Mothering Forum banner
1 - 14 of 14 Posts

·
Registered
Joined
·
7,165 Posts
Discussion Starter · #1 ·
I was just reading in the latest Midwifery Today about different approaches to managing transition and 2nd stage. A lot of midwives (including homebirth midwives) seem to favor having their clients in a reclining position, and doing perineal massage/support. Neither makes logical sense to me.<br><br>
Of course we know that a reclining position is pretty unoptimal for pushing a baby out, but midwives still deliver babies in this position. A friend of mine quoted a midwife as saying, "but what do you do if the mother <i>wants</i> to lie down to push?" What I want to know is, how often does a non-directed mother actually <i>choose</i> this? Of what I know of truly unhindered, non-guided births, this just does not happen -- when it is time, the mother instinctively gets into an upright position, usually rocking back and forth on hands and knees or just hunched over, and then straigtening up on her knees as the baby starts to come.<br><br>
As for perineal massage, I don't know whether you can actually make a difference in the suppleness and stretch of the tissue by putting pressure on it; I personally am skeptical about this. But that isn't what I think is the biggest issue. What I really want to address is the fact that women tense up when their genitals are touched, if they are not in an intimate situation of arousal (as with a lover.) This seems like it would be extremely counterproductive in birth, but it is never mentioned when the subject of perineal massage comes up.<br><br>
So -- what do you midwives think?
 

·
Registered
Joined
·
7,527 Posts
because I have already had this discussion with you personally, I think you won't be surprised by what I believe. Here is something that I wrote in my journal:<br><br><i>After some discussion with my highly intuitive, wise mama friends about birth this afternoon, I brought out the latest Midwifery Today issue, which is all about Preventing Tears.<br><br><b>One midwife asks the question: who or what are we protecting the perineum FROM?</b><br><br>
Good question. Are we really so sure that we prevent tears? According to many of the midwives in the MT issue, it's all about slow delivery of the head (getting the mother to slow down or controlling it with counterpressure) or some various hand positions. While I can see these viewpoints, I beg to take a different stance...<br><br>
What if I told you that I could do very, very little to prevent a tear on a client -<br><br>
whereas,<br><br>
I could do alot to create a tear on a client?<br><br>
Would you think that was accurate? All the warm olive oil, perineal stretching and pulling and hand positions cannot really prevent tears. There are many reasons I believe this:<br><br><br><b>Tissue Integrity</b> Every woman has different tissue and skin integrity. This is evidenced by the color of our skin, the amount of stretch marks we find on our bodies, and our nutrition. Supplements like Vitamin C and omega fatty acids will help assist this integrity, but it's unknown if it can make a huge difference. Women that smoke typically have less tissue integrity, although it's hard to find direct relationships with this - more anecdotal knowledge between midwives.<br><br><b>Position of pushing and delivery</b> We talk alot about upright delivery, but very people - even homebirth midwives - will really see it happen much. Why is this so? If left to her own devices, women will rarely lie down to push her baby out. Wouldn't it be harder to poo lying on a bedpan than sitting up on a bedpan? If nothing is said, women will stand and often lean forward. Sometimes, they get on their knees.<br><br>
If a midwife lies out a chux pad on the bed, there is an unspoken "sit here" expectation - and due to the conditioning in our culture, many women will follow the placement of the chux by the "professional" and reside wherever it is placed - even if there is no spoken direction by the provider.<br><br>
It's important that we look at how we support women during pushing. Do we find ways to support their instinctive behaviors or are we telling them that they "should lie here" or "should sit here on this birth chair"....<br><br>
Being upright means that women are able to reach their perineum and vaginal tissues much more easily than if they were lying down or in a "semi-sit" position.<br><br>
While we may look at the semi-sit or semi-reclining position much more "advanced" for pushing than lying flat on the back, think about this:<br><br>
In a semi-sit or semi-reclining position, there is alot of weight on the sacrum. This weight decreases the pelvic outlet. There is more force needed to get the baby down and especially under the pubic bone.<br><br>
When a woman is on her back, with her legs pulled back towards her, her sacrum is rounded up (which isn't the greatest position, considering the curve of the sacrum or not using gravity's benefits) - and there is no weight on the tailbone. It can move easily to accomodate the baby's head.<br><br>
Standing, supported squat, kneeling, hands & knees and bending over standing are all incredible positions for birth. Most women, if left to their own devices, will birth in one of these positions. Perhaps we need to think about why we don't encourage it more often - usually it's the belief that we, as midwives, need to get in there and "support the tissues"...how about supporting the woman in supporting her own and letting her be? Is what we're doing "down there" causing more trauma or is it helping?<br><br><b>How Women Push</b> - This sounds basic, but it must be hard to understand because many women are offered a scenario far different from instinct or listening to their bodies.<br><br>
I have found that when a woman is at 8 or 9cm, there are small grunts of pushes at the peak of contractions. I think these are totally involuntary - many women do not realize they are doing this at all - and actually help with the last couple centimeters of dilation.<br><br>
The most disruptive thing a provider can do at this point is to ask her, "were you pushing? did you feel pushy? wait - don't push...let me check you first to see if you're READY..." Of course she's not ready - she's not REALLY doing that full-baby-on-the-pelvic-floor type pushing. She's got a couple centimeters to go, but she's close. So, the provider will tell her that NO, she's NOT READY and DON'T[listen to your body] push. Not yet.<br><br>
She's in her head now about her labor, no longer trusting her body. Body = wrong. Fingers = right.<br><br>
She continues to look to the provider for direction now. Nothing she feels or knows is true. The birth no longer belongs to the mother and the wisdom of her body.<br><br>
Then again, if she IS ten centimeters, then there's cheerleading for pushing: counting to ten, holding the breath - "quick! another breath quickly, then push, push, pushpushPUSHPUSHPUSH!!!" with every contraction, whether or not the mother feels the urge to push. It's okay to wait - to sleep, to rest, to take a shower, to eat while waiting for an urge to push. Breathe through the contractions and relax, the mother can let her uterus do the hard work of bringing the baby down far enough on the pelvic floor before she gets those strong urges to push. A woman's uterus can push a baby out without her help - it's not a race.<br><br><b>Fingers in the Vagina</b> - Do you know that your vagina has a built-in protective mechanism? We experience it when we are getting a pelvic exam - fingers placed right outside the vagina or right inside the vagina will result in a contraction of your vaginal muscles. Women are often told, "just relax" at this point. This response to such touch is NORMAL and POSITIVE.<br><br>
We may love our midwife or doctor that is performing the exam. They may be a classmate, friend, or trusted provider. It doesn't matter - their fingers are not your fingers. They are not the fingers of your lover. Your body is so wise that it will offer some resistance for touch that is not sensual and/or our own.<br><br>
What happens when we, as midwives, put our fingers inside the vagina as the baby is trying to emerge? Isn't it hard for women to concentrate on pushing something OUT of their bodies when we're putting things IN? Are we helping women by dragging down on the perineum? By "pushing" tissue away as the head descends? Is the woman's vagina instinctively trying to protect her during all this? How does it feel to the mother?<br><br>
When women place their own hands on their vagina, they explore. They touch all the folds, gently inserting a finger inside to see if they can feel that hard little head that they're working on bringing down. With every push, they can experience the "one step forward, two steps back" motion as the baby comes down. Many women are physically unable to feel the baby's head inside until it really comes down. Still, when it's getting ready to emerge under the pubic bone, women will instinctively put their hands down there, feeling as if the head is "right there".<br><br>
(Fathers hands on the baby as it is emerging is far less invasive to women...they do not need to know anything except not to push or pull on the baby - just wait for the baby to slip into their hands. The same could be said for midwives, as well! The pulling up on the head, the pushing down as the body emerges - all not necessary in normal birth.)<br><br>
With the crowning, keeping the mother's hands on herself is important. She will gently push around her perineal tissues, knowing how much is too much pressure, feeling how each of her pushes brings her baby closer to her arms. She may apply counterpressure up by her clitoris - usually with counterpressure at the occiput.<br><br>
If the mother is standing, she will be leaning more forward, typically. If she is on hands and knees, she will want to rise to being upright on her knees. This alignment of her body with the baby's body is amazing to watch and oftentimes will occur with the birth of the head.<br><br><br></i><br><br>
~*~*~*~*~<br><br>
It's hard for me to think that I am so passionate about this - and yet feel insecure about sharing it with many other midwives. I am still a new midwife (in my third year as primary, second year of my practice), and feel that they will think I am a know-it-all. These are the things that I have seen from watching women birth without direction from me or anyone else, words from the women who have birthed unassisted (thank you so much for being my real teachers!!), and the logic of anatomy and physiology - as well as the sacred wisdom of our bodies and babies.
 

·
Registered
Joined
·
409 Posts
All I know <b>pamamidwife</b> is that I am going to save up lots of money and move to Oregon to have my next baby. With you around I think I'd be so relaxed I could projectile the baby out.<br>
You help everyone so much. Your posts radiate passion for what you do, and it's contagious and amazing.<br><br>
There needs to be so so many more midwives like you!<br><br>
Sorry to go OT, but I avidly read these boards, and I felt so inspired by <b>pamamidwife</b> to say something, anything!
 

·
Registered
Joined
·
1,331 Posts
WOW. I read this post with interest (I am due to have my 3rd baby, first homebirth with a LPM ANYDAY NOW) and I am going to take this information to heart. I am going to discuss this with her and how she handles this stage. I think I will try to hold off having her come until I am well into this stage, but who knows, it's my 3rd and it may be really quick! Anyway, great post, you are really passionate and I wish you lived here in South Carolina!!!
 

·
Registered
Joined
·
7,527 Posts
<div style="margin:20px;margin-top:5px;">
<div class="smallfont" style="margin-bottom:2px;">Quote:</div>
<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;"><i>Originally posted by seven_lux</i><br><b>All I know pamamidwife is that I am going to save up lots of money and move to Oregon to have my next baby.</b></td>
</tr></table></div>
<br>
Thank you so much! I didn't want to take over this post, and I still hope that other midwives will respond with their thoughts and feelings - even if they are in disagreement with what I wrote.<br><br>
Seven_lux, don't come to Oregon, I'll come down to Oz! <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/smile.gif" style="border:0px solid;" title="smile"> Fun!
 

·
Registered
Joined
·
392 Posts
I don't manage any part of labor, the mom does that. my clients deliver in whatever position or place that they want. i've had to configure my body into some weird positions before to catch babies & i prefer that the father of the baby/partner of the mom catch the baby.karen valcoiurt of BirthTender in the foothills of the NC Mtns.
 

·
Registered
Joined
·
1,511 Posts
"With the crowning, keeping the mother's hands on herself is important. She will gently push around her perineal tissues, knowing how much is too much pressure, feeling how each of her pushes brings her baby closer to her arms."<br><br>
This is so interesting that you say this b/c I had such an urge to do that with my son and I believe that if I had I would not have torn so badly. Next time around I will feel more comfortable doing so.<br><br>
About the position for birthing, I'm glad to have read this. I labored in the last part of the 1st stage (transition, pushing) on a birthing bar which was so much more comfortable than sitting or lying down. But when it came time for crowning my legs were worn out and the contractions were way too strong to squat anymore so I had dh sit behind me so that I was in a sitting position on a broken down bed (we were in the hospital) and that was so comfortable. However if I could have moved I would have liked to try a side lying position which is probably what I'll do next. Incidentally I think I did rebreak my tailbone during birth. Thanks for the post, very helpful!
 

·
Registered
Joined
·
7,165 Posts
Discussion Starter · #8 ·
Wonderful, Pam! Now if we could just get all the other birth attendants in the world to read it! Now how is it you got to be so smart? <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/orngbiggrin.gif" style="border:0px solid;" title="orange big grin"><img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/love.gif" style="border:0px solid;" title="love"><br><br>
Drewsmom, side lying is definitely better than reclining on your back. But what I want to comment on is not your choice of position but the idea that you can or should plan out what position to give birth in. Sometimes your body really does know better. This last time I had planned on giving birth squatting, but instinctively got into a kneeling position. That was the first time I had chosen my birthing position while *in the middle of giving birth.* And in retrospect I can see that it was by far the best birthing position of any of my births.
 

·
Registered
Joined
·
4,626 Posts
I would have loved to have pushed in other positions, and my midwife asked me if I would (though for the first part of pushing, DS's heartrate would only stay up if I was on my back, slightly on my right side, which also happened to be my bad hip. We had tried hands and knees, upright on my knees, and both sides.) like to. Anyway, by the time DS was doing better and it was safer to move, my hip was so sore and my leg so numb, the only position I wanted was on my back...I just couldn't move any other way. As for the midwife touching to prevent tears, her touching didn't bother me, it was comforting bc I knew she was helping...in fact her mantra of "you're fine, you are not tearing" was IMMENSELY helpful to me, and kept me from holding back. When I guarded bc I felt a tear coming on, she took over for me (I was pretty tired after 1 1/2 hours of intense pushing).<br><br>
However, what pamamidwife said is some very interesting info, and I'm going to copy and paste it into my birth folder here on my pc for future reference and personal reminders when the time for my next one comes!!! <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/smile.gif" style="border:0px solid;" title="smile">
 

·
Registered
Joined
·
4 Posts
I have the hardest time convincing midwives and doctors to leave women alone. I teach seminars on waterbirth throughout the the US and most of the questions that come up are about supporting the perineum during second stage and "delivering" the baby.<br>
"where do I stand?" "how do I reach down?" "what position do I get the mom into?"<br><br>
These are all typical questions. I encourage them to reexamine their practices, especially if they are going to attend waterbirths. In the water the mother can glide to another side of the pool, quickly change positions and get into a place that only she knows is comfortable.<br><br>
I hate seeing waterbirth videos or photos where the mom is in the birth pool and her provider is leaning over the side with the mother's legs supported by a person on either side of the pool and the midwife or doctor is "delivering" the baby. Mother has her chin on her chest and she is pushing until her eyes bulge out.<br><br>
It is a great mistake to think that you can translate a typical hospital bed birth into the bath and have the gorgeous outcome that you see in the waterbirth videos.<br><br>
After attending a few dozen waterbirths, most providers get that you really don't have to do anything to facilitate second stage, except lovingly support the mother and encourage her by touch to feel and touch her own perineum and baby's head. Once that transition happens for the provider, they battle with doing the same for bed births or floor births for that matter. But eventually it happens.<br><br>
I spoke with a physician the other day from Wisconsin who is now assisting more than 50% of her clients to have waterbirths. In a hospital no less. She said she prefers waterbirth because there is so much less to do.<br><br>
My typical response to the question, "how do you determine if it is second stage." is "baby's hair on the perineum."<br><br>
I attended a hospital waterbirth a few weeks ago and found it almost amusing when the nurse looked a bit confused and asked how she should chart when the mother was complete. You see, the midwife didn't do one single vag exam and the mother was on her hands and knees when she started to push. The mother had been pushing for about 10 mintues when the nurse thought about what to put on the chart.<br><br>
The midwife did not say anything to the mother to suggest another position. We all just watched as she pushed and then instinctively reached down between her legs and raised her torso up so that she could lift baby up to her chest. Awesome!!<br><br>
When I was lecturing in Trinidad a few years ago, I heard the midwives say that when it comes to second stage, you simply, "keepa da hands offa da baby."<br>
 

·
Registered
Joined
·
7,527 Posts
Right on, Barbara (and, might I add: I LOVE seeing you here!)!!!<br><br>
Call me lazy, but I don't want to be hanging over the edge of a tub! It seems like with waterbirth, the buoyancy really adds to the feeling of security - and I like to think that it's nice to keep people's hands away from your body! Women seem to naturally reach down more in water and support themselves. It's pretty powerful!
 

·
Registered
Joined
·
392 Posts
to find birth attendants who encourage the mom to listen to herself & get into various positions & open her own tissues (& some women do appreciate the guidance from a midwife at that point), one has to look for other attendants, other than the ones who are easier to find & take the time to really read through their Informed Documents & have a long initial consult & do talk to others who have used that midwife's services. Dont' automatically assume that the midwife/midwives in the area who are able to take insurance & are totally sanctioned by the state nursing boards/AMA are the only ones in the area doing homebirths, as the underground midwives are unable to advertise here in NC or they'll have the nursing board on them. Also, sometimes the attendant who meshes w/ you & your partner the best, may be further away than the more local one/s. Blessings, Karen Valcourt of BirthTender
 

·
Registered
Joined
·
2,027 Posts
pamamidwife I am so encouraged to read your post. Thank you for sharing your observations with us. I am printing them out to keep in my folder for classes on breastfeeding and childbirth education.<br><br>
I have been fortunate to have had a wonderful midwife myself that kept her hands off, allowing me to birth intuitively. In our area we have had several wonderful midwives that have been excellent examples of this model of midwifery.<br><br>
It is difficult for those in the medical community to make this kind of leap, as so much of their training is in "managing the labor and delivery." I find that even in homebirths midwives that have had a lot of medical training are the ones that can't seem to keep their hands off and let the woman "birth" herself.
 

·
Registered
Joined
·
1,524 Posts
I love reading the collective wisdom found here. Just briefly may I intorduce my history? My first baby was induced; I was pretty naive and thought I knew a lot, but really didn't. Luckily I did not end up with a c-section, but I did get a lovely 4th degree tear and a nasty episiotomy, after three hours of pushing. Of course I was on my back the whole time. I managed to do all of that without pain meds like I wanted, but the whole thing was a nightmare. The thing I want to share is that I felt such an urge to push -- it was totally encompassing every fiber of my being. And once I was able to honor that and push, boy my day got better! My son was 9 pounds, 8 ounces.<br><br>
When I got pregnant again I decided I wanted the loving care midwives would provide. My midwives were awesome! I planned another hospital birth, but we were in another city where the hospital was a lot more baby-friendly than the big city where my first was born. I knew if another practioner offered to induce me I would most likely say yes; my midwives do not present that as an option until the mom is at least two weeks over, unless there is something going on which truly is of medical importance. I waited to go into labor, which was so hard! Six days overdue I had my first "different" contraction -- it was 10:30 at night. Around midnight we went to the hospital. I was able to labor in a jacuzzi tub, but I could not sit like one would normally sit in a tub -- I had to be on my side. I just went with it, feeling if my body was telling me a position was not comfortable I must not need to be in that position. When I got out of the tub I had the lowered expectation of *maybe* being at a 6 (I had been at 4.5 before). When I was checked again I was at 9.5. I laod on the bed on my side -- I could not sit upright in any way, shape, or form -- it hurt my abdomen terribly. I even asked for an ice pack for my stomach! My nurse smiled and said, "That's a first," but she got it for me. I did some really low vocalizations for about an hour, on my side and sometimes on all fours. I never got the urge to push -- never. I finally got tired of nothing happening, so after about 2 hours of being at 10 my midwife asked if I wanted to try a push and I decided I did -- nothing else was going on! I was so throw by how I felt, but it hurt like nothing else every time I pushed. I was very thrown off because with my first the pushing brought such relief! The only thing that helped was my midwife placing her fingers in me so I could push against them.<br><br>
After 1.5 hours of pushing he finally emerged! He was only 9 pounds 9 ounces, but he was posterior. The weird thing was I never had any back labor -- it all hurt in my stomach? Sorry for the tangent, but I was wondering how you felt about that? Perhaps if I waited long enough I would have had the urge to push, but I was in such pain I felt I could not wait any longer. What would you think in a situation like that? What would you recommend for the mom? Incidentally he was born with me in a side-lying modified squat -- I could do nothing that would put me in any kind of upright position, including standing or squatting.
 
1 - 14 of 14 Posts
Top