BFB FtF Cycle 2

Why Optimal Birth?

image "Galactic Baby" copyright Cat Fancote - all rights reserved https://birthphotographyperth.com.au/ "Galactic Baby" -award winning image from Cat Fancote - all rights reserved https://birthphotographyperth.com.au/

Over the past few years, there have been times when the debate about childbirth and especially choices about how and where to give birth, have become deeply polarised. As always, the media have been quick to reduce the debate to extremes, pitting dire warnings of “great danger if a baby is born at home” or against midwivesd "obsessed with natural birth at any price".

While these extreme views may exist among birth practitioners they are uncommon. Any birth practitioner not blindly wedded to the guidelines will acknowledge there is much about the status quo in many obstetric units that work actively against "a good birth". It’s also recognised that challenging institutional drivers of practices can be very difficult, even those with little or no evidence to support them. Medical intervention has a place and can save lives but it is quite clear that many interventions are used inappropriately, are often ineffective and are, at times, harmful. This is particularly relevant to the current solutions offered when a labour dystocia is identified. Despite being one of the leading reasons for a multitude of interventions and the main indication for caesarean birth, there is not only no consensus on the interpretation of labour dystocia, basically it means difficult or obstructed labour, but there is no consensus on optimal solutions.

As a midwife my role is to help women have the best birth possible and to ensure they leave our care intact, whole and unharmed, ready for the next part of their journey into motherhood. The question that drove my practice in the birth room was how can I support and optimise the birth process. To do that I needed to develop a deeper understanding of birth physiology. Physiologically informed practice is my passion, and the reason I came to find out about about biomechanics, the study of human movement. The baby's path through the pelvis is amazing and it is insufficiently studied in obstetric and midwifery training. We learn from a pathological framework and don't have enough information to understand the reasons behind mechanical dystocia. In turn, this impedes our ability to recognise the signs before a dystotcia becomes a crisis and impedes our ability to offer physiologically informed solutions.

After years of self directed study, courses and training, putting it into practice and seeing results I started teaching. By asking the right questions I can now recognise signs of a mechanical dystocia over the phone. We all have this knowledge and ability, the solutions are not diificult and they are not harmful. I'm eager to share because it makes a difference!

It was already clear before the pandemic that interest in biomechanics was increasing and my life was going to be filled with teaching, I was and still am delighted! I was spending half my life on planes and trains travelling to hospitals as far apart as Chile and Oban and it looked like I was in for a busy year.

Covid brought everything to a crushing halt - but only for a little while. It forced the development of an online presence - and broke resistance to distant learning. It's changed "everything". I'm talking to and teaching birthworkers around the world, have a 4000 strong social facebook group that's a lively and supportive forum for physiological birth, working with midwifery lecturers to help bring biomechanics into midwifery degree courses. I said I wanted optimal birth to change the conversation about childbirth - it's a thrilling ride and the enthusiasm and positivity I'm getting with every course I teach is more than empowering. Can't wait to see what happens next!

Module 2.1 - Using the Rebozo

The Rebozo is a scarf that originates from Mexico. It is used in various ways in everyday life and women and midwives use it as an essential tool during pregnancy, labour and after the birth. It is specially woven fabric that offers a little elasticity or stretchiness so it can easily hug the body and abdomen. While some of the rebozos have beautiful patterns please be aware that the open weave rebozos are easier to handle if using them for abdominal sifting (massage). Otherwise any scarf with similar dimensions and elasticity will work. Doesn’t everyone have a pashmina in the back of their wardrobe!?

"Sifting" demonstrates how the rebozo can be used for gentle uterine massage. Gentle is the key word. Use a gentle rhythmic motion, can be fast or slow depending on individual preference. "Shaking the Apple Tree" massages thighs and buttocks helping to releive tension in the pelvis. Remember, be guided by the woman if they don’t like it or if it causes discomfort stop!*

In pregnancy a rebozo can be used daily with the cooperation of a partner. It can soften the broad ligament and increases the likelihood of successful optimal positioning of the baby. It is particularly useful before using other positions to help balance the pelvis. In early labour and the first stage the rebozo provides comfort and promotes relaxation by stimulating the parasympathetic nervous system. Sift in between contractions. Can be used without restriction.

*Dog warning - Labradoodles are not essential for rebozo use - but they do cause a lot of laughter when they walk into the improvised studio and lick the model's ear

Caution: if the placenta is anterior, be gentle with no jerky movements. Please avoid if there is a history of bleeding in pregnancy. A one off incident in early pregnancy is not a contraindication but using with persistent bleeding in pregnancy is not advised

Find out more about rebozos and their use in labour in this article describing its culture, use and background. Sophie Messager has an online shop where she sells ethically and sustainably produced rebozos

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Hip Squeeze

Words on their way but Molly explains it all in the video

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Sidelying release

This is a position that is used during pregnancy once or twice a week to improve and maintain pelvic balance and stability and is also one of the most effective postions to use during the birthing process. I’ve used it for years in my work as a midwife. It is not guaranteed to resolve a problem caused by a biomechanical issue but I’ve found it to be over 90% effective and feedback from midwives using the position report similar results - it's always worth a try - even on the way to theatre! Using it helps stretch the muscles and ligaments attached to the sacrum and cross over or through the hip to the leg, giving the baby a little more space to get into an optimal position.

Key points about SLR

This position requires the user to be close to the edge of the bed or sofa so the leg can hang freely. Make sure they are safe - arrange furniture to hold on to or have partner assist.

Sidelying release can be used at any point in labour, early or active, where malposition is suspected or if you’re experiencing a lot of sharp pain above the pubic area, backache, or if labour is lasting a very long time. Use the position for 5-10 minutes each side or for three contractions. It is suitable to use with an with an epidural.
Repeat the position every 4 hours if necessary.
It’s very effective in the pushing (2nd) stage when there is slow progress despite good pushing effort or contractions space out.
It’s advisable to mobilise for several minutes following Sidelying Release, Always work both sides.
Some users report hip stretch whilst practising the position - some don’t or feel it or feel it in one hip only - it is still effective.
If the user feels pain or discomfort under the bump or down the side or back of the legs it means the stretch is not happening in the right place - a minor readjustment of position will usually resolve this.

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Forward Leaning Inversion

This position requires a chair, bed or sofa to create a platform no higher than just above the users knee. The user should carefully and slowly lower themselves from a kneeling position onto their hands. The elbows should be bent to form a tripod, that's to say, with hands close to each other and elbows pointing away with the head hanging freely with chin slightly tucked into the chest. The head should not touch the floor. Encourage the user to breathe and relax for 30 seconds then slowly and gently ease themsleves self back into an upright kneeling position. A small table or step can be used to help return to an upright position without struggling. After this postion some people will feel a little lightheaded after using this position so guard them in the upright postion and encourage to take another couple of breaths and wait for any dizziness to pass.

This position can be used once a day during pregnancy and anytime in labour if the baby’ is thought to be in a suboptimal position. In labour it’s helpful to do the position twice in a row then walk around the room. Take note if the user reports any changes in how the contractions feel. Use in between contractions. If there is a contraction whilst in the forward leaning inversion, it’s safe to stay there and wait till it passes before moving.

Forward leaning inversion is a useful technique but special attention must be paid to the safety of users - making sure they are supported as they lean into the postion - falling is a risk - and when they come into the upright position in case of dizzyness.

Check that the user has none of the following conditions:

High blood pressure, glaucoma, polyhydramnios (that’s a lot of extra fluid around the baby) or any medical condition that makes you susceptible to strokes.

These positions and techniques should only be used in labour if sub-optimal position is suspected or diagnosed. With all of the postitions practitioners should be guided by the users comfort - if they are uncomfortable or feeling pain, stop using the position.

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