Healthy Mother Sanctum®

Won’t You Let The Hormones Play?

During the last few weeks, reliving the euphoria that I experienced as I birthed my daughter naturally, there have been many thoughts that have flitted through my head. I am amazed at what my body can do. I am thankful for the support that I got. I am happy that my daughter is perfect. But, I have been also thinking about what was so sorely missing in the “care” that I got for the first 40 weeks of my pregnancy, at the hospital where I work as an Emergency Physician. As I sit here, bonding with my baby, here is what I want to say to the medical establishment providing, routine maternity care:

Don’t just give me consultations:
Tell me something about pregnancy care, about birth, about labor, pain management, about after hours, about breastfeeding, about many things I wish I was taught – because we don’t have those grannies any more who knew it all .. and told it all. (We do have YouTube!)

Don’t tell me “XYZ” is the only plan:
I am a doctor myself. I have read similar books as you have. When our books have taught us something else, why are you telling different things to a patient who is at your door, in total surrender and so much trust?

Don’t tell me that I am putting my baby’s life to risk, making me look like a criminal:
Just because I want to make choices that seem to be appropriate for myself and my baby, why would you say that to me? No mother will put her body and her precious baby willfully at risk. Give me choices. Tell me the pros and cons of doing or not doing a test, or a scan or an intervention such as induction. And make me a partner in the decision making process.
When a woman becomes pregnant, it is not just the womb, but her entire physical, physiological and psychological body is working towards protecting the unborn.

Don’t tell me I will deliver your baby safely:
I made the choice to become pregnant, worked towards conceiving, protected my womb and the growing one with love, good thoughts, positive vibes, words, music, peace, exercise, good food, rest, dance, laughter, patience. And when the grand moment arrives where I welcome this one, I stay knocked out? Why would I do that? Why should you deliver me, when I can birth my baby? I think I can give birth more safely, the way nature intended!

Don’t tell me that I can’t handle labor:
My body is meant for this, the universe has made me that way, the one task which differentiates me from a man. You are telling me that I am incapable of that? Why do you mock me by saying “You found an internal exam painful, how do you plan to handle labor?” This is denigrating and disrespectful. Instead, why don’t you try to keep me calm and reassured, and educate me beforehand, and encourage me by being with me in labor, so that I will walk through it like a breeze?

Don’t tell me that my baby will die in utero (over and over again, just because I am asking questions, and trying to make my own choices):
An unborn in the womb can die and will die simply anytime if she chooses to. There is no guarantee, there is never a guarantee. And when that happens, and if I asked you ‘Why did it happen?’Or ‘What could I have done to prevent it?’ Or ‘Why did it happen to me?’… Would you have an answer?

Don’t tell that beyond 38 weeks my baby only gains weight, which only makes labor more difficult:
This is madness. Of course the baby will gain some weight. This is nature’s way of ensuring survival of the baby in those first few hours and days post-birth! My baby was born perfect!! I am sure that my baby gained a lot more than just weight in those “extra” days.

Don’t say “Lie down, I shall remove your baby”:
I do not need to lie down in labor all the time, in order to get monitored! If you are worried about mom and child safety, then arrange a ward/space where I can just walk or sit or lay down to rest, where my baby and I are monitored intermittently. This way I will be reassured and more comfortable to birth my baby actively. Or if labor is not really in its active phase, send me home with my baby, after checking me and giving me counseling and encouragement. Tell me to come back, when anything feels different, and to stay active.

Don’t give me deadlines for progress of labor.. 6 hours and 12 hours and so on:
Poo is made in 24 hours it arrives over ten mins. This baby is made over 277 days. Do the math it comes to 2 days(OK this part am kidding!)   But seriously, why is she expected to exit in 15 mins, or an hour, or just any arbitrary time that you have decided?

Please go the extra distance to make a vaginal birth possible:
It is more work for you, it demands more patience from you, it demands more observation, more checks, more space, AND it warrants LOVE. It is required that babies take the vaginal route, it is plenty of work and adrenaline – this is good stress for the unborn.

Hormones:
Hormones have made pregnancy possible, hormones have protected the pregnancy, hormones have induced labor, hormones have caused the birth, hormones cause recovery, hormones help breastfeeding, hormones gives best possible health to mom and baby, hormones cause love to happen naturally, hormones make the magic enjoyable.

Why don’t you let the hormones play?

~ Dr. Archana Satyam Madivada

Dr.Archana is 31 year old Emergency Physician by profession since 2009, working at Care Hospital, Banjara Hills. She loves her job and has intervened and successfully managed many lives. She finds it a very satisfying experience. Her other interests are music , dance, poetry, sketching , hanging out with friends, and movies. She is currently on maternity leave , enjoying being Mom to her three month old baby girl, whom she gave birth, completely naturally, with Midwives, at The Sanctum, Natural Birth Center, Hyderabad.

The Sanctum, Natural Birth Center – Natural Birth Rates 2016

What does gentle MotherBaby Centric Collaborative Model of Care look like at Healthy Mother? While birth stories, advocacy, knowledge sharing and testimonials are all important in helping mothers-to-be and fathers-to-be understand the immense beauty and safety of physiologic, natural birth, it is equally important to put out birth statistics.

This year, we also had an immense internal physical shift. From being a Midwife Run Natural Birth Center inside of an existing maternity care hospital, we moved into our own premises on November 23rd, 2016. We now are a free-standing Birth Center – The Sanctum, Natural Birth Center. It is not attached to any hospital, but has all the emergency infrastructure like a fully equipped operating theater, a small level 1 NICU, a Lab and a pharmacy built into it. And, after 8 years of having provided collaborative back-up partnership, our main Obstetrician, Dr. Jayanthi Reddy, has also come on board as a full time partner at our Birth Center.

What makes the Sanctum different from the average free-standing birth centers one might see in other developed countries is that though midwives run birth centers, they are restricted to taking on low-risk clients because they do not have the skills, facilities or backup required to manage clients with complex needs or complications. Obstetricians in hospitals do. At our Birth Center we can take on and assist clients with more complex needs. This includes women with twins, Gestational Diabetes, Gestational Hypertension, breech babies, etc. because we have full support of backup Obstetricians, Physicians, and Pediatricians if the help is required, all available on site. 

This collaborative model of care has led to some pretty amazing, safely assisted, and satisfying natural births. However, if there are any red flags during pregnancy or labor, we have a number of backup OBs nearby whom we can consult with or have come and perform a c-section if necessary, in The Sanctum itself.

Our collaborative model of care works. We have an amazing team of Nurses (who we have cross-trained to provide excellent labor support), Midwives who have education, training and experience in providing excellent maternity care with the Midwifery Model of care, Ayammas who provide MotherBaby Care from the heart, as much as with their hands, Physiotherapist, Prenatal Yoga Instructor, and Lamaze Certified Childbirth Educators who teach with unparalleled passion and energy, to help women have a safe and healthy childbirth experience. Of course, our team of back-up OB/Gyns , On Call Anesthetists, Physician, and Pediatrician excel in their respective roles, to provide well-rounded comprehensive care for both the Mother and her Baby, as per their individual needs.

Our statistics speaks for themselves. Of the 613 births so far (15 January 2017), we have an 8% C-section rate, 4 vacuum births, and only one forceps birth. These statistics span over 8 years. We currently have a 95% VBAC (vaginal birth after a previous C-Section) success rate, and have successfully helped 6 women have a successful VBA2C (a vaginal birth after 2 previous C-sections) – this in a country where VBACs are almost non-existent. 

Natural Birth RatesAll of this of course happens because mothers and their families want access to good evidence-based, respectful, informed, transparent maternity care. We are really thankful for excellent back-up obstetrical care, even though we very rarely need it. Just knowing that excellent Collaborative Care is available, also allows for the Mother to birth her baby without fear.

 

 

 

So here is “Birth By The Numbers” for 2016 at Healthy Mother – These are derived from all the births that took place between January 1 2016 to Jan 31 2017.

~ 150 babies were born

~ 93.24% were normal deliveries (overall C-section rate of 6.6%)

~ Of this, we had a Primary C-section rate (first time mother) – 4.72%

This is important! The more we reduce the incidence of C-sections in first time Mothers, the better their overall reproductive health for the rest of their lifetime!

~ And, a Repeat C-section rate (second time mother, with a previous C-section, needing another C-section) – 5.88%

Data about the 7 primary C-sections:-

  • One mother with postdates @ 41 weeks and 6 days, with meconium and fetal distress
  • Two first time mothers, with breech babies. 1 of them tried for a breech vaginal birth, but with non-progressing labor, decided to go in for a C-section. The other Mamma made a conscious decision to birth her breech baby via a planned C-section, after carefully considering the risks and benefits of a breech vaginal birth
  • Two mothers with severe PIH (Pregnancy Induced Hypertension), and cholestasis of pregnancy; One of them also had severe oligohydramnios
  • One mother with severe Gestational Diabetes, PIH with and an IVF pregnancy, and very slow labor progression
  • One mother with unexplained severe accidental hemorrhage (placental abruption)

 

On the other hand, having excellent collaborative care meant that we could also help women with complex needs birth their babies naturally, sometimes with medicines in pregnancy, and rarely with medical augmentation during labor and birth.

  • 5 mothers with PIH could birth naturally
  • 2 mothers with severe Gestational Diabetes could give birth naturally
  • 1 mother with an extremely low lying placenta (Placenta 2 cms from Internal Os) could also birth her baby completely naturally, with excellent monitoring and support.
  • 2 babies were born naturally despite having congenital deformities (one of them was known through prenatal scan testing, the other had been missed despite having a scan)
  • The heaviest Mom to birth her baby naturally weighed in at 128 kgs when her labor started at 42 weeks complete (Yes, there are risks of being obese, but with good monitoring and care, they can also have a natural birth. Being fat should never be a]the only factor determining whether Mom can have a natural birth!
  • At the other end, we also had a 42 kg Mom give birth naturally. When she switched care to us mid-pregnancy, she weighed 35 kgs (Yes, there are risks to being extremely underweight. But this alone should never be the only indication for a C-section)
  • Postdates – Routine in our practice. At least 80% of our first time mothers will go past their due date. Most will go into labor at some point prior to 42 weeks complete.
  • 2 sets of twins were born naturally
  • 1 Frank Breech baby was also born naturally
  • 1 baby with mild IUGR was also helped to be born naturally

VBAC (Vaginal Birth After Previous C-section) Data:

~ 51 women tried for a VBAC

  • 48 of them had a successful VBAC!
  • 2 women had successful VBA2C (Vaginal birth after 2 Cesarean Sections)
  • VBAC success rate for this year: 94.11%
  • VBA2C success rate for this year: 100%

Data about the 3 repeat C-sections:-

  • One mother had scar dehiscence (both mother and baby were well, it was a prolonged labor, with body indicating something was off when we spotted a small bleed which was disproportionate to the dilation)
  • One mother with severe PIH
  • One mother with unexplained severe fetal distress after complete dilation.

~ 100% Breastfeeding Rates (both at 6 weeks and at 6 months postpartum)

What do these numbers tell us?

Birth is inherently safe. Interventions are sometimes needed, especially if there are higher risk cases. In these cases, good Collaborative Model of Care such as the one used at Healthy Mother, with Primary Midwifery Care and the 24X7 availability of OB-Gyns, along with Physicians, and other professionals allows for most Moms to labor safely and birth normally in many instances. In the rare instance that a Cesarean is required, 24X7 in house facilities for surgery, and a excellent team of Ob-Gyns, Anesthetists and Pediatricians allow for excellent chances of optimal outcomes for MotherBaby.

Some key points to note –

  • Fetal distress is rare in normal progressing natural births
  • Cord around the neck is seldom a cause for a C-section (1 out of every 3 babies is born with a cord around the neck!)
  • Baby being heavy is seldom a cause for a C-section – planned or unplanned. We had at least 10 babies born this year who weighed in at more than 4 kgs. All of them were born naturally.
  • We never check pelvis shape or engagement of baby into the pelvis or cervical dilation, prior to labor (these things are routine at many hospitals)! And yet, almost all babies were born naturally, despite some of the Mammas having a very compact pelvis. The body that made the baby knows how to bring it out, in the vast majority of cases.
  • Short, tall, heavy/obese, or low weight/petite – mostly of the times, these mammas can give birth naturally!
  • Just going past the Expected Due Date is never a reason for a C-section! Patience is the key!
  • Meconium may cause fetal distress once in a while. However, out of 150 births this year, there was only one baby who needed to come out by C-section due to postdates, meconium and fetal distress! The rest of them, did just fine.
  • Just having a broken bag of waters for a few hours is not a reason for immediate inductions, which then lead to “failure of labor to progress”. Such non-evidence based approach can only be called by its true name -“Failure of doctor to wait!” With good monitoring, and good shared decision making, it should be possible to wait for at least 24 hours, and evidence says that it is okay to wait for upto 72 hours, prior to actively considering induction/augmentation. The longest we waited this year was for 8 days with broken bag of waters, and this particular Mamma had her much dreamt of VBAC successfully!
  • Midwives are experts at normal birth! The Midwifery Model of Care is holistic, personalized, evidence-based, MotherBaby friendly, and improves maternal fetal outcomes.
  • Collaborative Care is worth its weight in gold, in taking care of women with complex needs.
  • Mothers are the true rock stars and heroes! It is deeply satisfying and empowering to the Mother to know that she has powerfully birthed her baby naturally!

 

Birth Statistics for 2015: How Healthy Mother’s Collaborative Model Provides Optimal MotherBaby Care

birth statisticsWhat does gentle MotherBaby Centric Collaborative Model of Care look like at Healthy Mother?

While birth stories, advocacy, knowledge sharing and testimonials are all important in helping mothers-to-be and fathers-to-be understand the immense beauty and safety of physiologic, natural birth, it is equally important to put out birth statistics.

The birth statistics are derived from all the births that took place between January 1 2015 to Dec 31 2015.

Birth Statistics at Healthy Mother Sanctum (Jan 1, 2015 to Dec 31, 2015)

~ 104 babies were born

~ 92% were normal deliveries

~ 100% Breastfeeding Rates were accomplished

~ 2 Breech babies born naturally.

~ 4 mothers with Pregnancy Induced Hypertension (PIH)

Good Collaborative Care with co-management with our team of doctors and backup ObGyns meant that, all except 1 mother with PIH gave birth naturally!

~ 1 mother with Gestational Diabetes (GDM).

~ One Baby with IUGR (Intra Uterine Growth Restriction) and Low fluid levels was also helped to be born vaginally, again with excellent Collaborative Care.

Data about the 7 C-sections

  • One mother with uncontrolled PIH
  • One with true Placenta Previa
  • One growth restricted baby
  • One First Time Mamma with Very Low fluid and a Breech baby
  • 1 maternal request
  • Only 1 baby needed to be born by C-section due to meconium and fetal distress
  • Only 1 baby needed to be born by C-section due to prolonged labor and arrest of descent.

Data about Vaginal Births After Previous C-section (VBAC)

  • 24 women tried for a VBAC
  • 22 of them successfully completed their VBACs!

VBAC success rate for 2015: 91.66%

  • 0 scar related issues
  • 1 repeat C-section was due to cervix not dilating despite enormous trial of labor
  • 1 repeat C-section was due to maternal/family request
  • 2 women tried for Vaginal Birth After 2 Previous C-sections (VBA2C) – Both of these strong mothers successfully completed their VBA2C births!

What do these numbers tell us?

  • Birth is inherently safe.
  • Interventions are sometimes needed, especially if there are higher risk cases. In these cases, good Collaborative Model of Care such as the one pioneered by Healthy Mother, with Primary Midwifery Care and the 24X7 availability of OB-Gyns and team of Doctors allows for most Moms to labor safely and birth normally in many instances
  • In the rare instance that a Cesarean is required, 24X7 in house facilities for surgery, and a excellent team of Ob-Gyns, Anesthetists and Pediatricians allow for excellent chances of optimal outcomes for MotherBaby. Therefore mother has the Best of all Worlds !

If you noticed the above statistics, only one baby needed to come out via C-section for “fetal distress”. Then, one has to wonder – Why are so many babies born by C-section in routine hospitals in India for ‘fetal distress’ and ‘meconium’? Only 1 baby needed to be born by C-section due to inability to descent into the Birth Canal, despite hours of pushing. Then, why one wonders, is Cesarean commonly done for “failure of labor to progress” in routine hospital care?

So the Question arises, What is missing in conventional hospital-based “maternity care” in India?

Quite a few things, we would venture to say:
1) Lack of transparency
2) Lack of parental education in the antenatal period, and true informed consent/informed refusal
3) Lack of Trust in the Birth Process and thereby, not waiting till labor starts on its own.
4) Unchecked inductions, augmentations and other interventions – These in turn increase the chances of baby being stressed – and therefore increasing the chances of fetal distress (with or without meconium)
5) Admissions to hospital in very early labor, and hardly any one-to-one labor support. In the atmosphere of fear and apprehension – of course labor stalls out!
6) Convenience – Much easier to schedule C-sections! Natural births take time!
7) Lack of Scientific Midwifery Model of Care with Independent Midwives as the Primary Care-Providers. Midwives Save Lives. But, Midwives are Also Experts in Natural Birth and know how to support, monitor and encourage women to birth naturally!

As we write this year’s “Birth Statistics for 2015 at Healthy Mother” review, we are constantly amazed by the strength and conviction of the mothers who come to us for care. We are humbled by the incredible support that we get from families in our community – A big shout out to you All – You are the real pioneers in choosing Midwifery Care during this sensitive and sacred time of the birth of your baby. We are full of gratitude for our amazing team of Midwives and Nurses and Housekeeping staff, who keep the faith in the birth process, and who go above and beyond any call of duty to ensure that every Mom, every Baby and every Family gets the best possible care when they come to us. We are also incredibly indebted to our team of back up professionals – From our main partner ObGyn, to all other consultant Obs, to the entire medical team – these statistics are as much yours. Without your 24X7 availability, we would not be able to effectively support women and families the way that we do! So a big Thank you to you too!

Scientific Midwifery with Obstetric Backup – a Unique Collaborative Model in Maternity Care from Healthy Mother

We started the Scientific Midwifery based Healthy Mother Natural Birth Center, The Sanctum® in 2009 when I realized the sheer scale of sub-optimal care practices in the maternity and new born care system. To put it in perspective, during one of the early antenatal checkups one of our moms told me “It is no longer normal to expect a normal delivery”. Women who were under the care of the conventional medical system as practiced in big and small hospitals and clinics told us that their care provider never really felt empathy for their feelings and that every checkup was highly clinical and lacking a welcoming feeling and celebration of their motherhood. But then that is what I suppose the standard medical model in maternity is all about – At any given stage of pregnancy check the “patient” for problems, compare her “stats” with the normal, conduct tests, prescribe drugs, and send her off with advice. Questions, if any, were answered, but only upto a certain point. At the end of the session a mother, even if she was upbeat before going into the doctor’s office, really felt like a patient who was due for surgery. Moms who had a previous cesarean, or those who were even marginally outside the “normal parameters” were often told theirs was a “risky” or “precious” pregnancy and advised strongly that cesarean operation was the only option they had for a safe and healthy baby. Now that was a sure shot way of transforming her from an excited, happy individual to one whose confidence is in tatters, her mind full of fear and anxiety. Now these are not examples drawn from studies or third party sources – all of them are first hand accounts narrated by our moms, dads and their families.

We believe the time spent with moms during the antenatal checkups is a critical factor in instilling confidence in her that she capable of giving birth on her own. The time spent in answering questions from moms, dads and their families is always well spent – it has direct bearing in the ability of the family to support her during her pregnancy, and more importantly, during the hard moments of labor. We have seen husbands really rise up to the occasion every time a mother felt disheartened, unable to manage her contractions, unable to bear her pain and wanting to give up. We are constantly amazed at how husbands were able to trust the process of birth with confidence and convey that confidence to their wives during those moments. By talking and assuring the mother that she is strong, by giving her much comforting massage, walking or dancing with her, husbands are able to transform seemingly tense and discouraging situations where mother is about to give up, into moments where she rebounds with an insuppressible feeling of victory. And all along, her midwife is the one constant, staying with her through thick and thin, never thinking about the fact that she herself has not eaten or slept for those many hours, and has been there for her from the first checkup to this moment. Her midwife is her ultimate goto person even at the dead of night when she needs someone to talk to, when she feels that uncomfortable feeling that she cannot pinpoint, or to validate and assure her that she and her baby are doing well.

Difference between Midwifery Model of Care and Medical Model of Care

DIFF BETWEEN MIDWIFERY AND MEDICAL MODEL

And midwives believe that birth itself belongs to the mother! Not to the hospital, not to the doctors, or in the labor room! Birth is very personal, it is primal; and the woman’s body knows how to give birth. That is how nature has perfected the woman’s body to give birth since thousands of years. We acknowledge this strength in women, their bodies’ intuitive wisdom to bring together all the necessary components to create the baby and grow her. Throughout the pregnancy, we carefully nurture this amazing journey curated by nature where the baby and mother’s body complement each other to ensure birth happens when the baby is ready. All along the way, we counsel, educate and empower the mother and her husband/partner on what they can do to ensure a smooth journey. We as midwives prefer that mother takes charge of her own pregnancy and birth, by listening to what her body is telling her, connecting and bonding with her baby, and noticing the subtle queues her baby might be signalling. Many a times, this intuitive feeling may be a more accurate indicator of her and her baby’s state than all the technology driven tests and scans. We midwives are trained to notice these subtleties and to take appropriate steps, in any. During labor and birth, it is the mother who does the work, with encouragement and support from husband/family while her midwife ensured things were going well and the mother-baby team was working in tandem. At Healthy Mother Sanctum, every mother has the chance to go through labor for as long as she wants or is able to. Most importantly, it is She who has the choice, of course, within the parameters of safety for herself and for her baby.

So the question begs to be asked – “If mother is given the ultimate choice to continue to labor, what if there is a true medical emergency or if labor does not pregress beyond acceptable limit”? Yes, in rate cases situations do arise where, inspite of tremendous effort on the part of the mother, her husband, her midwives and birth team, labor just does not progress or the safety and health of the baby or mother may be compromized if labor is allowed to continue further. What do we do in those rare cases?

We have taken the natural birth focused Scientific Midwifery model that we pioneered in India, and judiciously married it with conventional Obstetric Medical model to create a unique Collaborative model of care. It is in precisely these situations that the Collaborative model is a life saver. Under this model, if there is a true emergency, all the emergency care infrastructure like Operation Theaters, ICU, Neonatal ICU, Surgeons, Anaesthetists, Pediatricians etc are available onsite and at the snap of a finger to tackle that emergency. The mother or baby does not need to be transfered to specialty hospitals except in the very rare cases. And even in those very rare cases we have preferred specialty hospital partners who work with closely to care for mothers or babies who need speciality care.

Healthy Mother Scientific Midwifery Based Collaborative Care Model

HEALTHY MOTHER COLLABORATIVE MODEL OF CARE
This Collaborative model is unique, not only in India, but also across the world. There are only five or six such instances where independent birth centers run by midwives have partnered with speciality hospitals to provide a one-stop solution to aspirations of mothers who want the empowering feeling of trying for natural birth but want the assurance that in case of any emergency they and their baby will have immediate care.

 

Thus the Healthy Mother Collaborative Midwifery Model of Care provides mothers, babies and families with the Best of All Worlds in their desire for empathetic, respectful care during pregnancy and labor, and empowering, transformative, safe birth.

We celebrate birth as a normal and empowering process.

Healthy Mother is India’s most trusted, Midwife-led maternal, newborn and infant care provider, Healthy Mother is India’s most trusted, Midwife-led maternal, newborn and infant care provider.

Wellmom by Healthy MotherTM brings to expecting mothers Prenatal Yoga classes, another service in our commitment to holistic, scientific and empathetic care during pregnancy, childbirth and new motherhood.

Wellmom by Healthy Mother Yoga program helps expecting mothers gain the physical, emotional and mental strength for the mind and body to become conscious of the needs of your baby. Our Yoga program not just teaches you exercises, but also helps you attain a higher level of spiritual calmness and upliftment of your mind.

You will be taught Asanas that help in loosening your body, relaxed breathing and strengthening your pelvic floor muscles among other techniques. Some important facets of our program are:

A) Breathing: The ancient science of Pranayama breathing is very effective in channelizing good energy through your body and mind. We teach you focused breathing techniques accompanied by chanting, the sounds of which cause positive reverberations in your body.

Benefits: Focused breathing techniques in Wellmom by Healthy Mother Yoga program help you reduce or manage shortness of breath during pregnancy, and will help you work through contractions during labor. In addition, the breathing techniques will help you relax, reduce stress and anxiety not only during the pregnancy period but also when you are in labor.

 

What are the facts about pregnancy and what are you missing?

A woman is considered to be in labour when she begins experiencing regular uterine contractions, accompanied by changes of her cervix – primarily effacement and dilation. While childbirth is widely experienced as painful, some women do report painless labours, while others find that concentrating on the birth helps to quicken labour and lessen the sensations. Most births are successful vaginal births, but sometimes complications arise and a woman may undergo a cesarean section.

During the time immediately after birth, both the mother and the baby are hormonally cued to bond, the mother through the release of oxytocin, a hormone also released during breastfeeding. Studies show that skin-to-skin contact between a mother and her newborn immediately after birth is beneficial for both the mother and baby. A review done by the World Health Organization found that skin-to-skin contact between mothers and babies after birth reduces crying, improves mother-infant interaction, and helps mothers to breastfeed successfully. They recommend that neonates be allowed to bond with the mother during their first two hours after birth, the period that they tend to be more alert than in the following hours of early life.[57]

Managing Labor – Tips to Make a Mammoth Task More Manageable

happy

The words “Labor Pains” evoke the mental image of women in distress and in need of rescue. The message is that labor is extraordinarily painful – while most women will experience “pain” in labor, some women have described their labor as “painless” in all cultures across the world. Surprising? But, it makes sense because pain thresholds are different for different women, but also that some of them are more prepared to “let go” and experience the pain of labor as a culmination of 9 months of pregnancy, and are more prepared for the whole experience. These women have “anticipated” the pain of labor, and we have had moms tell us that the pain of labor was “less” than they had anticipated!! Cool, isn’t it?

So, what can you do to make labor more manageable?

1) Early Labor:

Do not tell anyone except your labor partner (husband/mom/friend/sister/anyone that you have chosen) that you are in labor. This is especially important in India, where the mom-to-be is with her mom at the end of pregnancy, and there are tons of people around the house waiting for her labor to start!! Early labor or pre-labor pains can last for hours or days – they come and go; start and stop; increase and decrease; have rhythm for some time and then no rhythm – However, in each case they last for a very short period and are very easily managed. If you have learnt some breathing techniques use it; if not, do what comes naturally to you. The fact is that more the people who know about your labor, the more everyone thinks that something needs to happen – And, the shy hormone Oxytocin, which is needed to help labor move along, just runs away with all that prodding and watching done by everyone around you in labor!!

There is a reason why labor starts at night or in the early morning hours for most moms – A) the body is rested; and B) there is no one watching it!

So, what else can you do in early labor?

  • Take a shower, walk around a bit, have something warm to drink (or cold – if you do not like warm drinks, there is no set rule). Usually, these things will make you comfortable enough to go back to bed and rest. Yes, REST. In early labor, resting and relaxing are the 2 most important things that you can do. Sleep if you can. If the contractions are 10, 15 or 20 minutes apart, there is no reason that you cannot sleep in between, and then just breathe through 20 seconds of contractions!
  • If your back or your lower belly hurts, you can keep a hot water bag to the area and the warmth gives you enough relief to get some rest
  • If needed, ask your labor partner to give you a massage – back massage, foot massage, leg massages work great!
  • Keep the lights off! I cannot emphasize this enough. Keeping low light not only allows you to rest, but also does not over-stimulate your brain into thinking and over-anticipating the progress of your labor
  • Eat and drink normally.
  • You may find that each contraction sets of a need for you to visit the bathroom. This is okay. Go, then come back and rest.
  • If it is broad daylight, and you cannot rest anymore, go about your daily activities. Can you cook for yourself/your family? Yes. Can you go shopping to your neighborhood grocery store? Yes. Can you iron some clothes? Yes. Can you read, or watch TV, or play cards? Yes. Can you go back to bed, and rest? Absolutely, Yes. Can you walk, climb stairs, or do your exercises? If you feel comfortable, absolutely Yes. Can your husband take you out to lunch or to the mall? Yes. Do you HAVE TO walk or do exercises for labor to progress? NO. In early labor, doing too much will actually tire you out, and not leave enough energy for the hard part of labor.
  • Will you somehow miss the progress of labor if you rest and relax and go off to sleep? Absolutely NO! Your body is smart, and it signals you that things are moving into the next gear. You will know as the pain intensifies, pelvic pressure increases and you generally feel more uncomfortable! This is usually the time to go to your hospital or birth center. As a rule of thumb, by this time, your contractions are 4-5 minutes apart, 45-60 seconds long and strong enough that you have to stop doing whatever you are doing, and breathe through the contractions. You may be vocal or you may be silent, but usually by this time, you will not be able to carry a conversation at the peak of the contractions. Yes, by this time everyone in your house will know that you are in labor!

So, what has your early labor accomplished? By now, your cervix (the opening of the mouth of the uterus) has softened, come into a forward facing position, and opened out to some extent. Do not be surprised if you are a few centimeters dilated! Even if you are not much dilated, early labor still has so much meaning to the overall progress of labor – your baby may have come further down into your pelvis, she may have turned into a more optimal position, and your body’s hormones are primed to lead you into stronger, longer contractions, which will be needed to bring your baby out!

2) Active Labor & Transition:

If you are in the hospital, chances are that there will be lots of activity around you. Nurses walking in and out, Doctors wanting to check you internally. Electronic fetal monitors strapped onto you. Hopefully, you have managed to negotiate at least a few things with your care-provider during your pregnancy, and you will be able to do the things that help your labor to progress.

So, what are some of the things that can help you labor progress in this stage?

  • Walk, Move Around, Remain Active  – in this stage of labor, activity helps to progress labor along.
  • Assume positions that feel comfortable to you. Mostly you will find that lying down just makes the pain feel worse! Sitting on the toilet seat may be very comfortable. Or a birth ball or bean bag may help. Squatting may feel very comfortable, as may slow dancing with your labor partner. Try out different positions and postures or even exercises that you have learnt in prenatal yoga or Lamaze classes – You may be surprised to find out that you are managing the pain of contractions more easily than you anticipated!
  • Sway to a rhythm, keep your hips loose. Keep your lips loose too – Loose lips = loose hips!
  • Shower or take a bath in the tub – Nothing more relaxing than this. Getting into a tub, seems to give an “AHH” effect to most moms in labor! In water, you will find that you can manage your contractions far more easily. Even a simple bath using the humble bucket and mug, can give you much needed relaxation and rest.
  • Think of your contractions as a wave – It comes and goes. When it goes away, there is no pain. Can your partner give you a foot massage or a neck massage when there are no contractions? Absolutely. Can you rest on a Birth Ball leaning forward over some pillows? Yes. Can you play music or Hypnobirthing positive affirmation tracks? Superb choice. Can you eat and drink during the periods of rest? Excellent idea.
  • Keep the mood in the room as light as possible. This is really a responsibility of your entire birth team! The more everyone or even one person around you gets anxious, the more you will experience the pain of labor as acute and unbearable. As a mom you have to do enough work during labor, without having to bear the tension of others too!!
  • Will you sometimes ask “how much longer”? Of course, you will. Does anyone know the exact answer to that question? NO. The best thing you entire labor support team and especially your husband/partner can do is to reinforce that “You are marvelous”. “You are doing great.” “You are strong.” “You can do this.” “You are doing this.” “Every contraction is bringing you closer to seeing your baby.” While some moms will want absolute silence, so that they can focus during the contractions, most moms that I know love and want to hear those 1,2 or 3 positive affirmations over and over again during their labor.
  • Rest and Relaxation is important now as well. Often, the hard work of labor, combined with the hormones of labor will ensure that mom goes into a deep sleep/ or rest even in the minute or two between contractions. Dads will ask “Is it normal that she is sleeping soundly?” Yes, it is. The best we can do is to leave her alone and not disturb her. She will wake up and manage the next contraction better when it comes on again!
  • You may feel afraid at some point. Can I complete this? Your doula, midwife or labor partner can focus you with some eye contact, breathing with you and telling you that you are doing great. The hormones of fear make you go into a fight, flight or freeze mode and make the pains feel even more painful. In contrast, the hormones of labor are those which make labor and birth easier and less painful. This mind-body connection is very important to understand and once you surrender to your labor, without fear, you can usually manage it far more easily!

3) Pushing:

  • While this is a topic that I can write a whole blog post on, for now, I will just say that you will know when to push and how to push. Pushing is an instinctive, primitive process and there will come a time when you can do nothing but push. Follow your body’s cues. Rest between pushes. Yes, it will seem a monumental task at times. For some women, pushing can be as less as 20 minutes, and for others it will be hours before they see their baby. Be mentally prepared either way. Most women will not want to eat anything while they push. Drinks that give quick energy are absolutely essential for this phase, and even sipping on some water between pushes will help.
  • Change positions to harness the effect of gravity. Upright positions such as kneeling, squatting, using the toilet seat or birth stool, using a rope/saree/squat bar to do supported squatting, all fours position, low stool, or even being in the Birth Tub will help you to push more effectively, as compared to being on your back.
  • Many moms find that warm perineal compresses help to ease the burning pain of the final few pushes. Easing and breathing the baby out works really well.
  • Again, privacy and calm helps. Unfamiliar people coming and going out of your room. Voices telling or yelling at you to push, are usually not conducive to the hormones of labor.
  • Remember Oxytocin, the shy hormone? It is also the hormone of love and comes in its final surge with the final stretch of the perineum as the baby’s head crowns and the baby is born! The euphoric feeling surrounding birth, is so pleasant that the pain that is present, just seconds before, is often erased, or pushed into the background!
  • And, not only this, the same hormone allows for bonding and breastfeeding your baby!

Do prepare your mind and body to manage the pains of labor. Do not over-think or over-anticipate it. Do relax and do things that feel comfortable to you in labor. Do not over-analyse why it is going slowly, or when you will get to the next stage. If your labour is taking longer to establish than you hoped, don’t feel disappointed! Your body is working very hard – long early labor, short active labor, short early labor, longer active labor, and any combination of these are all normal variations of labor!

Remember, feeling anxiety or stress can slow or stall your labour – and that’s the last thing you want to do! Enjoy this very special time before your baby arrives, as much as you can. Remember that this extraordinary mixture of vulnerability and power that comes to you in labor and birth lasts with you for a lifetime!

Safe Prevention of the Primary Cesarean Section

Yesterday, I was talking to one of the moms who came to us for her first check up in this pregnancy, and she said something to me that blew my mind away. She told me that in her last pregnancy, she set into labor, and that her bag of waters broke after a few hours of labor. Contractions were coming a bit faster, but still very manageable. Then comes the nurse and hooks her onto the continuous EFM machine. The baby is doing fine. But, at the peak of the contraction, the baby’s heartbeat in around 130-135 bpm, as compared to 140-150 bpm without contractions. She is looking at the monitor, she feels fine, her baby is moving well. But, the doctor says that these are early decelerations, this is fetal distress – so she is advised a C-section immediately!! This time, she wants to try for a normal delivery. As I counsel her, I find it hard to believe that 130s heartbeat is thought of a deceleration, and just not as a normal response of the baby during a contraction! How much evidence based practice do routine hospitals use in maternity care?

With the tremendous increase in Cesarean rates over the last few years, the American College of Obsetricians and Gynecologists and the Society for Maternal Fetal Medicine issued a joint Obsetric Care Consensus statement on the Safe Prevention of the Primary Cesarean Section. This statement provides fantastic guidelines in the way maternity care should be delivered, and in the way hospitals and doctors should look at progression of labor, electronic fetal monitoring, breech presentations and twin pregnancies. All of this, in an effort to reduce that first C-section!

The Consensus Statement first establishes that vaginal birth in most cases is less risky and more beneficial for most mothers and their babies: “Childbirth by its very nature carries potential risks for the woman and her baby, regardless of the route of delivery. The National Institutes of Health has commissioned evidence-based reports over recent years to examine the risks and benefits of cesarean and vaginal delivery. For certain clinical conditions––such as placenta previa or uterine rupture––cesarean delivery is firmly established as the safest route of delivery. However, for most pregnancies, which are low-risk, cesarean delivery appears to pose greater risk of maternal morbidity and mortality than vaginal delivery.

Table 1. Risk of Adverse Maternal and Neonatal Outcomes by Mode of Delivery
Outcome Risk
Maternal Vaginal Delivery Cesarean Delivery
Overall severe morbidity and mortality*† 8.6% 9.2%*
0.9% 2.7%
Maternal mortality 3.6:100,000 13.3:100,000
Amniotic fluid embolism§ 3.3–7.7:100,000 15.8:100,000
Third-degree or fourth-degree perineal laceration|| 1.0–3.0% NA (scheduled delivery)
Placental abnormalities Increased with prior cesarean delivery versus vaginal delivery, and risk continues to increase with each subsequent cesarean delivery.
Urinary incontinence# No difference between cesarean delivery and vaginal delivery at 2 years.
Postpartum depression|| No difference between cesarean delivery and vaginal delivery.
Neonatal Vaginal Delivery Cesarean Delivery
Laceration** NA 1.0–2.0%
Respiratory morbidity** < 1.0% 1.0–4.0% (without labor)
Shoulder dystocia 1.0–2.0% 0%

So, what are some of the recommendations for prevention of the Primary Cesarean Section?

1) Slow, but progressive labor in the first stage of labor should not be an indication for a C-section. As long as mother and baby are doing well, cervical dilation of 6 cms should be the threshold for active phase of labor.

2) Adverse neonatal outcomes have not been associated with the duration of the second stage of labor (pushing stage). Therefore, at least giving 3 hours of pushing to a first time mother, and minimum 2 hours of pushing to a women with previous children, is recommended. Cochrane database considers spontaneous bearing down as the beginning of second stage of labor. So just using complete dilation as start of second stage is not recommended, and this itself can lead to decreased C-sections for non-progression of second stage of labor.

3) Instrument delivery can reduce the need for Cesarean section. The authors note with concern that many obsetricians do not feel competent using forceps for delivery.

4) Now for some real good observations: Recurrent variable decelerations appear to be a physiologic response to repetitive compressions of the umbilical cord and are not pathologic. The guideline goes on to have some good in-depth discussion about how to monitor fetal heart rate patterns, and what are some of the other solutions available, other than jumping into a C-section for variable decelerations. This in turn has the potential to remarkably reduce Cesarean rates!

5) Induction of labor can increase the risk of a C-section! Induction is not recommended prior to 41 completed weeks, unless there are compelling maternal/fetal indications. Cervical ripening with induction can reduce the need for a C-section. Only after 24 hours of induction with Pitocin/Syntocinon and ruptured membranes can induction be considered as a failure! Obviously this gives so much more time to the laboring mother!

6) Neither chorioamnionitis (infection of the maternal/fetal membranes) nor its duration should be an absolute indication for a C-section. In other words, as long as mother and baby are well, and are being monitored, and other interventions as needed being provided, a C-section can and should be the last option.

7) Late pregnancy ultrasounds is associated with an increase in cesareans with no evidence of neonatal benefit! Macrosomia (a big baby) is not an indication for a C-section.

8) External Cephalic Version for breech presentation, can lower the C-section rate. The recommendation for breech vaginal birth is that the parents should be told of the risks involved (perinatal/neonatal morbidity/mortality), but should be given a choice to birth their baby vaginally, with a good informed consent being provided for the procedure.

9) Outcomes for twin gestations, especially when the first twin is cephalic (head down) are NOT improved by a Cesarean delivery. Hence, the recommendation is that a trial of labor should be given to the mom in this circumstance.

10) Continuous Labor Support is one of the most effective ways to reduce Cesarean rates! The authors note that this resource is probably underused.

As Judith Lothian points out in her article in the Journal of Perinatal Education, “These guidelines offer great promise in lowering the cesarean rate and making labor and birth safer for mothers and babies. They also suggest an emerging respect for and understanding of women’s ability to give birth and a more hands off approach to the management of labor. Women will be allowed to have longer labors. Obstetricians will need to be patient as nature guides the process of birth. Hospitals will have to plan for longer stays in labor and delivery. And women will need to have more confidence in their ability to give birth. Childbirth educators can play a key role here. The prize will be safer birth and healthier mothers and babies.”

All of the above is no surprise to us at Healthy Mother. When mothers are provided with a safe space to birth their babies, when they are supported and monitored in labor, when they have been given adequate antenatal support, advice and preparation, nature has its way of guiding the process of birth. Midwives around the world have low interventions and C-section rates since they respect the woman’s body and the innate intricacy of maternal/fetal hormones that drive labor and birth. It is satisfying to see that these recommendations from ACOG are slowly aligning with good birth practices.

So, how does your hospital and care-provider measure up when it comes to using evidence-based practices in pregnancy, labor and birth? It may be good for you to invest time and energy to find out, so that you can have a safe, healthy and optimal birthing experience!

Bibiography:

http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery

Routine Ultrasounds in Pregnancy: Is there evidence for long term effects on the baby?

ult

Getting an ultrasound during pregnancy is such a routine practice these days. So many mothers in India, start having a first transvaginal ultrasound as early as week 5 or 6, when neural organization is taking place in the baby. Thereafter, most mothers in routine practices, get a quick ultrasound check almost at each antenatal checkup, and then at least one big scan every trimester, if not more!

While we at Healthy Mother, are not against scans, we counsel every mother about the pros and cons of each scan that is available, and let them make an informed decision after they do their due diligence. We believe that while the technology of prenatal ultrasound can be life-saving , as well as aid in clinical decision-making in some instances, especially in women with history of multiple miscarriages, women who have had a baby previously with a congenital defect, etc., overuse of it in otherwise healthy, low-risk women should give us a reason to pause and reevaluate: Is it doing more harm than good?

Here is a small study done as early as 1993 – this was done when scans were not as prevalent and routine as they are now. In this retrospective study of children with speech delay, it was found that they were twice as likely to have been exposed to ultrasound in pregnancy, as compared to babies with normal speech development.

Conclusion from this study? “An association between prenatal ultrasonography exposure and delayed speech was found. If there is no obvious clinical indication for diagnostic in-utero ultrasonography, physicians might be wise to caution their patients about the vulnerability of the fetus to noxious agents.”

Here is the link to the article.