Science & Sensibility

This is a guest post by Trish DeTura, RN, CNM, MS, MAMA President

Pregnancy is such an exciting time in a woman’s life filled with the great wonder of what is to be. However, it may also be a time of great stress as a woman’s body goes through a great metamorphosis. Some of the common discomforts of pregnancy are round ligament pain, indigestion, aching back and pelvic pressure, just to name a few.

Add to this list the mental/emotional challenges a woman experiences in pregnancy surrounding the uncertainty around motherhood, sadness and depression.

One wonders as a practitioner, what can I offer this woman that will benefit her and her unborn baby?

While attending the Art of Birthing Conference in the New York Academy of Medicine in 2000, I found a wonderful complementary technique.

Complementary techniques are popularly used by many women for the relief of aches and pains during pregnancy and birthing (Jones et al, 2012). Leanna Jones and her colleagues (2012) found complementary methods were most often offered and used in midwife-led births. Relaxation, acupressure/acupuncture, massage and immersion in water were found to provide pain relief and positive maternal outcome without invasive side effects. Also, regarding acupuncture/acupressure, a decrease in the use of forceps, ventouse and cesarean section was noted (Jones et al; 2012).

I learned about Maya Abdominal Massage from Rosita Arvigo and Ms. Hortense Robinson. Rosita is a naprapath, herbalist and teacher of Maya medicine. She who apprenticed with Don Elijio Pante, a traditional Maya healer, in Belize, Central America. Ms. Robinson is a midwife.

They shared how the Arvigo Technique of Maya Abdominal Therapy (ATMAT), restores the body to its natural balance by correcting the positions of organs that have shifted and restrict the flow of lymph, blood, nerve and qi energy. Thus, ATMAT promotes homeostasis.

As a result of ATMAT, the pregnant woman experiences an increase of arterial blood carrying oxygen, nutrients and minerals to the mother and her unborn along with removal of any waste via the venous system and lymph. In addition, the mom experiences a removal of any congestion or blockages enhancing better hormonal, nerve flow and flow of chi.

I thought this all made good physiologic and common sense. I was hooked! Onward to learning this technique to support women with all kinds of challenges then onward to learning the pregnancy aspect of this method.

This gentle, non-invasive approach of this abdominal massage begins at 20 weeks of gestation continuing up to when the woman delivers. ATMAT eases the common discomforts of pregnancy.

I find it to be a lovely complement to a midwifery practice, the mom gets to focus on her baby and her developing baby intimately, thus preparing her to open psychologically and physically to her pregnancy and birth.

Tiffany Field, Ph.D. at the Touch Research Institute in Miami, has collected extensive data on the profound healing effects of touch, which is what ATMAT is- healing and nurturing touch- for both the mother and her unborn.

In the Journal of Psychosomatic Obstetrics and Gynecology, Field (2010) published a study demonstrating that regular massage during pregnancy results in: decreased anxiety, improved mood, reduced back pain, improved sleep patterns, reduced stress hormone levels, fewer complications during labor and fewer complications for infants following birth.

Further, Field (2010) reports women who have received massage therapy experienced significantly less pain and their labors were on the average three hours shorter.

The data collected by the midwives providing ATMAT to their pregnant clients supports these findings. In addition to the shortening of labors, mothers who receive ATMAT bond with their unborn baby leading to less postpartum depression. This has been substantiated by Dr. Tiffany Field and her colleagues in a 2009 study revealing that postpartum depression was lessened as a result of prenatal massage.

It is my hope that one day the Arvigo Technique of Maya Abdominal Therapy will be recognized as an essential and vital aspect of maternity care. To learn more about this great modality please go to: www.Arvigotherapy.com

References:

Field, T. (2010). Pregnancy and labor massage therapy. Expert Review of Obstetrics and Gynecology, 5, 177-181.

Field, T., Diego, M., Hernandez-Reif, M., Deeds, O., & Figueiredo, B. (2009). Pregnancy massage reduces prematurity, low birthweight and postpartum depression. Infant Behavior & Development, 32, 454-460.

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP.Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

Trish DeTura, RN, CNM, MS specializes in the Arvigo Technique of Maya Abdominal Massage, a non-invasive and natural technique of restoring health to the reproductive organs. She is in private practice in Hoboken, NJ. Contact her at trishdetura@gmailcom

Kathy Morelli Cesarean Birth, Childbirth Education, Continuing Education, Do No Harm, Guest Posts, Midwifery, Pain Management, Uncategorized complementary techniques, massage, Maya Abdominal Massage, midwife, Midwifery Care, mindbody techniques, relaxation, relaxation in childbirth

All pregnant women deserve to have access to compassionate, evidence-based maternity care which inherently supports the normalcy of labor and birth—and remains poised to effectively handle the occasional circumstance when birth strays from normal.  They deserve to be cared for by well-trained midwives, family physicians or obstetricians–depending on their particular situation and which type of care is most warranted–who work together seamlessly as a congruent maternity care team.  They deserve to be cared for by maternity care professionals who trust each others’ skills and resist the urge to question each others’ motives.  Expectant families deserve to remain center stage throughout their pregnancies, labors and births—avoiding being lost in the cacophony of politics that so often suffocates the system and obscures the practice of pure, evidence-based care.

Last weekend, Dr. Brian Goldman introduced his CBC Radio audience to this very scenario, during his show, White Coat, Black Art.  During the show “Dr. Brian,” who is both an emergency department physician in Toronto, and a medical journalist, takes listeners to Nelson, B.C., Canada, where he follows obstetrician Shiraz “Raz” Moola and registered midwife Ilene Bell who both work at Kootenay Lake Hospital.

Only minutes into the radio show, it becomes clear: expectant families delivering at Kootenay Lake Hospital are the beneficiaries of a truly integrated maternity care team where family physicians and midwives handle the majority of deliveries, leaving the complicated scenarios to obstetricians.  This is despite Canada’s fee for service medical system in which, “an obstetrician uses the fees he or she earns from doing easy deliveries to offset or subsidize the more time-consuming and more stressful deliveries that require additional skill and experience.”

During the course of the radio show, scenarios in which obstetricians are called in for deliveries are described.   Despite what sometimes feels like a disbelief in the humanity of obstetricians that some normal birth advocates imply, this radio show does an excellent job of pictorializing  the “why” behind the impetus to medicalize labor and birth.  During the interview, Dr. Moola describes a scenario in which he could palpate a fetus inside it’s mothers abdominal cavity—but outside the womb—following a cesarean scar rupture during an attempted VBAC.  Carrying around past experiences like this can prompt a level of caution—even if not evidence-based caution—as the human side of a physician hopes to avoid dealing with such a circumstance in the future.  And yet, the maternity care providers interviewed in Dr. Goldman’s story don’t seem to allow those past experiences—as few or frequent as they may be—to prompt a technocratic approach to their maternity care services.

“Our training is to promote the normal,”  says Ilene Bell.  “We want to normalize.”

In fact, the radio show audibly follows the progress of a VBAC candidate through parts of her labor and successful delivery, attended by  Bell.

“At one level, we all think we can do it the best,” says Dr. Moola.  But he goes on to describe how the “best” (maternity care provider) is most often a midwife or family physician, and only sometimes an obstetrician.

I highly recommend listening to the whole radio show, and forwarding the link onto your colleagues.  After listening, please come back here and answer the following questions:

1.  What elements of the maternity care partnership described in this show does my local birth community already harbor?
2. What elements of the maternity care partnership described in this show can my local birth community/hospital learn from?
3. What are three steps I can take in my community to encourage this type of partnership approach to maternity care?

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

Kimmelin Hull Evidence Based Medicine, Science & Sensibility, Uncategorized, Vaginal Birth After Cesarean (VBAC) Black Art, collaborative maternity care, Dr. Brian Goldman, Ilene Bell, Kootenay Lake Hospital, MD, midwife, Shiraz Moola, VBAC, White Coat

Introducing….the concept of the “natural” cesarean…
I have struggled with whether or not to post on this YouTube video for some time.  The title, in and of itself, is aggravating.  And I don’t mean from a judgmental standpoint, but simply from a realistic standpoint:  cesarean birth—whether positively, clinically indicated or not—is not “natural.”  It is an alternative method to birth compared to how nature originally designed it.

I have heard many others refer to the practices described in the video as “gentle cesarean.”  This, at least, seems to be a bit more accurate—except for the cutting, pushing, tugging, pulling, suctioning, cauterizing, and externalizing of the uterus that goes on.  (In a former career life, I used to surgically assist on cesareans, so I’m pretty familiar with what the procedure looks like.)

A list serve I’m a member of has recently spent a lot of time debating practices that surround cesarean births: should hospital policy allow for placement of baby skin-to-skin with mother directly following birth?  Should breastfeeding be allowed in the OR while mom is still being sewn up?  Should separation of mom and baby in the minutes and hours be avoided following a C-section in the same way this practice has taken hold in the vaginal birth setting?

Other questions about cesarean birth discussed frequently in my own local birth network include:  Should birth plan elements such as low lighting, quiet music and delayed cord clamping be integrated into the C-section setting?  Should doulas be allowed into the operating room to provide the emotional support the mother/parents hired her for?  (An aside here:  the most common argument against allowing doulas into the OR at my local hospital is that, “the OR is too small to have an extra person in there.”  Every time I hear this I nearly explode:  the OR seems to be large enough to admit medical and nursing students at-will, along with the various OR staff coming and going from the room throughout the procedure.  And yet the presence of a doula sitting quietly and still beside the birthing woman/couple seems to take up WAY too much space!)

The “Natural C-Section” video encourages many of the issues discussed above.  It follows a second-time-mama into the OR for her second cesarean birth and features obstetrician, anesthesiologist and midwife talking heads who all describe this version of a cesarean birth in a universally positive light.  In fact, mood lighting does seem to be implemented.  The sterile drape separating mom’s head and the rest of her body is dropped in time for her to see her baby being pulled from the incision in her belly.  The doctor holds the baby up, legs spread, so mom and partner can “discover” the baby’s sex on their own, as the OB narrates, “…it’s one of them.” Baby is placed right away, vernix, fluid, blood and all, on mom’s chest.  Dad cuts the cord following a delayed cord clamping.  In this video, the midwife’s job following the baby’s birth is explained as being focused on facilitating bonding measures like skin-to-skin contact and early breastfeeding, while also assessing baby’s well-being.

Interestingly, the anesthesiologist included in the video describes the birthing woman as ‘awake and participating in her baby’s birth.’  I have a hard time agreeing with his sentiment.  While it is certainly preferable for the mother to be awake and aware the moment her baby exits the womb, I’m not sure how much ‘participating’ she is doing when strapped down with 2/3 of her body numb and immobile.

For women who must deliver via cesarean—I can definitely see the appeal in this version of a surgical delivery.  It attempts to come up to speed in so many ways.  There is no hour-long separation between mom and baby.  When mom goes to the PACU (Post Anesthesia Care Unit), so does baby.  The midwife in the video even acknowledges the associations between postpartum depression and cesarean rates as well as decreased breastfeeding initiation rates amongst women who have undergone a cesarean birth.  She then goes on to imply that this gentler approach to the C-section might just ameliorate some of this association.

Criticism Against the “Natural Cesarean”
Here is the cause of my hesitation:  does this promotional video of the “Natural C-Section” run the risk of making surgical birth look so enticing that the risks of C-section get pushed under the table?

Dr. Andrew Kotaska, an obstetrician in Yellowknife, NT, Canada describes his concern over the “Gentle Cesarean” this way:

“It is admirable to minimize the necessary disruption of normal early maternal- neonatal contact associated with NECESSARY cesarean section. The gentle measures employed will not, however, reduce the maternal risk of amniotic fluid embolism, pulmonary embolism, operative injury, infection, severe hemorrhage, and death – all several times higher with C/S than vaginal birth. They also will not help achieve the neonate’s normal immune system activation during labour, perhaps leaving it more vulnerable to autoimmune disease later in life.

 

“In no way can the “gentle cesarean” be construed as making C/S safer. In the best quality prospective data set on elective C/S, 1/2300 women died. Soft, family-centered window dressing does not change the cold, hard risks; it is important practitioners and women keep this in mind.” (Landon; NEJM 2004)

In the United States, we are struggling against an ever-increasing cesarean rate.  Readers of this blog are well-aware of the ~ 33% C-section rate that doesn’t seem to be decreasing any time soon.  In an age when we should be working to reduce the C-section rate to somewhere at least close to that which the WHO recommends, the promise of a gentler, naturalish surgical birth could threaten the work many maternity care professionals and normal birth advocates, alike, are doing to properly inform women (and some providers) of the true risks associated with cesarean birth.

On the same list serve I mentioned above, another related thread developed:  should we “allow” post-cesarean moms to initiate breastfeeding while still in recovery?  The meat of the debate was whether or not women with anesthesia levels up to the nipple line will suffer nipple damage from incorrect infant latches, if they cannot feel the latch.  Hospitals apparently have policies on this:  when a mother is and is not allowed to nurse her baby, depending on the type of birth they have experienced (and the resultant side effects—such as prolonged numbness).  Since when did it become reasonable for maternity care facilities to dictate when a woman is and is not “allowed” to feed her own child?

This is exactly the type of down-stream effect of surgical birth that 1) likely does not get discussed prior to consenting for a cesarean and 2) is not erased by a gentler approach to the procedure and 3) involves the institution of policies that certainly are not evidence-based.

A Wolf in Sheep’s Clothing
I will never become the person who denies the importance of C-section as an option in a few, particular cases:  umbilical cord prolapse, placenta previa, abruptia or accreta to name a few.  The cesarean method of birth was, after all, developed to be a life-saving measure and, to this day, continues to be just that in a handful of circumstances.   And when a C-section is truly indicated (but not emergent) then, YES, incorporating gentle, respectful, best-practices elements into the cesarean experience should be done.  To me, this should quickly cease to be a point of debate at all. But for the remainder of women who find themselves in the position of contemplating the type of birth they’d like to experience—those who might be considering an elective C-section; those who have had a previous cesarean and are toying with whether or not to go for a VBAC—the promise of a “Natural C-Section” may turn out to be a wolf in sheep’s clothing.

As one participant on the list serve summarized:

“Can we work to make cesareans less common and also kinder–at the same time?”

Click on image below to watch the entire video on YouTube

Posted by:  Kimmelin Hull, PA, LCCE

Kimmelin Hull Cesarean Birth, Films about Childbirth, Science & Sensibility, Uncategorized, Vaginal Birth After Cesarean (VBAC) "natural cesarean", Andrew Kotaska, Gary Stocks, gentle cesrean, indications for c-section, Jenny Smith, MD, midwife, Phillip Bennett, VBAC, YouTube videos on c-section