The positive impact of prenatal exercise

The following is a re-post of my August 2008 post Wanna Improve Your Odds?:

I mentioned back in April that I had been skimming the book Exercising Through Your Pregnancy, by James F. Clapp M.D. I was really impressed at that time with the amazing benefits of exercising through pregnancy. But I didn't read the book in-depth. I decided earlier this week that I wanted to take a closer look. Now that I've read several of the chapters and examined the data thoroughly, I am telling you... it absolutely blows me away.

There are risks inherent in pregnancy and childbirth, but we can do things to minimize those risks. We all know that good nutrition is essential for pregnant women. Poor nutrition often leads to pre-term and low-birthweight infants as well as pre-eclampsia in mothers. Eating well is one of the absolute best things you can do for your unborn child's physical and neurological growth. But now I'm convinced that exercise may be just as important.

I won't go into all the benefits of prenatal exercise here. I'd just like to focus on one set of benefits in particular--the effects of exercise on the course of labor. You might remember my very early post about the benefits of doulas. Having a doula assist your labor and delivery reduces many chidbirth risks significantly. Prenatal exercise has even more pronounced benefits.

Women who continue exercising regularly through the end of their pregnancies (three times a week for at least 20 minutes at a moderately hard to hard level of exertion) demonstrated the following reduced risks during the birth process...

* 35% decrease in the need for pain relief
* 75% decrease in the incidence of maternal exhaustion
* 50% decrease in the need to artificially rupture membranes
* 50% decrease in the need to induce or augment labor with pitocin
* 50% decrease in the need to intervene because of abnormalities in the fetal heart rate
* 55% decrease in the need for episiotomy
* 75% decrease in the need for operative intervention (forceps or cesarean section)

In addition, check these out...

* More than 65% of the exercising women delivered in less than four hours.
* 72% delivered before their due date (but fewer of them delivered before 37 weeks--preterm--than the control group). The exercising women delivered, on average, 5-7 days earlier than active women who did not exercise regularly.
* Significant reduction in the incidence of umbilical cord entanglement.
* Much lower incidence of fetus passing meconium from distress.
* Umbilical cord blood samples indicated that babies of exercising moms remained relatively stress-free with plenty of oxygen. They seemed to tolerate the stresses of labor and delivery better than the control group.
* The exercising mothers' infants were, on average, 14 oz lighter but overall growth was not compromised.
* Placentas of exercising mothers are larger, more efficient, and healthier-looking.
* Infants born to exercising mothers were more alert postpartum and needed less consolation from others.

(All of these results are taken from Dr. Clapp's studies as reported in Exercising Through Your Pregnancy. See this fabulous book for even more amazing benefits.)

It blows my mind.

Imagine how huge the risk reductions would be if you exercised through pregnancy AND had a doula. Whoah. We can do so much to avoid the pitfalls of pregnancy and birth. It gives me so much joy and hope to know that I am not at the mercy of chance. I have a great deal of power over my circumstances when it comes to pregnancy and birth. It is a wonderful thing to be able to choose to pro-actively reduce risks and bring so much benefit to myself and my babies. I love it!

Re-post: Tips for avoiding tearing and episiotomies

Things have been quiet in my corner of the blogosphere despite my having one or two posts in the works in my head.  I just haven't had a block of time to get them on "paper."  In the meantime, I thought I'd re-post and oldie but goodie from the early days of my blog since some of my newer readers might not have seen it and might find it helpful.  (Stay tuned for a post about waterbirth next.)

Giving birth for the first time was one of the most empowering experiences of my life. My water broke, my contractions started, everything progressed smoothly, and, less than six hours later, my baby girl was born. It was an ideal birth experience, except for one thing. That one thing made my next few weeks of recovery extremely painful. I tore. I really tore....

Read the rest of this post over at my new website!

Hear me roar

After a few weeks of caring for her precious first-born baby, my friend Fig declared, "Motherhood is blood, sweat, and tears. Rinse and repeat." Are you nodding and chuckling at the same time? Fig's good at inducing the chuckle-nod. She's so witty. And right on.

So I've been thinking, of late, about how I focus so much on the intense physical challenge of labor (some, including me, call it "pain") that I have sort of neglected to give attention to other physical "pains" associated with bearing and nurturing children. For example...

* The cramping associated with ovulation and/or menstruation is painful for some women.
* PMS can cause painful bloating, headaches, etc.
* Love-making is painful for some women.
* Some women experience round-ligament twinges and/or cramping in early pregnancy.
* Morning sickness can range from mildly bothersome to excruciatingly miserable.
* Some pregnant women suffer with back pain, sciatic nerve pain, joint pain, etc.
* Preterm labor pains keep some women on bed rest for weeks or months.
* Then there are the after-pains (I think they get worse with each birth... wowza!).
* Some women endure general perineal tenderness, pain from perineal tears/episiotomies, or cesarean section wounds.
* Breastfeeding hurts like the (toe-curling) dickens in the beginning, being compounded initially by painful breast engorgement, painful milk let-down, and more intense after-pains due to the uterine contractions produced by suckling.
* The muscle strain from carrying around a 5 to 10 lb newborn can lead to sore arms and/or sore backs, especially with a first child.
* Once an infant has teeth that introduces a whole new kind of potential pain during breastfeeding.
* Back pain can continue and intensify from carrying increasingly hefty babies and toddlers.
* Rinse and repeat.

(And that's not even getting into the emotional pains we endure.)

The other day a first-time pregnant woman I love told me she's pretty sure she'll get an epidural 'cause she's (and these were her exact words) "such a pansy." I couldn't help myself... I rushed toward her, grasped her face in my hands, and said, "No! You're not!" This woman has endured excruciating menstrual cramps every month for over a decade followed by miserable morning sickness for the last couple of months... and she thinks she's a "pansy!"

Look at the list above, ladies. Take a good, long look at it. Do you really think God would entrust those challenges to a bunch of pansies?



Nope.

We are women. We are strong. We can push ourselves to our absolute limit and somehow find the strength to push some more. And then rinse and repeat.

Don't you dare call yourself a pansy. 

 (Photo by Fife Photography, Fall 2005)

Eye-opening little nugget

I was googling "rhombus of michaelis" to see what else was out there on the web and found an archive link apparently documenting a letter written by a chiropractor, Todd Gastaldo, to Jean Sutton. I guess they were in some disagreement about what happens to the pelvis when the rhombus of michaelis moves, but that's not my reason for posting.

They were in total agreement that lying on the back or semi-reclined on the tailbone prevents the birth canal from opening to its full capacity--substantially. Apparently by 20 to 30%! That's huge. Then the doc gave the following eye-opening observation, calling it "obvious OB crime" (and I would add that OBs aren't the only perpetrators--midwives are also to blame sometimes):

OBs are slicing vaginas en masse (euphemism "routine episiotomy")--surgically/FRAUDULENTLY inferring everything possible is being done to OPEN birth canals--even as they CLOSE birth canals − up to 30%.

OBs are slicing abdomens en masse ("c−section")-- surgically/fraudulently inferring everything possible has been DONE to open birth canals--even as they CLOSE birth canals − up to 30%.

Now--to be sure--allowing the birth canal to open the "extra" up to 30% is not going to prevent all caesareans and episiotomies--but it can't hurt. Incidentally, when babies' shoulders get stuck, OBs KEEP the birth canal closed--even as they say they are opening it maximally.

OBs don't charge for their mass vagina slicing--but it is known to increase severe perineal tears by 50X--and perineal tearing is the most common reason for hospitalization of women:

"The most common diagnosis for hospitalization among all women is trauma to
perineum due to childbirth" (source).

It blows my mind that we just lie down and take this... over and over and over and over and over and over again.

When will we demand that these crimes end?

Re-post: To the women of the world

I've been reminiscing about two years ago when I started this blog and thought it might be fun to do a re-post of my very first post ever... which also happened to be one of my first publications ever--an opinion piece in the newspaper. It was a long-time goal of mine to have something I had written published. And it was all the more satisfying and fulfilling because I was able to educate people about something I was passionate about in the process. Here it is...

After two years of reviewing 15 years of medical literature, a team of national experts has come forward with this reality: Many of the routine medical interventions used in births in the United States do not improve outcomes for mothers and babies. Some even cause harm.

Their findings demonstrate increased risks and problems with many prevalent interventions including labor induction, cesarean section, continuous electronic fetal monitoring, routine use of IVs, amniotomy (artificial breaking of water) and withholding of food and liquids. Though these interventions have become commonplace and viewed as part of "advanced" and even "superior" medical care, this study indicates these practices are not improving outcomes in most cases. In fact, they often create more problems than they eliminate. These findings will appear in the winter 2007 supplement to "The Journal of Perinatal Education" in a summary report entitled "Evidence Basis for the Ten Steps to Mother-Friendly Care."

This is not the first time these facts have been brought to the nation's awareness. Time and again researchers, activists and organizations, such as the Coalition for Improving Maternity Services, have tried to create change by raising awareness about the problems with maternity care in the the United States. Generations of women have recounted their birth horror stories over and over to each other. Scores of women wear the physical and emotional scars of unnecessary medical interventions.

Who is listening?

Does anyone care?

Let me use the words of Thomas Paine from his fiery call to arms, "Common Sense," with just a few of my own insertions: "Every quiet method for [change] hath been ineffectual. Our [appeals] have been rejected with disdain; and only tended to convince us, that nothing flatters vanity, or confirms obstinacy in [an old, broken system] more than repeated petitioning." The methods we have used thus far have been passionate and have brought about small victories, but the changes most needed have yet to be recognized or addressed by the mainstream medical community. We need a new approach.

Buckminster Fuller said, "You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete."

Women and mothers of the world, I call on you to "build a new model." The time for complaining, pleading and persuading is over. Those methods have been tried, and they have done little. It is time to say, "Enough!"

Let us no longer accept mediocrity and "go along blindly" with any procedure. Let us no longer tolerate practices that have been shown to cause us or our babies harm. Let us stop playing the victims and start creating the reality that we all deserve — the absolute best maternity care possible. Let us demand the best of the best for ourselves and our babies.

We cannot underestimate the power of women united in behalf of themselves and their children. "There is a woman at the beginning of all great things," said Alphonse de Lamartine. Imagine what we can accomplish if we unite our efforts. Imagine what we can create.

Awesomeness and Awfulness

I'll start with the awfulness, so we can end on a good note...

Remember this post? The one where I mentioned that baby lotions and soaps are basically totally unnecessary and possibly harmful? Well, last Friday's Washington Post warned: "Probable Carcinogens Found in Baby Toiletries." Though the manufacturers of these products claim the levels are very low and within government regulations, health and consumer advocates argue that repeated exposure could have a cumulative damaging effect. In any case, there are more natural alternatives out there, and warm water alone does the trick just fine for newborns. Remember... dirt is good for babies.

Now the awesomeness...

I met another home birthing momma at church yesterday. We had a fun chat and she gave me some helpful tips. But... get this... she pushed out a 12 lb baby in ten minutes with no episiotomy or tearing! My response: "That is AWESOME." I love hearing those stories. Don't let anyone tell you, "Your baby is too big." Mommy hips and baby heads are flexible for a reason.

Honey for perineal healing

I just read this great little tidbit in the Midwifery Today E-News and had to share!

"Raw honey is a great remedy for first-degree [perineal] tears. Honey's thick consistency forms a barrier defending the wound from outside infections. The moistness allows skin cells to grow without creating a scar, even if a scab has already formed. Meanwhile, the sugars extract dirt and moisture from the wound, which helps prevent bacteria from growing, while the acidity of honey also slows or prevents the growth of many bacteria. An enzyme that bees add to honey reacts with the wound's fluids and breaks down into hydrogen peroxide, a disinfectant. Honey also acts as an anti-inflammatory and pain killer and prevents bandages from sticking to wounds. Laboratory studies have shown that honey has significant antibacterial qualities. Significant clinical observations have demonstrated the effectiveness of honey as a wound healing agent. Glucose converted into hyaluronic acid at the wound surface forms an extracellular matrix that encourages wound healing. Honey is also considered antimicrobial."

—Demetria Clark
Excerpted from "Herbs for Postpartum Perineum Care: Part I," The Birthkit, Issue 46
Order the back issue

It's my hope that I'll never need to try it out ('cause I'm NOT going to tear ever again), but I thought it might be helpful to someone out there. I sure could have used this information after my previous births!

Some Birth Research Headlines

Courtesy of the Lamaze Institute for Normal Birth Research Summaries:

Prenatal Diagnosis of Suspected Fetal Macrosomia Increases Risks of Cesarean Section and Maternal Morbidity without Improving Newborn Outcomes

Sadeh-Mestechkin, D., Walfisch, A., Shachar, R., Shoham-Vardi, I., Vardi, H., & Hallak, M. (2008). Suspected macrosomia? Better not tell. Archives of Gynecology and Obstetrics, doi: 10.1007/s00404-008-0566-y.

"An initial suspicion that the baby is large may instill fear in the pregnant woman which may impede both her confidence in her body and her labor progress. Slow labor progress reinforces the suspicion that the baby is big and more aggressive management ensues. This management often hinders the woman's ability to move freely and assume the positions that may help her baby negotiate through her pelvis, further slowing progress and reinforcing the perceived need for surgical intervention. Based on this study and previous evidence, women should strongly consider refusing tests late in pregnancy intended to estimate fetal weight.

"The estimate itself may be bad for her health because the care provider's expectation that the baby will be macrosomic appears to increase both unnecessary medical intervention and the morbidity that may accompany it" (exerpt from the Lamaze Research Summary).

Women Having Spontaneous Vaginal Birth Without Episiotomy Least Likely to Experience Postpartum Pain

Declercq, E., Cunningham, D. K., Johnson, C., & Sakala, C. (2008). Mothers' reports of postpartum pain associated with vaginal and cesarean deliveries: Results of a national survey. Birth, 35(1), 16-24.

"One argument made for elective cesarean surgery is that it avoids the pain of labor. Its proponents also allege that surgery occurring before labor offers advantages over intrapartum surgery. This study, however, finds that women having cesarean surgery are more likely to experience pain that interferes with routine activities and to experience long-term pain than women birthing vaginally and that timing of the surgery makes no difference.

"Women considering elective surgery to avoid labor pain should be advised that while labor pain can be controlled, cesarean surgery substantially increases their risk of experiencing many months of pain postpartum or pain that affects their quality of life. Instrumental vaginal delivery likewise increases the probability of experiencing perineal pain in both the short and long term compared with spontaneous vaginal birth" (exerpt from the Lamaze Research Summary).

Prenatal Yoga May Result in Less Labor Pain, Shorter Labor

Chuntharapat, S., Petpichetchian, W., & Hatthakit, U. (2008). Yoga during pregnancy: Effects on maternal comfort, labor pain and birth outcomes. Complementary Therapies in Clinical Practice, 14(2), 105-115.

"This study provides evidence that regular yoga practice in the last 10-12 weeks of pregnancy improves maternal comfort in labor and may facilitate labor progress. The researchers offer several theories for these effects. First, yoga involves synchronization of breathing awareness and muscle relaxation which decrease tension and the perception of pain. Second, yoga movements, breathing, and chanting may increase circulating endorphins and serotonin, "raising the threshold of mind-body relationship to pain" (p. 112). Third, practicing yoga postures over time alters pain pathways through the parasympathetic nervous system, decreasing one's need to actively respond to unpleasant physical sensations.

"Prenatal strategies that help women prepare emotionally and physically for labor may help reduce pain and suffering and optimize wellbeing in childbirth by providing coping skills and increasing self-confidence and a sense of mastery. More research is needed to confirm the findings of this study. However, yoga's many health benefits and the lack of evidence that yoga is harmful in pregnancy or birth provide justification for encouraging interested women to incorporate yoga into their preparations for childbirth" (exerpt from the Lamaze Research Summary).

Posterior Ponderings

My second baby came into this world upside down, or "sunny side up" as some people say. She was posterior (facing my front side) rather than the normal anterior position (facing my back). Her posteriority (I think I just invented a word!) brought with it some surprises. I had fully expected my second birth to happen very quickly. My sister's labors were each roughly half as long as the previous. My first daughter's birth lasted less than six hours, so I was expecting my second to come in less than three! I suspected she might be posterior, however, when that supposed-to-be-fast labor turned into an on-again-off-again roughly 28-hour labor.

Fortunately, for me and my baby, the planets aligned to make our birth experience smooth and uncomplicated. My labor started and stopped every few hours, eventually kicking into full gear after about 26 hours. I arrived at the hospital nearly 6 centimeters dilated and delivered my baby about two hours later. There was no need for forceps or vacuum to get her out, I pushed for less than 20 minutes (it wasn't until then that my midwife said the p-word and confirmed my suspicions about my baby's position), and I suffered only a minor tear. My recovery was terrific compared to my previous birth. My first baby was not born posterior, but I suffered extensive tearing followed by a very painful recovery. Ultimately, I succeeded in having a very satisfying unmedicated labor and delivery despite having a posterior baby.

I feel fortunate, because, for many women, a posterior position is a recipe for disaster. A 2005 article, "Digital/manual rotation reduces need for C-section," in OB/GYN News explains: "Previous epidemiologic studies have estimated the prevalence of the occipitoposterior position to be about 5%. Among such pregnancies, there is a high incidence of cesarean section, instrumental delivery, third- and fourth-degree perineal tear, postpartum hemorrhage, and puerperal infection" (source).

I shudder to think what my experience could have been like. If I had gone to the hospital earlier when my labor was periodically stalling, it is likely I would have been given Pitocin. The contractions produced by the Pitocin would likely have been too painful for me to handle without medication, so I would have likely asked for an epidural. Epidurals make the pushing stage more challenging for many mothers, particularly those with posterior babies, so it's highly likely I would have ended up with an instrumental or cesarean delivery. I feel so fortunate to have evaded those outcomes!

I will be forever grateful that I trusted my baby and my body enough to wait things out and let labor kick into full gear on its own. I spent most of my labor upright, moving, walking, rocking my pelvis, getting on my hands and knees--outdoors and in my own and family members' homes until the last couple of hours. Sometimes these measures will help a baby to turn. Sometimes babies just stay put. And that's okay. Don't let the "p-word" scare you. Having a posterior baby doesn't have to mean a horrible birth experience. For me it was smooth and satisfying. I believe it can be smooth and satisfying for most women when labor is allowed to progress without interference.

Tips for avoiding tearing and episiotomies

Giving birth for the first time was one of the most empowering experiences of my life. My water broke, my contractions started, everything progressed smoothly, and, less than six hours later, my baby girl was born. It was an ideal birth experience, except for one thing. That one thing made my next few weeks of recovery extremely painful. I tore. I really tore.

Despite the painful recovery, this was actually the lesser of two evils for me. Though some caregivers continue to cut episiotomies in as many as 80% of their patients, medical research does not support routine episiotomies. Studies from as far back as the 80s made it clear that routine episiotomies have no benefits and carry real risks. One of the most detrimental risks is that episiotomies can lead to further tearing, sometimes extending into the anus. These fourth degree anal tears almost never occur without an episiotomy. In addition, a spontaneous tear may only reach into the surface layers of skin, while an episiotomy cuts into far more layers. Episiotomies are rarely warranted and should be reserved for those unusual emergency cases. Ultimately, even without all the evidence, I just didn't want someone cutting me. I knew, going into my first birth experience, that if I had to choose between them, I would choose to tear. And, tear I did.

The best case scenario, obviously, is neither. The best outcome is a happy, healthy baby and an intact perineum. So how does a woman improve her chances of keeping her perineum intact?

1. Choose a midwife, or a doctor whose practice is evidence-based. The typical midwife's philosophy of birth is one of non-intervention. Most midwives tend to avoid episiotomy and are aware of the best positions and techniques to avoid tearing. I saw a group of certified nurse-midwives with my second daughter's birth, and was relieved to hear, at my first appointment, that 70% of their patients end up with intact perineums. I had only a very minor tear--what my midwife described as a "skid mark"--and my recovery was vastly superior to the first. If you choose to use a doctor, be sure that he/she practices evidence-based medicine, is aware of the research against episiotomy, and understands your desire to remain intact.

2. Exercise regularly. We all know exercise is beneficial to our health, but it's also beneficial to your perineal tissues. Women who are physically active are less likely to end up with episiotomies and are more likely to retain strong pelvic floor muscles post-partum. General exercise is great, but doing exercises specialized for the pelvic floor--"Kegels"--will not only strengthen those muscles, but also increase your awareness of how those muscles function so you can learn how to fully relax them for birth.

3. Have a doula present for your birth. A doula is a trained labor support professional. Research has shown that a doula's presence reduces a laboring woman's risk of requiring pain medications by 36% and forceps deliveries by 57%. Epidurals and forceps deliveries are both associated with increased incidence of tearing and episiotomies, so a doula is handy to have around when you're trying to stay intact. Doulas are the most highly rated providers of labor support and work wonders in improving women's birth experiences, so it won't just be your perineum that thanks you.

4. Deliver in an upright, hands-and-knees, or side-lying position. Research clearly indicates that the worst possible position for delivering a baby is the very position most hospitals direct women to take--on the back, legs stretched out wide, feet in stirrups. The best positions for avoiding perineal trauma are unconventional in most U.S. hospitals, but the evidence is clear. If you want to maximize your chances of staying intact, don't let hospital conventions hold you back. Be sure your caregivers know of your intention to deliver as you choose--upright, on your hands and knees, or on your side. Fortunately, the best positions for avoiding perineal trauma are also the ideal positions for a smoother, easier delivery, so you won't be sorry about breaking with convention.

5. Use "spontaneous" pushing rather than the conventional Valsalva method. Most women in U.S. hospitals are encouraged to take a deep breath, hold it for ten seconds and bear down--the Valsalva maneuver. Breaking with convention in this case is also beneficial for your perineum. Women who push spontaneously are more likely to avoid tearing. Spontaneous pushing typically involves shorter periods of pushing and more breathing in and out which promotes relaxation of the perineal tissues. A woman following her body's instincts and impulses will deliver her baby far more easily, efficiently, and painlessly than one who is being coached to disregard her body's guidance.

Episiotomies should be rare, and tearing isn't inevitable. Women who arm themselves with information and support can travel through birth uplifted, empowered, and intact. I, for one, intend to do just that the next time around.