Yoga-Based Birth Skill #1- Movement (Asana) - The Barriers, Complications, and Contraindications

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Before we move into this section I wish to state that the intention of this article is explore the varying roles of movement during childbirth, and with the realization that the vast of majority of your labor will be spent in the early and active phases of Stage One Labor is my way of saying:

The remainder of this work will address using Movement as a healthy mother-friendly birth practice.

I would also like to give you the reminder that no study has ever shown that walking in labor is harmful in healthy women with normal labors, it is a mother-friendly birth practice to provide the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor.

The primary focus this article are movements that you could choose to employ during Stage One Labor and through Transition, strategies to be used to assist labor progress and to distract your mind from the sensation of contractions.

Moving on—

Human organs, while amazing, are not totally infallible and the uterus is no exception, so just like hearts can skip beats, stomachs upset, and lungs fill with fluid—sometimes birth becomes complicated.

It might become medically necessary to remain still, in bed, and it might even mean you need to turn gravity on its head for awhile. It might also mean you need an intervention or two on your journey towards a healthy outcome for you and your baby.

I tend to take an empirical approach so I must look at using movement from all angles, it would be a disservice to my readers if I did not.

External Barriers:

In America, the majority of women give birth in a hospital setting and Pittsburgh is no exception. This choice almost always means, once admitted, being placed in bed and tethered to a variety of medical devices. The current practice of the vast majority of hospitals and healthcare providers today is intervention intensive.

When you place yourself under medical supervision, staff will begin to tell you what you need to do as is if their requests are mandatory rules necessary to keep you and your baby safe.

These are some of the mandates that entail “risk managed care” and routine interventions.  All of these represent a barrier to being free to use movement and upright positioning.

  • bed rest/ recumbent positions
  • continuous Electronic Fetal Monitoring
  • IV insertion and administration of fluids
  • limited oral intake
  • frequent vaginal exams
  • induction and other augmentations
  • amniotomy (manually ruptured membranes)
  • epidurals and other regional anesthesia
  • catheterization
  • Ineffective pushing (recumbent positions)

You need to learn to distinguish the difference between a procedure that represents a routine practice (done “just in case” as a preventative) and one that represents a genuine need for this particular medical intervention for a wide range of hospital and healthcare provider mandates and policies.

Is it disapproval—or is it a healthcare provider preference? Something that makes it easier for the provider—not the mother?  Answers that are normally expressed in terms of “it’s hospital policy’ “its my practice to..”, “that’s not our routine”…

For example:

Staff states, upon your arrival, that it is hospital policy that you remain in bed attached to a blood pressure cuff so as to prevent the possibility of you developing an abnormally high blood pressure, just as a precaution to keep you and your baby healthy. You and the baby are fine now but there is a potential life risk, so it is better to play it safe.

Versus,  the staff member who states I would like you to remain in bed for now, because every time you are upright your blood pressure skyrockets which is adversely effecting your health and that of your baby’s—we need to get this under control.

Learn the difference between genuine medical need versus routine usage for all of these “unfortunately” common routine interventions.

If there is no genuine dire medical need for you to remain flat on your back in bed tethered to machines and it is NOT your preference then DON’T stay there.

It is my personal belief that women are experts in their own bodies and babies, and without interference, they will make the choices that are right for themselves and their babies.

Going to bed and/or staying immobile (if not medically necessary) for entire length of your labor is a bad idea as these types of positions slow down labor and interfere with efficient progress—instead use gravity which will work to keep the baby’s head pressed downward against the cervix.

Recumbent positioning is a highly artificial position for laboring women, it was not until the end of the 18th century in Europe that women began to lie down in order to give birth. Before that time they walked around and used birth stools or sat up in a chair.

Lying on your back causes the fetus to press against the big blood vessels in the lower body, the resultant constriction interferes with circulation, lowers blood pressure, decreases urine production and can cause fetal distress.

Not lying in bed is supported by research and clinical tests— upright positioning and movement are evidence based and are proven to produce stronger contractions, shorter labors, and that utilizing an upright position results in the uterus working nearly twice as efficiently to dilate the cervix.

There exists an astonishing amount of ignorance regarding the natural physiology of birth in healthy women and this lack of knowledge has resulted in obstetric care practices that promote deliberate injury to both mother and fetus during their utilization.

Birth is a highly coordinated bodily function that is primarily handled by the uterus. In our bodies there exist organs that we just assume will get the job done—like the heart, the stomach, and the lungs.

We do not normally question their ability to do their jobs—instead we just let them do the work they were created to do and we don’t even spend much time thinking about them until something goes astray. We innately trust them to beat, digest, and breath.

The most highly evolved organ of this type is the female uterus, it is a strong powerful organ and if left to her own devices is highly efficient in birthing a baby—as if she was designed to do this job. We would hardly still exist as a species if our uterus was not.

Unfortunately, human females have been and continue to be brainwashed by healthcare providers, social media, and “well-meaning” friends and family into thinking that our uteruses are totally incompetent—a flaw in the design of the human female body.

That birth is a medical condition that needs to be cured, that technology does it better, and that it is not a matter of “if” something goes wrong it is a matter of “when”.

Most hospitals and healthcare providers do give lip service to mother-friendly birth practice #2 by suggesting change of positions, being upright, walking—in theory this is their advice.

However, in practice, while they “permit” you to be out of bed this comes with the caveat that movement and positioning must remain conducive to the monitoring of the the mother and the baby.

It bears repeating:  While all medical interventions, have their place and time when indicated—they cannot be justified as a standard procedure for a normal physiological occurrence in a healthy full term pregnancy.

In light of all these studies, reports, reviews, and secondary analyses, medical healthcare providers who still insist upon recumbent positioning seem woefully unaware of the contrary evidence.

The action of signing hospital intake permission paperwork does not mean that you lose your right to informed consent or informed refusal—you are the legal authority in the birthing room, office, etc. —the legal authority is you as the pregnant woman seeking medical guidance.

You have the legal right to make all decisions about your body and your baby, just like any American citizen, pregnant or not. This is your constitutional right and this right has been affirmed by the Ethics Committee of ACOG and it was re-affirmed in 2013.

So speak up—if you don’t want a procedure or to remain recumbent after proper counseling then politely refuse it.

The decision to utilize upright positioning and movement are birth preferences that you need to discuss thoroughly with your care provider, well before birth. Approaching the discussion in a calm reasonable and accommodating manner.

According to Cynthia Gabriel you are unlikely to convince a healthcare provider who has developed a different style of labor management that you are right and they are mistaken.  Instead you will be better served by explaining how important a physiological vaginal birth is to you, that you deeply desire something different, that you believe it is better for your health and your baby’s as well, and make a heartfelt request for their support.

I am paraphrasing Cynthia Gabriel’s “Natural Hospital Birth” phrasing:

“Certainly, my most important objective is a healthy baby. Your support for our birthing preferences would give me peace of mind. If the baby or myself aren’t doing well, I will gladly reconsider. But, if both the baby and myself are doing fine, I would really appreciate your support in allowing for intermittent monitoring, no routine fluids, and freedom of movement. As I am planning a vaginal birth, with minimal medical interventions, I’d like to do all I can to utilize gravity always assuming that both my baby and I are doing well.”

The best way to avoid unwanted and unnecessary medical interventions is to stay at home for as long as possible and this is where having a Birth Doula can really come in handy. She will give you the strength,confidence and support necessary to promote a calm positive birth.

Complications

Ideally, when labor begins at full term there is nothing between the baby’s head and the cervix except amniotic fluid. This not always the case:

  • Cord Prolapse where the cord slips between the presenting part of the fetus and the cervix,
  • Placenta Previa where the placenta is attached to the bottom of the uterus, between the presenting part of the fetus and the cervix

In theses rare instances, the smart move is turn gravity on its head and thereby taking the pressure of the presenting part of the fetus off of the cord and the placenta. These circumstances represent scenarios in which remaining upright is a contraindication as the additional pressure from gravity can result in harm and even mortality to the fetus.

Ideally, when labor begins at full term your placenta remains firmly attached to the side wall of the uterus and your fetus floats free on a long loose cord. This is not always the case:

  • Placenta Abruption where the placenta either partially or totally tears away from the uterus before labor begins or during the earlier stages of labor.  Abruption is rare and is usually a result of trauma.
  • Tight Nuchal Cord where the umbilical cord is short, knotted, or wrapped around the fetus. This scenario is more common, in extreme circumstance it can be a life threatening to the fetus—but it is normally not a serious complication.

In these rare instances, the smart move is turn gravity on its head and thereby making some slack space in the cord protecting yourself from further tearing and assuring that your baby continues to get sufficient oxygen and blood through the cord. These circumstances represent scenarios in which remaining upright is a contraindication as the additional pressure from gravity can worsen the damage causing harm for yourself and your baby.

These conditions are extremely rare, BUT if you turn out to be the exception then turn gravity on its head and take the pressure off the cervix, the cord, and/or the placenta while you deal with any of these genuine medical emergencies.

Most of the pressure can  be relieved by moving into and remaining in a head down, bottom up position. *****

Ideally when labor begins at full term your baby is in optimal fetal position for birth and is occiput anterior (OA). Head down, facing towards tailbone. Right OA and left OA are also compatible with ease of vaginal birth.

But this is not always the case, labor can begin with a baby in any number of head down positions, including face up (Occiput Posterior OP, right, or left), brow first, head tilted to one side, or hand/hands beside the face.

Vaginal birth is still a viable option as are a variety of positions and movement— with any of these presentations— your choice of movement and position will be made with the goal of shifting the baby into a more optimal position in mind.

The OP presentation or “sunny side up” presents the most challenge both during labor and during delivery. Intense back labor is often a common consequence as the hardest part of the baby’s head is constantly pressed against the lower spine and tailbone.

It is my intention to address this birth presentation at a later point as there are specialized movements that can be utilized to both alleviate the pain and assist vaginal birth. There are a multitude of viable strategies and techniques to try and the majority of babies shift into more optimal positions before transitioning through the cervix.

For now please realize that OP presentation needs specialized movements and patience, and if after considerable time the baby remains at a high station, showing little if any descent then a Cesarean Section may indeed be medically necessary.

Ideally when labor begins at full term your baby is in optimal fetal position (both head down and Occiput Anterior) but this is not always the case as some babies are more directionally challenged than others.

  • Breech positioning where the baby presents feet first (Footling breech) or the baby presents butt first (Frank breech) instead of head down.
    • In the United States, a Footling breech means an automatic Cesarean Section, this is a very complicated presentation.
    • While a Frank breech position is a less complicated presentation, the majority of American doctors are seldom adequately trained, even fewer have hands-on experience delivery experience.
    • Vaginal breech delivery is rapidly becoming an obsolete skill set among today’s obstetricians as their preference is to deliver all breech babies by Cesarean Section.
    • With a Frank presentation your doctor or midwife may attempt an External Cephalic Version (ECV) at full term. This is a “hands to belly” external attempt to rotate the fetus so that the baby is head down and in a more optimal position for birth.
    • It is my intention to more fully address this birth presentation at a later point as there are specialized movements and techniques that can be employed to encourage a breech baby to turn. This includes but is not limited to: chiropractic techniques, alternative practices, acupuncture, body work, inversion, myofascial release, the Webster technique, and active birthing techniques. The website Spinning Babies specializes in techniques to get your baby to move on its own.
    • Transverse positioning or “sideways position” where the baby is laying across the womb with head to one side and bum to the other-either stomach or back facing up. Babies can be completely horizontal or “at best” with a shoulder presentation.
      • This a normal albeit uncomfortable presentation for babies up to around 31 weeks gestation, this is not the case at term. A baby who is lying sideways can not be born vaginally, labor contractions are not strong enough to bring a transverse baby through the pelvis. The website Spinning Babies is also a good go to in this presentation as well.
      • Your best move here is to take steps to move your baby into a head down position before labor. This includes but is not limited to: ECV, inversions, tilts, releases, body work, chiropractic technique, Webster, massage, acupuncture, and myofascial release.
      • A vaginal birth with this presentation is highly risky to the mother who risks uterine rupture and subsequent infections. An attempt at delivery also causes fetal trauma and distress.
      • A baby who cannot be persuaded to move into a more optimal position needs to be delivered by Cesarean section.  As transverse positioning is sometimes due to less than optimal pelvic anatomy a Cesarean Section just might be the safest option for you and your baby.

Twin pregnancies (Multiples) where instead of just one cute bundle of joy you have “bundles” of joy.

  • this usually always means a scheduled Cesarean Section at close to term and more than two babies always means a Cesarean Section.
  • If you stumble across a healthcare provider who is willing to let labor begin on its own and who is willing to let you give labor a try then what movements you choose to use will be determined by the presentation of the first twin.

Vaginal Birth After Cesarean Section (VBAC)

  • depends on your doctor and hospital but if all indications are good then it is fine to proceed with normal range of motion and the positions of your choice.

Other Genuine Medical Reasons to Give Moving Around a Timeout

  • Fetal distress in the form of a prolonged stretch of non-reassuring fetal heart beats with no breaks.
  • Maternal instability in the form of light-headed, high or low blood pressure, preeclampsia, or other pre-existing physical injuries or concerns.
  • Preterm premature rupture of membranes
  • premature labor before 37 weeks
  • epidural

Second Stage Contraindications

Once you are completely dilated and the baby begins to make its descent down through the birth canal you enter what is designated as Stage Two—the Pushing, Crowning and Birth Phase.

In the recent Cochrane Review (2017) the results showed that there were two contraindications to remaining upright during delivery (2nd stage labor):

  • an increased risk of a second degree tear and;
  • an increased risk of losing more than 500ml of blood
  • For now, while no one wishes to tear-it is a better option than receiving an episiotomy. I also believe that women need to employ a completely different pushing strategy rather than the “pelvic floor destroyer” method commonly practiced in most hospitals. Most authors politely refer to this as “directed pushing”—I no longer do.
  • For now, please note that 500ml is approximately the amount you would donate if you gave blood and that staff was allowed to give a best guess estimate as to the amount of blood lost during the studies.

The methodologies and techniques are very different at this point in labor—so much so— that it seems to set Stage Two altogether apart and in a class by itself, therefore before I veer too far off of course, I will rein myself in:

I am leaving all further discussion of Stage Two including the two contraindications of the 2017 Cochrane Data Base Review to a later article. For now it will have to remain in the realm of “coming soon” as I have a lot more of research to do before I can write more knowledgeably on this topic.

Psychological Barriers

Ideally, when labor begins at full term your mind and your body are on the same page—ready to rock Birth but this is not always the case. We live in a complex busy world, full of social media, bombarded by scaremongers with their misconceptions, misunderstandings, and “good intentions” about Birth. Nor is life always sunshine and daisies.

  • The Fight Flight Freeze response
  • The Fear Tension Pain syndrome
  • Previous birth trauma
  • Previous sexual trauma

All of these can leave a woman curled up in a tight ball stiff frozen fighting against birth. A goal of this article is to start you on a path towards inner understanding. When you have the right knowledge your choices become clear. You are able to move in the direction that is most helpful for YOU.

The Fight, Flight, Freeze and The Fear, Tension, Pain Syndrome responses are discussed in more detail later in this article and will have in-depth articles in the future.

Movement is a viable non invasive option to get yourself unstuck and literally moving forward. Meditation is an optimal way of moving the mind through inner “mind stuff” before birth.  The role of previous trauma on your birth experience deserves and will eventually get its own article.

Timing and the Physical endurance

Birth is a marathon not a sprint. Pace yourself. Save big movements for later. At the beginning of labor remain in a semi upright resting position for as long as possible. In doing this you will give the uterus’ oxytocin receptors time to proliferate thereby letting your labor get well established. Let your body dictate when it is time to move. Don’t move just because you think you should, move because you can’t make yourself not move. Use all of what you've got to the best of your ability.

Let’s move on and get to the “fun” stuff!