby.

It is a wonderful technique to use on most pregnant women, as it often helps to ease any lower back discomfort that is common in pregnancy.

* DUMPING Dumping is a technique that was brought to my attention by my friend and chiropractic care provider, Dr. Joella Pettigrew. When a pregnant mama comes into her practice and she determines that baby is lodged into a bad position, before she performs an adjustment on the mother, she will have her get up on her table, and bend down – feet on the raised platform, bottom in the air, and hands on the floor. This is something that should not be done by oneself, but with supporters on both sides. What happens with this position is that it allows gravity to work on getting the baby out of the mom’s pelvis, in order to then get the baby to rotate into a better position through the chiropractic adjustments. Dumping prior to the other movement techniques helps to increase the likelihood of getting a posterior baby into a more optimal position.


Referring back to the second part of the OFP posts, whether or not a baby’s head is flexed can make a huge difference on the ease with which the baby will fit through the mother’s pelvis. How to get a baby to flex its head may be a question that arose while reading through that post. While it’s not as simple as the rotational techniques, there are still some things that can help get a baby to have a well flexed head.
First off, before a baby has engaged deep into the mother’s pelvis, a skilled midwife can feel, through palpation, whether or not the baby’s head is flexed. And, if the baby’s head seems to be extended, she can help the baby to flex its head all from the outside of the mother.
Another way to encourage a baby to have good flexion, is to have toned abdominal muscles. Women with multiple pregnancies, which tend to stretch out both the uterus and the abdominal muscles, seem to present more babies with extended, or asynclitic heads. Keeping the abdominal muscles toned in between pregnancies, and through pregnancy with pelvic rocks, will greatly help with getting the baby to flex his head.
Along with well-toned abdominal muscles, sifting can be very helpful in getting a baby to flex his head. The shifting movement of the mother’s body can help to shimmy the baby down in the most accommodating place of the pelvis and encourage the baby to tuck his chin.


Many of the techniques for optimal fetal positioning during pregnancy can also be applied during labor. While it’s best to have baby in an optimal position prior to labor starting, sometimes it cannot be helped!

*MOVEMENT Key to any labor, but especially one in which the mother is trying to get a baby to change position, movement allows gravity and momentum to work together to get a baby to rotate. Walking is simple to do and a wonderful way to encourage rotation! The back and forth shifting of the pelvis as the mother takes her steps helps to get baby moving too.
Rotating the hips while sitting on a birth ball is another movement which encourages baby to move and find the best fit through mom’s pelvis. Dancing with a partner, or just moving side to side, swaying your hips, these primal, unconscious movements that many mothers make during labor are all ways that the body works to get a baby to move around and down.

*UPRIGHT Unless you are trying to get the baby out of the pelvis, or to move more specifically, upright positions will allow the most opportunity for babies to rotate and find their good fit. It also tends to be most comfortable for moms, allowing them to freely move.

*TURNING A BABY FROM RIGHT TO LEFT If the baby is starting with its occipital bone facing the mother’s right side, it is important to remember that babies tend to move dextrorotationally. Meaning that they move clockwise and will therefore have to move into a posterior position before swinging around to the left. How will you know if the baby is in a right position? One way is belly mapping, which can be discovered at the spinning babies website. Another way you can see a baby’s position is by looking at the mother’s hips from behind her. If a baby’s occipital bone is pressing down into the pelvis, you will most likely see that side of the mother’s pelvis bulge out. This is only visible if the baby is in a more posterior position. If the baby is starting in an ROA position, you will probably not see any difference in the hips.
If baby is starting out in an RO position, the best way to get it moving in the right direction is to purposely rotate the baby first into a posterior position. That may not sound pleasant, but if a baby is turning clockwise, it will need to move around the back before coming back over to the left! Depending on which position baby starts in – ROA , ROT or ROP, you may need to start with right side-lying to get baby to move farther back.
If the baby is engaged into the pelvis, and especially if the bag of waters has broken already, it might be necessary to first get the baby out of the pelvis. Dumping was one option already mentioned, though it might be scary to do during labor. Another technique for lifting babies out of the pelvis is called the belly lift and tuck (described below). I discovered this technique on the spinning babies website and have used it very successfully! Once baby is brought back up out of the pelvis, sifting while mom is on her back is what I’ve found to be best.
This shimmies the baby to rotate into a posterior position. Sift only between contractions. Babies rotate between contractions, move down during.
Once baby is established in the posterior position, moving mom onto her left side will help get the baby rotated into an LO position. Just side-lying can do the trick. A little hip shaking while mom is side lying isn’t bad, either.
When you feel certain that baby has moved to the left side (again, look for the hip bulge), have mom get up and walk around to get baby to engage in this position. Hopefully, once this is done, progress will be seen soon after!

*SIFTING This was brought up as part of the rotational process above, but it can be helpful no matter what position you either think, or know, the baby is in. Sifting is also the best technique to use if a mother has one of the “other” types of pelvises in which the baby best descends in a posterior position, or with an asynclitic attitude. Sifting is like jiggling a key in a lock to make it fit. It will help to get the baby into the pelvis because it is moving the baby around until it finds the best fit!

*BELLY LIFT AND TUCK This is a technique I learned from the spinning babies website and have used successfully in getting stalled labors going again. What I discovered with labors that progress with contractions but not with dilation, is that it often has to do with either the attitude of the baby’s head, or the position of the baby. If a baby cannot fit down into a pelvis, it will not be putting pressure on the cervix to dilate it. In Bradley® classes, we talk about the NAP – the Natural Alignment Plateau – that occurs in over one-third of all births. While there are many reasons for an NAP (emotions, hormone production, head molding), one of the most common is what the name infers. Alignment.
When you help the baby get into a better alignment, the labor will progress with dilation and descent.

What the belly lift and tuck does is lift the baby out of the pelvis where it is assumed he has tried to descend, either with a wonky head, or in a suboptimal position. Once he got there, he couldn’t go any further. So, when the mother lifts her belly up during a contraction, it helps to lift the baby out of the pelvis. While mom lifts her belly, she also tucks her pelvis under as she would do during a pelvic rock. This helps the baby find a better entry point into the mother’s pelvis. If the stall in the labor is due to the baby’s need to flex or straighten his head, this may be all that is needed to finish labor rapidly. If baby still needs to rotate, this technique in combination with some of the others will be best in getting labor to progress further.

*HIP SHAKING Like dancing, moving, and sifting, the hip shake technique described in the pregnancy portion can help to rotate a baby into a better position. This is a useful technique if a mother does not want to lie down to be sifted, or does not want her belly touched with sifting. The partner can stand behind her, ask her to lean over the bed, counter, chair, etc., grab her hips firmly and move them in the same fashion as the sifting would.

Optimal fetal positioning is a wonderful skill to know, whether you are the pregnant mother, a doula, a nurse, midwife or doctor! Knowing how to utilize these techniques may mean the difference in a vaginal or a cesarean birth. It may mean the difference in a 12 hour labor and a 48 hour labor. It may mean the difference in an extremely intense back labor, or a labor that is more manageable. Knowing how to make the difference is an invaluable skill to have!

While all of these techniques can help get a baby rotated and into an optimal fetal position, it is important to remember that pelvises and babies’ heads are still amazing at adapting. Babies can still be born in posterior positions, with brow and face presentations, and in other “non-optimal” positions. It may take a little more time, and a lot more effort, but the human body is amazing at making birth work.

WHERE I LEARNED THIS STUFF (a.k.a References and Resources)
* Childbirth International Physiology in Birth Course Manual
* Childbirth International Birth Doula Skills Course Manual
* Understanding and Teaching Optimal Foetal Positioning by Jean Sutton and Pauline Scott
* The International Chiropractic Pediatric Association
* Joella Pettigrew, D.C.
* Spinning Babies

* The Belly Mapping Workbook
* Personal Experience

Friday, September 10, 2010

Optimal Fetal Positioning, Part 3 - Putting the Pieces Together

In my first blog post on Optimal Fetal Positioning I focused on the dimensions of the human pelvis. With my second post, I explored the shape and angles of the fetal head. This next post on OFP will be bringing these two parts together, showing how well they can fit when things are done right.


The way a baby moves through the mother’s pelvis on its exit from the womb is described as the “cardinal movements.” The cardinal movements always begin with the fetal head in the LOA position, though sometimes babies do not go that route. The reason why LOA is the most described starting position is as follows.
As the baby enters the inlet of the pelvis, the widest diameter is transverse – from side to side. The baby’s head, when flexed well (or even when not), will be wider front to back. So, the best way for the baby’s head to enter the pelvis is in a sideways, or OT position.


As the baby is pushed further into the pelvis by the power of the contractions, and enters the pelvic cavity, the dimensions change. The cavity is more equally rounded, and since body movements tend to move in a clockwise direction (I’ll explain this more below), the baby is rotated from LOT to LOA.


The pelvic cavity is where head flexion really has a big impact. With an equal diameter of 12 cm, a well-flexed head will have a much more successful journey past the ischial spines than an extended head with an 11-13.5 cm diameter. As the baby moves through the cavity, it will continue its rotation from LOA to OA.


Once the baby has moved through the pelvic cavity, the front part of the pelvis basically disappears with the pubic arch. But the sacrum and coccyx at the back are still creating a posterior resistance. The pelvic outlet is absolutely wider from front to back than to side to side. But, if mom is in a position that allows free movement of the sacrum and coccyx (side-lying, hands and knees, upright/squat), the front to back opening will be even greater as the baby pushes the sacrum and coccyx back. This anteroposterior opening creates a space that favors an OA position for the baby’s head.


As the baby’s head moves through the pelvic cavity, and under the pubic arch, on the outside of mom’s body we see the baby start to crown. Through the pelvis the baby has rotated from LOT to OA, and when the baby’s head is born, the baby is usually looking toward mom’s back


The baby’s head has already gone on its internal rotational journey. As the head emerges, the shoulders follow with their own rotations. The shoulders enter the pelvis side to side, because they are widest that way, which puts the baby’s head in the OA position. As the shoulders move through the tight pelvic cavity, the body spins clockwise, and on the outside you’ll see the baby’s head turn toward its mother’s right leg.

As the shoulders move through the pelvic cavity, the rotation continues until the shoulders are front to back, this being the widest diameter of the pelvic outlet. Because of the pubic arch, the anterior shoulder will emerge first, followed by the posterior shoulder. The baby usually continues rotating until its facing up as the rest of the body is born.


What I’ve just described is the best way that a baby fits through the twists and turns of the maternal pelvis. The two were designed to work together in this manner and allow the baby and the mother to remain intact. Getting a baby to this starting point is what optimal fetal positioning is all about.


Why does it matter if the baby starts in a left position or a right position? Inside the body, there’s a certain phenomenon that takes place called dextrorotation. This describes the body’s tendency to have its processes move in a clockwise direction. Our uteri move the same way. As the uterus contracts and releases, babies are turned in a clockwise manner. If a baby were to start out in an ROA position, this would mean that the baby would need to rotate all the way from ROA to ROT to ROP to OP to LOP to LOT to LOA. That’s quite a long journey and includes a nice length of time moving through the posterior position, which can be extra painful for many mothers. Starting out in the LOA position means that the uterus can focus on pulling open the cervix and moving the baby down, instead of also working on getting a baby into a good position.


One of the best ways you can help start labor off right is by paying attention to your body movements in pregnancy.
Consider the way your spine curves. Most of us are lazy when we sit, especially if we like to sit in comfy seats such as couches and overstuffed chairs. In these places, we tend to tilt our pelvis back and curve out our lower spine, rolling our shoulders forward. Because the back of the baby’s head is heavier than the front of its head, sitting in slouched or reclined positions allows gravity to turn your baby to a posterior position, and the baby’s back is curved nicely along your curved back. If you were to sit with the pelvis tilted forward instead, your lower spine would have a nice curve inward, and your body would be more upright. This would allow the uterus to move forward, the baby to fit itself along the curvature of your spine, and the heaviest part of the baby’s head would then be toward your front.

Friday, August 6, 2010

Optimal Fetal Positioning, Part 2 - The Fetal Head

In the first blog entry on Optimal Fetal Positioning, I discussed the shape and variations of the first participating body part of OFP – the maternal pelvis. Before we discuss how Optimal Fetal Positioning really works, I need to explain the next participating body part – the fetal head.

As with the maternal pelvis, the fetal head is made up of various mobile bones that form a variety of shapes and sizes. Because babies’ heads move in different directions, both on their bodies, and in relation to the mother’s pelvis, I’m going to break down the different ways we describe the fetal head.


The first part of the baby’s head position to consider deals with “attitude”. This describes the amount of flexion or extension of the baby’s head, or how tucked the baby’s chin is. Why is flexion important? The amount of flexion going on will alter the diameter of the baby’s head as it moves through the pelvis, the cervix, and through the vagina. A cervix opens only as far as it needs to fit around the baby’s head. If the diameter is small, it will only need to dilate that amount. If the diameter is larger, then more dilation will need to occur. . A well-flexed head is a baby whose chin is tucked well into its chest, with the occipital (or back of the head) bone as the presenting part. From here there are varying degrees of flexion and extension.

Complete Flexion: this is the optimal position for a baby’s head to be in. The angle of the head and neck are less than 90 degrees, baby’s chin is tucked well into it’s chest, and the very back of the head presents first. The diameter of a completely flexed head, the suboccipitobregmatic diameter, is measured from just below where the occiput starts out to the center of the front fontanel. This diameter is about 9.5 cm

Moderate Flexion, or Military Attitude: with the military attitude, the baby’s head and neck are at a 90 degree angle, as if the baby is looking straight forward. The diameter of a military attitude, the suboccipitofrontal diameter, is measured from just below where the occiput starts to about the center of the forehead. This diameter is about 10 cm

Extended or Brow Presentation: this attitude has the baby’s head tilted back a bit, the angle of the head to the neck greater than 90 degrees. The diameter of brow presentation, the occipitofrontal diameter, is measured from the occiput start at the back of the head to about the eyes or the brow. The diameter is about 11.5 cm.

Hyperextended, or Face/Chin Presentation: this attitude has the baby’s head tilted way back and can be referred to as “star gazing”. The diameter of a hyperextended attitude, the mentovertical diameter, is measured from the tip of the chin to the highest point on the back of the head on the vertex. The diameter is about 13.5 cm.

As you can see, the variation in diameter of the fetal head is great in relation to how well flexed is the baby’s head.

Fetal Head Bones/Molding

So, can an unflexed head still fit through the pelvis and birth canal? Though it often takes more time and effort, yes, an unflexed head can still fit through!
Many pregnant women cringe when they think about pushing out a newborn baby’s head through their vaginas. How could something so large come out of something usually so small, they may wonder. While the majority of that topic can be turned into a blog post all on it’s own, for the sake of this blog post on OFP, we will discuss how the baby’s head can change size in order to fit through the mother’s pelvis.
We’ve already talked about how the attitude of the baby’s head alters the diameter of the presenting part. But, what if the baby comes down in one of those suboptimal positions, or what if the baby really does have a large head? The wonderful thing is, we were designed to deal with this as well. Just as the maternal pelvis can expand to allow more room, the fetal head can contract to take up less room.

The fetal skull is formed from five main bones – two frontal bones, which make up the forehead area; two parietal bones, which make up the majority o fthe skull; and the occipital bones, which makes up the very back of the skull, protecting the spinal cord.

The adult human skull has a static shape – it is not going to change unless the bones are broken. But from fetus up until eight years of age, the sutures between these bones have not yet fused. These unfused bones and the fontanels, or small gaps, between the bones, create a skull with the ability to shift, bones overlapping bones, reducing the diameter of the skull. This ability can even allow a malpositioned baby to fit through his mother’s pelvis. I’ve seen some pretty amazing coneheads in my practice! The ones that are always so amazing to me are those that cone at an angle, or off to the side of the baby’s head. It amazes me that we are able to adapt so well; that vaginal birth really is very accommodating!

Fetal Head Position

Fetal head position is different than the attitude of the head. The attitude deals with moving the head up and down from the neck. Position deals with the direction in which the head (and the body that follows) is facing.

When discussing fetal head position, the occipital bone – the one at the very back of the head – is always what is used as the point of reference. We describe the fetal head position as which direction of the mother is the fetal occipital bone pointed toward.

The front portion of the mother is called the anterior. The sides are called transverse. And the back portion of the mother is called the posterior. So, if the back of the baby’s head is pointed toward the front of the mother, the baby would be in an occiput anterior position

The various fetal head positions are as follows:

ROA (Right Occiput Anterior)
ROT (Right Occiput Transverse)
ROP (Right Occipital Posterior)
OP (Occiput Posterior)
LOP (Left Occiput Posterior)
LOT (Left Occiput Transverse)
LOA (Left Occiput Anterior)
OA (Occiput Anterior)

Tuesday, July 27, 2010

Optimal Fetal Positioning - How Baby's Position Can Alter Your Labor

The words "Optimal Fetal Positioning" may sound like technical jargon to many, but to my ears they are the sound of hope and relief. While my beliefs about birth are mostly rooted around the ideas of keeping hands off of the pregnant mama, and letting the laboring mama and the baby inside do the work they were made to do, understanding the way our bodies were designed can lend an enormous amount of insight into what makes labor work, and what doesn't.

When dealing with optimal fetal positioning, we mainly focus on two parts of the participating bodies. The mother's pelvis, and the baby's head. Now, of course, these body parts do not function on their own, and are intricately connected to the entire rest of the body; but for now, we're going to break it down into these two parts so that we can have a better understanding for how this works.

Part 1: The Pelvis

Most scientists will concur that the human birth process has evolved into a series of compromises. As humans became bi-peds, our pelves narrowed. In order to walk upright, we gave up the ability to birth with the ease of a wide pelvis; a pelvis that would essentially allow us to release our babies without any pushing. Whether you are of a scientific mindset, agreeing with the degrees of evolution that have brought humans to this point in history, or more of a faith-based mindset, agreeing that a Creator had a perfect plan for how a baby would come out of it's mother, the fact remains that this process works - when done right.

The pelvis is a complex and dynamic set of bones. It cannot be defined by one shape or size. It is both wide and narrow, short and long. And it has the ability to alter its shape! What is so wonderful about all of this, is that babies heads and bodies are still able to maneuver their ways through the various turns and twists of the pelvis, and still find their way out!

Pelvic Diameters

There are four main types, or shapes, of pelvises among humans, but they all have the same basic structure of the inlet, the cavity and the outlet. The diameters of each of these parts of the pelvis differ significantly.

The inlet of the pelvis is about 11-12 cm from front to back, and 13-13.5 cm from side to side. When I get to discussing the baby's head, you'll see why this is significant. For right now, I'm just talking about the structure of the pelvis.

The pelvic cavity is the narrower part of the pelvis. It has a more equally rounded diameter, each direction being about 12 cm wide. The ischial spines, the boney prominences that make up the narrowest part of the pelvis, are typically 11 cm apart.

The pelvic outlet is narrower side to side than it is front to back. The transverse diameter is about 11 cm. The anteroposterior diameter on an immobilized pelvis is about 11.5 cm. The amazing thing about the pelvic outlet is that the joints that hold the lower pelvic bones together are quite flexible. If a mama is allowed to be upright, and baby is able to press it's way through, the sacrum and the coccyx are able to move freely and will open up as the baby's head comes through the pelvis, creating an additional 3.5 cm of space!

Different Pelvic Types

With about 50% occurance, the most common pelvic type among women is the gynecoid pelvis. This pelvis type is the ideal shape for childbirth, with a rounded pelvic brim, blunt ischial spines, round sciatic notch and a pubic arch of about 90 degrees.

The next common pelvic type, occuring in about 25% of women, is the anthropoid pelvis. The pelvic brim on this pelvis is wider front to back than it is side to side, the ischial spines are blunt, sciatic notch is wide and the pubic arch is greater than 90 degrees. This type of pelvis is common among women who are tall and have narrow shoulders. Because of the shape of this pelvis, it is common to have posterior positioned babies.

About 20% of women have the next type of pelvis, the android pelvis. This pelvis is similar in shape to the male pelvis and tends to be more common in women who are short and stockily build. The pelvis is heart shaped, making it more likely to have a posterior positioned baby. Because the ischial spines are prominent and close together, the baby's descent may be slow late in labor.

And the final type of pelvis, occurring in only about 5% of women, is the platypelloid pelvis. This type of pelvis is kidney shaped, being much wider side to side than front to back. The ischial spines are blunt, and the sciatic notch is wide. Because of the width of this pelvis type, the baby may need to tilt its head in an asynclitic position in order to engage into the pelvis.

No matter which type of pelvis you have, each of these pelvis types are able to give birth to a baby! Why? In the next section you'll learn how amazing the fetal head is in relation to fitting in tight places.

Thursday, January 21, 2010

How Healthy Are We?

This year marks the end of the second “Healthy People” decade. Healthy People is a program that puts together an extensive set of 10-year health goals for our nation with the intention of promoting health for America. Various government agencies, along with outside organizations, have worked together to come up with goals that are of the highest priority for our nations’ health.

Being in the field that I am in, I am always eager to see the goals they set for maternal and infant health, along with how we do in meeting those goals. Of specific concern to me is how they view the rate of cesarean sections.

In the Healthy People 2000 set of goals, a target of a 15% total cesarean rate was set for our nation, with a 12% rate for first time, low risk (full-term, singleton, vertex presentation) moms, and 65% target for repeat cesareans. The actual numbers were an improvement from what they had started at, down to 21.8% for total, 15.7% for first time moms and 66.4% for repeats, but did not meet the intended goals.
For Healthy People 2010, you may notice that the target rate went up. The goal for first time cesarean section was set at 15%, and target repeat cesarean was for 63%. A few points difference, but when you take into account how many thousands of women those points account for, that’s a lot of cesareans. We do not have any comprehensive data on these statistics any more current than 2007, but if we are continuing along the trend we see from that year’s rates, we are far, far, FAR from our goal! Last I heard, our overall cesarean section rate was around 31.8 %.
That’s more than twice the intended rate.

So, what’s going on here? Our health agencies and organizations believe that reducing the rate of cesarean sections is imperative for improving the health of our nation, but we are moving away from our goals in this area.

Why is a low cesarean rate an indication of a healthier nation? Isn’t cesarean a life-saving technique? Yes, it is. Having access to technology that can be used in emergencies is an indication that our country is advanced, but the use of these procedures does not mean that we are healthier because of our advancements. My belief is that we are too quick to use our advanced techniques when low-tech approaches could work just as well, if not better. If our high cesarean rates are a reflection of the number of emergency births that take place, there is something seriously wrong happening. Our women are becoming very unhealthy if one-third are unable to birth their babies. Our babies are becoming very unhealthy if one-third are too distressed to be birthed. Not only is our high cesarean section rate an indication of poor health prior to birth, but it increases health risks following birth, creating a new epidemic of young women with fertility problems, uterine problems and needing hysterectomies. If it is true that one-third of our nation’s births are emergency situations, we need to back WAY up and figure out how we can help women become healthy prior to, and throughout their pregnancies. We need to figure out how to grow healthy babies and promote that.

My question for Healthy People is how they intend for these goals to materialize into action? It’s one thing to set a goal, it’s quite another to make a plan of action and follow it. What is the point in setting these rates when there is no plan also set in place in how to achieve them?

Healthy People states that they are “grounded in the notion that establishing objectives and providing benchmarks to track and monitor progress over time can motivate, guide and focus action” but this is clearly not the case in obstetrical care. Though the “Mother-Friendly” and “Baby-Friendly” stamps of approval were established as an incentive to practice evidence-based, goal-meeting, care in hospitals, in the 14 years that these guidelines have been established, I can only find 86 hospitals in the entire United States that can claim being Baby-Friendly, and have yet to find one Mother-Friendly award.

Do we just not care? On the one hand, we see it important enough to list in our health priorities, but on the other hand, the shows we watch, the organizations that are respected, and the numbers themselves all show us that we really don’t care enough to do anything about it. Instead of it being seen as a medical emergency, cesareans are beginning to be seen as the norm.

Setting a goal without a plan of action is like saying you want to lose ten pounds and then continuing your life as you always have. If you want to lose weight, you need to make an effort and have a plan of what you are and are not going to do. The same goes with the Healthy People goals. Just setting a goal is not inspiring enough to the obstetricians in our nation. They need steps to guide them.
So, let’s look into the cesarean epidemic. Why are our rates so high? Why do they continue to climb when our goal is set for something much lower?

The first thing we need to do is address the top reasons for medically necessary cesarean sections.

1. A Previous Cesarean
Well, the easiest way to avoid this is to avoid the first cesarean! But, since that’s not always an option, we need to look into the reasons why a primary cesarean necessitates a repeat cesarean. Research shows that the risks of a vaginal birth after cesarean are much less than the risks of having another cesarean section.
A previous cesarean should not automatically place a woman in need for a repeat cesarean. The opportunity for women to have a vaginal birth after cesarean (VBAC) needs to be supported and encouraged.

2. The Baby is Too Big
This is a commonly given reason for a truly rare problem. American women, with their access to plenty of nutrition, should not be suffering from debilitating bone growth conditions, such as rickets, which would inhibit their ability to birth a baby. American women, in general, have pelvises that are perfectly suitable for passing a baby.
The problem lies in a misunderstanding of a pregnant woman’s anatomy, physiology, hormone production, and the baby’s role in his exiting.
 A woman’s production of relaxin and hyaluronidase during the last part of
pregnancy and throughout labor loosens up the ligaments of the pelvis, enabling it to stretch and move a lot more than a typical non-pregnant pelvis. As a side note, dehydration can decrease hormone production, so do not restrict access to fluids.
 A woman needs to be able to move in labor in order to allow the baby to navigate its way through the twists and turns of the pelvis. This is best done if a woman is upright and has the use of her legs.
 Squatting during pushing can open the outlet of the pelvis by more than 10% to allow more room for a descending baby.
 Physiological pushing ensures that mom is not wasting energy and only pushing when she and baby are truly ready.
 A well-toned pelvic floor can encourage a proper head flexion of the baby to allow for the smallest diameter of the head to lead the way out.
 Allowing enough time in labor and encouraging movement with the mom will help baby get into a good exit position, rather than rushing a baby down into a more difficult position.
 Not rushing a labor, and letting it progress on its own time will help with the baby’s head molding into a shape that fits through a mother’s pelvis.

3. Breech Baby
Delivering breech babies vaginally has been taboo for so long now, that it has come to the point where there are very, very few doctors who even know how to deliver a breech baby. Preventing breech babies should be the first consideration, followed by more attempts at delivering breech babies vaginally. The best ways to discourage a breech presentation are through the following:
 Have an extensive knowledge of optimal fetal positioning, and practice it throughout the end of pregnancy and in labor.
 Make time for body work such as chiropractic adjustments, craniosacral therapies, myofascial release, massage therapy, acupressure, acupuncture, and physical therapy.
 Have a practitioner who is good at palpating to have an understanding of how the baby lies, or do it yourself through belly mapping.
 If baby is not moving through home techniques and body work, try an external version.
 Allow mom to go into labor and utilize the wide range of movements to allow for baby to turn in labor.

4. Transverse Baby
A transverse baby is a problem indeed. A baby truly cannot come out of his mother shoulder-first. To reduce the likelihood of this position, the guidelines for preventing a breech presentation apply to transverse presentation as well.

5. Placental Problems
We cannot prevent all, but a healthy lifestyle and good nutrition prior to conception and throughout pregnancy, will greatly reduce these issues. Mothers with previous cesareans are at greater risk for placental problems due to the scar tissue acquired from the cesarean.

6. Slow or Arrested Labor
Failure to progress is one of the most common reasons for cesarean sections. The reasons why labors slow down or stop are so various it’s hard to address the issue unless you know all the little details surrounding each woman’s circumstances. But here are some basic things to consider.
 Starting a labor with artificial means increases the chance of a labor stalling out, because sometimes, a body just isn’t ready! Letting moms go into labor on their own will increase the chances of labors happening at a time when both mom and baby are ready.
 Women in labor are incredibly sensitive to what’s going on in their surroundings. Privacy is vital in order for a woman’s body to follow the natural course of labor. If she does not feel safe or respected, her body will shut down the labor process. Being respectful, quiet, and calm around a laboring woman will help to support her through the process.
 Encouraging movement and walking throughout labor can help a labor along. Studies show that it can shorten the length of labor by 25 %. Walking opens the inlet of the pelvis, allowing room for the baby to descend and move into a good position.
 Epidurals are known to slow down labors when given too early, or just as a reaction in some women. Using natural pain coping techniques can be effective in managing labor pain, as well as helping labor progress at a steady rate.
 A body that is well nourished and has the strength and stamina to endure hours of labor will be less likely to wear out and give up. Encouraging good nutrition and exercise throughout pregnancy can give women a better chance of a healthy labor.
 The presence of a supportive birth partner has been shown to shorten labors by 25%. Encourage participation by husbands, partners, and the use of doulas.
 If a woman is not in good active labor, she should not be wasting her time in the hospital! Being admitted at an early stage of labor can cause boredom, stress, excessive use of medication and fear, all of which can slow and stall a labor.
 In about 1/3 of labors there is a phenomenon that occurs called the Natural Alignment Plateau. During this time, contractions may continue but dilation does not happen, or contractions may stop all together. While dilation is not occurring, progress may still be occurring. Muscle revitalization, hormone production, a baby changing position, head molding, the release of fears, colostrum production – these are all ways in which progress can be made while dilation is not occurring. Staying patient while this occurs can lead to a labor which ends in rapid dilation (once all of the unseens are taken care of, things tend to move quickly). To force a labor forward that is experiencing a natural alignment plateau may be interfering with processes that are vital to the mom, baby, or both.

7. Umbilical Cord Prolapse
A cord prolapse is a true emergency situation. The umbilical cord is the baby’s lifeline while it is in utero. If the cord slips down past the baby’s head and gets pinched or compressed, the baby’s oxygen source is cut off.
> One of the ways to avoid a cord prolapse is to not artificially rupture membranes, especially early on in labor. Early ruptures are at a higher risk of cord prolapse because the baby tends to still be high in the mother’s pelvis, allowing more room for the umbilical cord to slip past.
> Avoiding internal exams during pregnancy and excessive exams during labor can help prevent early rupture of membranes. Each time an exam is done, bacteria from the birth canal is pushed up toward the bag of waters. This bacterium can eat away at the membranes and increase the likelihood of an early rupture.
> Healthy diet throughout pregnancy helps to create a strong membrane that is less likely to rupture early on.

8. HIV or Genital Herpes

In this instance, preventing the diseases prior to pregnancy is a must. Continued education on abstinence and safe sex practices needs to be encouraged. Women with genital herpes may still be able to have a vaginal birth if they are able to suppress a herpes outbreak at the time of birth.

9. Multiple Births
Multiple births seem to be on the rise now that infertility treatments have become so readily available. In order to grow healthy multiples, a healthy diet and lifestyle is absolutely necessary. Just because there’s more than one baby growing in the uterus this should not automatically put mom in the cesarean category. Vaginal birth of multiples is possible and should be attempted. Because of the increased likelihood of a breech presentation with multiples, vaginal breech deliveries need to be revived and doctors should relearn this practice.

10. Fetal Distress
The majority of cesarean sections I know of are a result of fetal distress. This is a scary situation. Why are so many babies unable to handle the rigors of labor? If this was the intended way for babies to come out, shouldn’t they be able to endure contractions and birth? While contractions and exiting through the vagina is the way that our bodies and babies are intended to work together, the rest of the labor story tends to stray from the intended course.
While distress can occur even during a completely natural and hands-off labor, it is important to note that any time you interfere with the natural process of labor, you are inviting repercussions. That’s why every single intervention should be weighed in a risks vs. benefits analysis.
One of the most noted side effects of pitocin is fetal distress. Pitocin, which causes unnatural contraction patterns, affect babies differently than normal contractions. Because they are stronger and last longer, they are adding stress to the baby in utero.
Add the epidural. Again, one of the most noted side effects of an epidural is a drop in mother’s blood pressure and decelerated heart rates in babies. And when an epidural is used in conjunction with pitocin, the pitocin is much more likely to be abused. If the mother cannot feel the intensity of the contractions, the medication can be administered in higher doses, without thinking that the baby still is feeling the intensity.
So, to counter the cesarean due to fetal distress, we need to:
 Lower the induction rates! Starting a labor chemically can stress out a baby who isn’t ready for labor, and it can cause stress to a baby due to the intensity of the pitocin-powered contractions.
 Utilize movement in labor! Movement in labor helps a labor to progress, which means less likelihood of having it augmented by pitocin or artificial rupture of membranes. Rupturing the membranes can also increase stress on a baby, as the cushion of water is no longer present and the strength of the uterus squeezing directly on the baby’s head can become harmful after time. Movement also helps to move baby into good positions. Many times women are asked to lie down on the bed and not move in order for the baby’s heart rate to be picked up on the fetal monitor (to ensure that baby is not in distress). The funny thing is, laying down and being still can put baby in a compromising position and cause distress in and of itself! Fetal heart tones can be picked up on a woman upright and moving by holding the monitor to the belly in conjunction to where the baby is during that time.
 Avoid pitocin. Avoid it for induction, avoid it for augmentation. It’s just better to stay away from the stuff.
 Avoid epidural. Having an epidural can slow down contractions which can then lead to augmentation with pitocin. Epidurals in and of themselves can cause fetal heart rate deceleration. Epidurals also prevent a mom from being able to move and when mom lays in one position, babies can get stuck in compromising positions.
 If fetal distress is suspected, fetal scalp sampling can be done to test for true distress in a baby.

11. Maternal Medical Conditions
There are many different medical conditions that cause concern for mothers who are carrying a baby. Some are truly incompatible with labor, some can handle labor if mom is
If there’s a chance for a mom with a medical condition to give birth vaginally, it’s important to keep these in mind:
 healthy eating and a healthy lifestyle prior to conception can make a huge difference in your options once you are pregnant.
 Controlling your medical condition through nutrition, exercise and medications throughout pregnancy can help increase your chances of a normal labor and birth.
 Try labor. See how the mom’s body reacts. Don’t just rule out labor.

12. Baby’s Birth Defects
Some birth defects are incompatible with labor, so cesarean is the best option for these babies. But often times, labor is beneficial for the health and well-being of a baby who has problems, so this is something that a parent needs to really research.
The March of Dimes has gone through a huge effort to help prevent birth defects through education. Good nutrition and a healthy lifestyle prior to conception and throughout pregnancy cuts down on the chances of birth defects, as well as a mother taking the right supplements (i.e. folic acid).

Now that we’ve addressed the top reasons for medically necessary cesareans, we need to figure out the steps to take prior to the cesarean becoming necessary.

1. Nutrition and lifestyle counseling. This should not start *in* pregnancy, this needs to start in infancy! This is a lifelong goal, and not one that should be brought to action only after a woman is pregnant. If a woman is unhealthy when she enters a state of pregnancy, encouraging good health and nutrition still can make a difference, and should occur, but the earlier, the better.
2. Utilize midwifery care. We are seriously lacking in balancing out the specialized practice of obstetrics with practice of caring for normal pregnancy with midwives. The midwifery model of care goes a long way in preventing many of the reasons for cesarean sections, and our nation needs to look seriously at this.
3. Utilize doulas. Because doctors and nurses are kept so busy, doulas are wonderful additions to the labor room. They provide continuous labor support for the mother, father and family. They help the mom with the emotional side of labor and help her through finding her own way. They drastically cut down the medicalized part of labors and help moms get up and moving. Insurance companies would be very, very wise to reimburse families who use doulas. They can greatly reduce the cost of a hospital stay.
4. Train nurses in taking care of laboring women. Because of the high percentage of medicalized births, many nurses do not know the needs of a naturally laboring woman. If cesarean rates are to go down, those who work with laboring mothers need to know how to help them in ways that protect, rather than interfere, with the natural process.

Wednesday, January 20, 2010


Watching birth videos always makes me cry. Not because of fear, or thoughts of pain, or sympathy. I cry because watching women bring forth life fills me with an overwhelming feeling of awe. Because women are so beautiful, so strong, so amazing.