Friday, February 15, 2013

The Evidence Base

When I speak in Academia I'm asked if my approach is evidence based. Its funny because first I'm invited. The nurses, like a nurse named Nancy,  tell me how excited they are that I'm coming. They share their goals for integrating the approach into the hospital and share their dreams of spreading the solutions to obstructed labor which they are experiencing themselves with the help of my Spinning Babies approach. We set a date for me to come out and talk with the staff, offer a workshop, start applying for the CEUs needed by their particular group of nurses and then, a month or two into planning, even weeks before arrival, Nancy, or Christine, or another nurse calls me back, and sheepishly explains, So-and-so saw that you were a homebirth midwife and wants the references for the studies that support your claims and techniques. Can you prove that these work.

So-and-so means prove it on paper, S/he doesn't mean with a pregnant woman in labor.

I could say, oh yes, I have three pages of references and more except I don't like participants to have to shuffle through more than 3 pages of citings for a 7 hour workshop. Some of them are even within the 4 year publishing requirement.

But seriously, co-madres, I would need about 28 studies all done in the last 4 years to satisfy the Ivory Tower Docs in New England. And which universities today are working that hard to research the reduction of cesaresan due to breech, posterior, oblique lie, transverse lie, transverse arrest, brow, face, deflexed and asynclitic fetal positions and presentations?

Baby won't come out? Chop her.

Wait, you mean, give her more time? Labor room hours are expensive. Chop her.

She doesn't want a cesarean? Scare her.

If she is in labor, tell her that her baby could die, but if she is still pregnant, tell her she'll wet her pants.

Evidence based studies show that vaginal birth isn't significantly worse for bladder incontenence than cesarean surgery six months out from birth, but yet, Professor Philip Steer steered his Obstetrical students and followers to drop the bladder bomb on pregnant women to manipulate them into asking for an elective cesarean in his Editorial, Caesarean section: an evolving procedure?. He reassures OBs that the mother he is conning will not likely have heard of a neighbor who died from complications of a cesarean but she'll likely know an older woman who leaks in her pants occasionally.

BJOG: An International Journal of Obstetrics & Gynaecology
Volume 105, Issue 10, pages 1052–1055, October 1998

Within two years of his article women were telling me they were choosing cesareans because they didn't want to wet their pants. How's that working now? See the studies that show little difference after 6 months and no difference after age 50. (Bridge pose, baby. And pelvic floor balancing.)

Please stop thinking I'm a fanatic, which you might about now. Cesareans can be life savers. I KNOW that! But when the rate goes up from 5% to 35% and more in 4 decades and evidence based studies show 10% is ideal and over 15% unjustifiable and yet we have this kind of pro-chop publicity in our prenatal exam rooms,

How can we all stand in the choir and sing, Evidence Care Come Be My Savior?

Right now we are short of new evidence on Shoulder Dystocia techniques, with the glorious exception of two articles in 2011 by Leung, and Hoffman. I love those guys for their proof that bringing out the posterior shoulders is the most successful technique. I've been using the steps towards bringing out the posterior arm as the basis of my Resolving Shoulder Dystocia class, though when you do my first three steps, you rarely have to bring out the posterior arm.

In 2004 when I began teaching midwives how we can systematically resolve shoulder dystocia in the active, mobile woman, I wasn't about to wait for those studies.
Now, many of the new studies look at models and pressures, and at success of drill trainings. Not many in recent years, other than Hoffman and Leung, are giving practical solutions applicable to us in the field. 

Several techniques in my presentation have not been studied. The goal of my class is not success in the culture of academia (state clearly the rates, references, and protocols) but in the birth room (where is that arm, why doesn't it match the text book description, and what can be done about it?).
  Yes, I cite several studies where they exist. I'm not against studies, I just realize studies continue on what is being done. Trying to study something that isn't being done in the obstetrical system already is sorta like asking Americans to be bilingual. We don't want to, English is fine. 
My husband, Vic Froehlich, worked 40 some years creating new stuff with a team of innovative geniuses that didn't exist in the computer engineering world. I can't tell you what, but it wasn't a weapon. That I know. He told me this, 

I know from my experience, is that what everybody knew was not solving the problem. All they know is what they learn in school. 
They don't how to solve the problem, they know a procedure.  
We had to make up new stuff. 
And the evidence for that is that the problem got solved. 
Vic Froehlich
Super Computer Engineer and Programmer

Ok, after this rant, I came across, quite serendipitiously Rebecca L. Dekker, PhD, RN, APRN is an Assistant Professor of Nursing
Blog, Evidence Based Birth.
I'm chuckling here because if we had evidence based birth in this country we would have a cesarean rate under 15%, breech babies being born vaginally, and a doula in every birth room.

But Rebecca does a really fine job on her blog and I took her survey. Take her survey on how you use evidence base research article in social networking media. When I took it, I realized that I really do like to have evidence based articles to share and discuss. I do respect those articles to present "Facts" rather than an article promoting "Facts" without citings.
While I feel the same that control studies are too limited to study the complexity of birth and this is why I don't derive satisfaction among existing evidence based studies on maternal positioning to support the Spinning Babies approach. I could pick a technique (other than pelvic tilts, please!!!) but when we show the improvement due to Balance, the Number One Principle of Spinning Babies, we are limited to the general use of one technique to all women regardless of history, torsion, or laxity.

Ken Johnson wrote a chapter for Robbie Davis Floyd on the problem of trying to isolate variables within a complex physiological process in Authoritative Knowledge in Childbirth. See Understanding Birth Better.  Here's the citation.

Johnson KC. Randomized Controlled Trials as Authoritative Knowledge: Keeping an Ally From Becoming A Threat to North American Midwifery Practice - book chapter, Davis Floyd, R (ed)) Authoritative Knowledge In Childbirth - University of California Press, 1997.

Still, I'd like to see the Sidelying Release studied. 

Thursday, February 14, 2013

VBAC Support Valentine's Day 2013

NEEDS EDITING From a Pregnant Woman hoping for VBAC

I am 37 years old and am about to give birth for the second time (I'm at 39 weeks, 2 days).  Thank you so much for your website because I have been reading it and practicing your techniques for optimum baby positioning throughout my pregnancy.  And it has worked!  My baby is in the LOA position, looking directly at my right hip!!!  And I think that is due to all my hard work.  But I just found out at my scan yesterday that the baby's chin is not tucked and that has worried me.  (Also, I have an anterior placenta, located to the right of my belly button.)

I am 5 ft, 1" and I have mild scoliosis, which tilts my hips, maybe an inch to the right.  I had a lot of back pain first time around so I have been going to a Chiropractor since around 20 weeks, so everything should be as aligned as it can be.  I have also had 3 sessions of reflexology over the last 3 weeks.  I wish I had known about your website in my first pregnancy because my daughter was in a posterior position and didn't have her chin tucked, because of this she never engaged and I didn't go into labour.  At 10 days overdue I was taken into hospital and given induction gels, it took three days of this for me to go into labour and get to 2.5 cm.  But the labour waned even after breaking my waters and I was put on a sintocin drip.  After two hours on this I needed an epidural because we could tell things were going to be slow.  About 10 hours later I was fully dilated and started pushing.  I was not able to push her out, even with ventose and we were sent for an emergency section.  I should also say that all the women, my mother and 2 sisters, never have their babies before their due date.  We have all gone overdue and mostly have induced labours.  I am the first though to have a section. 

So, my plan this time around was to try my hardest to avoid another section and give birth naturally.  A lot of people don't understand but I want to experience natural childbirth, not in a operating [room] where you barely get to hold your baby afterwards!  I am a bit disheartened by the news I got yesterday because I thought the baby was in a really good position.  Since I got home from my scan, I have only been sitting on my birthing ball, doing vigorous hula hooping motions on it (I'd say the neighbors are finding it very entertaining!).  Last night with the help of my husband I did an inversion for 30 sec, Abdominal release, pelvic tilts and lots of sitting on my ball.  So, my question is, and I'm sorry its taken me so long to get to it but I just wanted to make sure you have all the information, is there anything else you can think of that might help tuck this little rascals chin in?  It has been difficult to get the doctors to let me go overdue, they wanted to schedule me for a section at 39 weeks, but I've managed to get them to let me go to term +7 days, then I'll have a scan and if things haven't changed probably a repeat section.  So I have about 11-12 days to work on it!

Thanks so much for reading all this and for any help you can give.  Let me know if you need any more information.
Gail Tully 

Dear VBAC Mama,
Hi, How do you feel after trying the inversion? 

Can you repeat it 1-2x a day since you have less than 2 weeks left? 
You are just beginning the exercises on my site. Think of them as play and a way to meet the many muscles of your body. Also, not on my site, lift your arms and release your upper body, making more room there for your ribs to expand and baby to come down later by helping those muscles that start high but reach low.

Please try the sidelying release also, its fantastic for most people, do it on both sides with a helper, and you can do it daily.

Please stretch your legs in deep lunges to help your psoas and alternately, squats for your legs. Look up hip openers on the internet and get going on hip flexibility. 

Belly dancing movements and swishing your hips during pelvic tilts and while standing. 
Try going the other way with those hula hoop moves on your birth ball! 

Please see a professional myofascial person for additional pelvic alignment AND myofascial release.The chiropractor is great, necessary, but Chiropractors vary so extremely that I have no idea if you are getting the care you need for your situation. See professional help in my website for a list of what the chiropractor might add to your care.

 Eat whole foods with little grain and milk, lots of dark leafy greens and smart fats, with salt to taste, and no "bad" fats. Smart fats are butter, avocados, cold pressed fish oils (Nordic Naturals are suggested or Spectrum --some conscientious brand) olive oil and coconut oil (extra virgin).
Borage oil is excellent to help hormonal function. You are doing everything well. These are additional supports for a great routine. 

Term + 7 is Excellent! I'm impressed! Most women will start labor then, and if you do just start contractions, please consider giving yourself a day
to get active labor going. That said, even a little labor before a cesarean is beneficial to a healthy mom and baby. 

Give yourself the opportunity to come into as much balance as you can.  
Repeat the forward-leaning inversion in early labor through a couple contractions and between them. 
Repeat the sidelying release through a couple contractions ON EACH SIDE and between them. Follow the directions posted on my website excellently.

There are tricks in labor 
Inlet, or "baby's high," -3 station 
 In the presence of regular contractions,
Open your brim with the Abdominal Lift and Tuck during 10 contractions (but not between). 
And if baby remains high, Walcher's (during and between 3 contractions.

Midpelvis, or '0" station
Lunges for more room 
Put your longer leg up on a stool during contractions with your foot and knee pointing towards your side for lunges through contractions (but not in-between) and open up that side of your pelvis and pelvic floor.

Outlet,  "+2" station
Sidelying release works at all stations (all 3 levels) so do myofascial releases preventively as soon as contractions are regular enough to do it during 3 contractions on each side.

I have so much to say I should get off the email and write the ____ book!
Let's see if we can find what your pelvis needs. The soft tissue body work will open your muscles and let your pelvic diameters expand.

Please keep in touch as I would like to learn from your situation.

Much love and support for your VBAC!

Taking calls for breech

The phone is ringing today. Four calls about breech births. The first was a doctor friend who heard a rumor of a bad outcome to a homebirth baby. Did an inexperienced midwife go too far? A Pediatrician told her the baby left NICU with "neurological problems that would last their whole life." Noting the time frame, I realized the midwife in this story was me. Due to premature separation of the placenta the baby had a hard start, spending a few difficult days in NICU. However, he went home 100% -without any detectable problem.

I put in the next call to double check on this baby, in case something came up in the last couple of months which I didn't hear about. Baby is doing great, a happy camper - cooing, drooling and smiling appropriately for the age. He's on track with mental and physical health and milestones tested regularly with current infant developmental measurements as part of a community program the family takes advantage of.

We know from Hannah, PREMODA, and other studies that professional third-party observers can not find increased harm or development delays to breechlings born two years earlier. While a baby in either the cesarean born group or the vaginally born group may sustain injuries or even death, how often this happens doesn't favor one method of birth over another. Other things, like gut flora, make vaginal birth preferable for those babies and mothers that don't have a medical reason to go cesarean.

Hard starts happen. Hard endings are harder.

The next set of calls connected me to a far away care provider whose working with a family whose baby isn't expected to live many days after birth due to an anomaly incompatible with life off the umbilical cord. So sad. The parents would like to avoid separation at birth so they can hold and be with their child every minute possible. The OBs want a vaginal delivery with extraction and forceps and the Family Practice Doc would like a more gentle, physiological breech birth. The OBs rule, though, UNLESS the mother exercises her informed dissent.

Avoiding a cesarean or forceps breech birth is likely to offer a comparitively better quality of life for this child, as short as it may be. There is interest in physiological breech birth on mother's hands and knees to reduce the need for complete or partial breech extraction. Perhaps my words will impart some trust and calm for this care provider so he can meet the needs of this family. If he calls.
In my opinion, this mother will be "allowed" to avoid the risks of cesarean to her because the hospital staff are less afraid of causing death or injury to a child who will, sadly, start dying after birth from natural causes.

Cesarean is associated with a broad set of side effects that the baby and mother will experience. Vaginal breech birth may cause a certain set of side effects that the baby may experience if born vaginally. Its the choice between may and will. We think the side effects of the cesarean end with discomfort and long recovery time compared to vaginal birth. Most side effects of either type are not severe, except, we are discovering, the reduction of beneficial probiotics due to cesarean delivery could cause lifelong immune compromise. Rare side effects of cesarean are severe, chance of death of the mother then or later, and chance of death of a subsequent fetus is higher. Due to the increasing cesarean rates, we also have increasing deaths. Women have the difficult choice of choosing one set of risks over another, but there is no option to choose No risk over some risk. Both ways carry risk.

The fifth call came from across the country from a midwife I adore whose been working with a first-time mother carrying breech. She'd introduced the mother to Obstetricians who had given her an MRI and were willing to help her with a vaginal breech delivery in the hospital -if one of them were on-call and available when she went into labor. They planned to do a partial breech extraction and then show the residents how to apply piper forceps to baby's head during her birth--A standard American Breech Delivery in a teaching hospital. The mom chose to exercise informed refusal and went back to the midwife and asked for help with a home breech birth. The midwife called to chat about it. She's got a breech experienced midwife coming to join her birth team, but just wanted to discuss some things with me.

Being a practical person, I asked a few questions and presented my point of view.
I like to know

  • Mom's determination level is high
  • Baby's approximated size in relation to mom is a fit
  • Baby's favoring the mother's right, even  RSP is reassuring as a starting position 
  • Hands and knees and air birth are preferred for the early breech experiences of no or low- experience midwives - even though an experienced midwife is attending (which is so highly recommended as to be mandatory if such a midwife lives in your 100 mile radius).
  • Frequent monitoring, as much with a fetoscope as possible to keep doppler to minimum because the side effect of secondary noise tends to cause the "Ultrasound wave" which means an arm could possibly be swept up, Jane Evans' observation) but monitor with doppler if fht can't be tracked with fetoscope due to midwives's lack of skill or dense muscles of abdomen or uterus, maternal fat, or placenta blocking the subtle sounds of fht. I'm getting into too many details...)
  • No touching, not the mom or baby unless baby needs help due to stuck arms or head
  • No breech extraction or partial extraction (increases chance of needing resuscitation)
  • Which means, no reaching up and pulling down a leg, etc.
  • Stalls in active labor or second stage (beyond an hour or two) = transport. Yes, even if that means a cesarean. 
  • Internal exams optional, but recommended when there is time, a check upon arrival, if labor seems slow, to assess complete dilation or if labor sounds and progress don't match, or transport is being considered.

And more details were discussed about freeing breeches who get their arms or head stuck, poor little dears.

I hold the families and midwives in my heart and mind every day. Most women accept the current recommendation to have a cesarean surgery to deliver their breech baby. They want what is safest for their child's birth. Few physicians, or even midwives, today will tell the woman that there are risks to both cesarean and vaginal breech birth. But this information can be found from reliable sources, such as the Society of Obstetricians and Gynaecologists of Canada.

Should women choose the set of risks for vaginal breech birth or vaginal breech delivery (partial extraction) ? That is an individual decision based on her body and her baby and the people and resources she has around her. Some women will travel to where a skilled provider is willing to care for her during her birth. We have so much more to discuss on this.

Midwifery Today will carry the discussion in their upcoming breech issue of Midwifery Today Magazine. Sit loose, its coming!

Tuesday, February 12, 2013

Can breech twins be helped to flip head down?

Please do not post in your site or online. NO permission to take and reproduce.
Resolution of a Twin Breech Presentation with the Application of Webster and Diversified Chiropractic Technique

A case study of a mama with breech twins. Read the article at 

Journal of Pediatric, Maternal & Family Health


Danita Thomas Heagy, D.C.Bio & Shawn Wrubel, D.C. Bio 

Journal of Pediatric, Maternal & Family Health - Chiropractic ~ Volume 2012 ~ Issue 4 ~ Pages 118-121 

Clinical Features: A 28 year old pregnant patient of twins presented to the chiropractor with a diagnosis of a breech presentation by her obstetrician at 30 weeks gestation. 

Intervention and Outcome: Over a nine-day period of time the patient was analyzed and adjusted according to her findings.  Both Gonstead and Webster analysis were utilized during each appointment.  After the patient underwent five adjustments over three weeks her obstetrician confirmed that the involved twin was in cephalic lie.

Its lovely to see this article from the Chiropractic Community. Thanks, Dr. Danita, for taking the time to share your experience! A lot of mamas are going to appreciate this approach. I'm glad this Mom had her twins naturally! (Not the twins in the photo, that was another mama who had her twins naturally.)

Changing the Earth by supporting Birth

Mothers bring forth life; medical corporations do not. Birth can be simple, powerful and loving. Fetal positioning, natural birthing and practical help for normal birth.