Posts Tagged ‘freedom of movement’

Disputed Territory: A doctor reviews “Birth Territory and Midwifery Guardianship: Theory for practice, education, and research”

November 16th, 2009 by avatar

This is a guest contribution from Katharine Hikel, MD. Dr. Hikel is a writer on women’s health for Medscape/WebMD. Peer-trained in feminist women’s health clinics, she is also a graduate of Harvard and the University of Vermont College of Medicine. She lives in northern Vermont with her family.

Birth TerritoryReview:
Birth Territory and Midwifery Guardianship: Theory for practice, education, and research
Edited by Kathleen Fahy, Maralyn Foureur, Carolyn Hastie.
Butterworth Heinemann (Elsivier): Books for Midwives. 2008

The next vital revolution in maternity care may well be the overhaul and redesign of the birthplace. In “Birth Territory and Midwifery Guardianship,” writers describe the relationship of the birth setting to the emotional-physiological state of laboring women.  In this regard, ‘Birth Territory’ encompasses not only physical space, but also personal relationships, power structures, and access to knowledge.

Maternity care as we know it has evolved along divergent roads: the midwifery, expectant-management ‘natural’ approach; and the obstetric, interventive, ‘actively-managed’  model.  Midwifery care is a woman-centered approach; it relies on relationships which support women’s natural abilities to give birth. The obstetric model, designed by and for doctors, operates on  principles of academic exclusiveness, described by Louis Menand:

It is a self-governing and largely closed community of practitioners who have an almost absolute power to determine the standards for entry, promotion, and dismissal in their fields. The discipline relies on the principle of disinterestedness, according to which the production of new knowledge is regulated by measuring it against existing scholarship through a process of peer review, rather than by the extent to which it meets the needs of interests external to the field…

[T]he most important function of the system is not the production of knowledge. It is the reproduction of the system. To put it another way, the most important function of the system, both for purposes of its continued survival and for purposes of controlling the market for its products, is the production of the producers

Academic obstetrics is impervious to knowledge and input from other disciplines; it exists in a closed, parallel world; it exists not for the purpose of taking care of women, but for the purpose of taking care of itself. The chief concern of any obstetrical unit is the viability of the department, of the program; if outcomes figure into that, well and good; but women’s actual experiences and opinions, because they are not part of the published literature, are of no concern.  Small wonder, then, that so little thought has been given to the environment of hospital birth, other than for the convenience of hospital practitioners.

Meanwhile, midwives have continually concerned themselves with what the authors of Birth Territory and Midwifery Guardianship call ‘the elements in the geography, architecture, and metaphysics of birth spaces to which women will consciously and unconsciously respond.’

In their book, the writers – midwives, and an architect of birth spaces – asked women what they wanted in their birthing places. Responses included:

  • A pleasant place to walk
  • Sufficient pillows, floor mats, bean bags
  • Availability of snacks and drinks
  • En suite toilet, shower, bath; a birth pool
  • Comfortable accommodations for companions and families
  • A homey, non-clinical environment
  • Control over temperature
  • Control over brightness of light
  • Privacy; not being overheard by others
  • Not being watched
  • Control over who comes into the room

The majority of birthing women surveyed did not have these options. The authors argue that lack of a woman-centered birthing environment, and little control over that environment, are reasons for high rates of obstetric intervention. Labor and birth are whole-being experiences; the autonomic nervous system will shut the whole process down if the woman perceives stress, threat, or danger.  In typical hospital settings, with shift changes, strangers walking in and out, bright lights, confinement to bed and monitor, and restricted oral intake, it is no wonder that the process doesn’t go as smoothly as it could. “Failure to progress” – the diagnostic reason given for 50% or more cesareans – is largely an environmental issue.

Katharine Hikel, MD

Katharine Hikel, MD

Birth territory is also defined by relationships; yet medical obstetrics has constantly worked to sequester birthing women away from all sources of comfort, including non-medical practitioners; only in the 1960s were fathers and partners invited into hospital delivery rooms; and only lately, with the advent of doula practices, has one-to-one attendance – the cornerstone of midwifery – become recognized as a significant predictor of good outcome.  But few hospital practices are relationship-centered. Prenatal visits are fifteen or twenty minutes long, mainly focused on weight gain and lab work. There’s usually a team of doctors and midwives; the person who’s available at the time of one’s birth is not a matter of preference, but of the practice’s call schedule.

Obstetrics is statistics-based, not relationship-based; obstetricians know that the average due date is 40 weeks from the last menstrual period; they know that if a woman is laboring (in a hospital) with waters broken for over 12 hours, her chance of infection skyrockets; they know that the Friedman labor curve shows that the average progression of dilation is one centimeter per hour; they know that the average pushing phase is under two hours. They are under pressure to make everyone fit those statistical norms, and they have the tools to make it so; and that’s what they do.

The best birth territory requires the best attendants. Fahy and her coauthors argue that birth is a reflection of relationships – with oneself, and with others; that relationships depend on love, and spiritual development (words you will never see in any obstetrical textbook).  In developing the best birth attendants, they see open-heartedness as a requirement for good practice; they describe the characteristics of a good practitioner in Buddhist terms of ‘right relationship’: empathy; ethical behavior; self-awareness; capacity for love. In a chapter called “Reclaiming the sacred in birth,” they describe the conditions for nurturing ideal midwives: ‘to know and nurture themselves within their own families and communities,’ and emphasizes working on personal development, as well as clinical skills, with a supervisor or professional partner. The training environment of midwives should encourage the development of nurturing and intimate, though professional, relationships with her clients; it is that relationship that forms a necessary part of optimal birth territory.

The territory of obstetrics residents is largely devoid of patient-relationship considerations; it is rather consumed with concerns about on-call hours, clinical rotations, numbers of procedures, and one’s place in the departmental hierarchy. The knowledge itself is based in pathology – ‘problem-oriented’ – a diagnostic/treatment approach that assumes there’s trouble, and goes about finding it. This works well in the rest of medicine, which is really about disease; but colors the teaching approach to the normal, healthy event of childbirth.  The knowledge that’s important – taught and practiced – is all within the limits of academic obstetrics, which ignores, if not devalues, ‘nonscientific’ knowledge. The ‘permitted’ knowledge supports what the authors call the ‘metanarrative’ of academic medicine: the postmodern myth that the safest and best place to give birth is under obstetric management. Any knowledge that counters that myth is disputed or ignored.

The history of obstetrics is also viewed differently from within the specialty than without. The obstetricians’ view, reproduced in most obstetrical textbooks, is the development of one intervention after another, all by men – from forceps to vacuum extractions. The authors present a larger-scale view:

Medicine in the late 19th and early 20th centuries was composed almost entirely of men who shared the same power base as other dominant males: they were white, well-educated and from economically richer families. It was these males who owned or managed every institution of society: the army, the church, the law, the newspapers, the government, etc. These privileges, combined with an informal brotherhood of dominant men, created a powerful base for the success of the medical campaign to subordinate midwifery.

The authors describe the territory of hospital birth as disputed ground, where the biological requirements of birthing women are at odds with the design of institutions.  They provide ample evidence about how the dominance of obstetricians’ needs over women’s welfare has contaminated the culture of birth. In a wonderful section on oxytocin – the hormone of love, bonding, social interaction, birth, and lactation – they describe the effects of this natural hormone:

[T]he higher the level of Oxytocin, the more calm and social the mother; thereby stress is reduced; levels of the stress hormone cortisol drop; pain threshold is increased…  body temperature is regulated… and heart rate and blood pressure are lowered… Women’s response to stess may not be the automatic ‘fight or flight’ response seen in men, but is more likely to be the ‘calm and connection’ system integrated by Oxytocin.

These oxytocin-mediated events are most necessary during labor and birth; they are best enabled if the birth territory includes oxytocin-positive relationships.  Oxytocin is thought to be the source of women’s power to endure labor and birth; and its pathways are the most likely to be deranged by the institutional birth environment – the lack of oxytocin-facilitating relationships of trust and love, as well as the routine administration of oxytocin-blocking drugs such as epidurals and Pitocin – a form of artificial oxytocin that has never been proven safe in long-term outcome studies. Blocking oxytocin, whether through fear, disturbance, or Pitocin, leads to disrupted or painfully difficult labors.  These authors suggest that disruption of normal oxytocin pathways, and supplanting them with intrapartum Pitocin exposure, may also result in serious mental health problems on the love-and-relationship axis: schizophrenia, autism, drug dependency, suicidal tendencies, and antisocial criminal disorders. It’s not just the mother who’s affected by the birth territory.

But what is the best birth environment?  In a chapter called “Mindbodyspririt architecture: Creating birth space,” architect Bianca Lepori describes her designs for hospital-based birth rooms that are meant to enhance, not counteract, women’s abilities to give birth. She created suites of rooms with “Space and freedom to move; to be able to move to the dance of labor; to respond to the inner movements of the baby; to walk, kneel, stretch, lie down, lean, squat, stand, and be still.” The rooms have “Soft and yielding surfaces; or firm and supportive surfaces; different textures; the right temperature; soft curves; darkness or dim light.” A birthing woman can be ‘immersed in water, flowing or still; respected, safe, protected, and loved.”  Access to the suite is through an antechamber; the bed is farthest away from the lockable door, and not visible from it, so that privacy is respected.

Lepori’s birth architecture reproduces the comforts of home. There is access to the outdoors, and private walking places. There are birth stools, exercise balls, bean bags, hooks for hammocks or ropes for stretching. Tubs and beds are large and accessible from both sides. There are accommodations for families. There are comfortable chairs for nursing. Medical equipment – supplies, oxygen – is tucked behind a screen or put in a closet. A refrigerator and light cooking equipment is available. This ‘birth territory’ certainly outshines the typical hospital OB floor; though it begs the question: Why not just stay home?

The answer, of course, is that, for those four to ten percent of births that truly need intervention, the OR is right there. It’s better not to have to transport a woman whose labor has turned complicated; it makes sense – for many – to have all the birth territory under one roof.

This birthing-suite design indeed takes into account the all-encompassing, body-mind-spirit event of childbirth. It honors laboring, birthing women and families; it respects the process. It worked well for a designated maternity hospital in New Zealand – a facility already designed for childbearing. But most US hospitals are multi-use facilities; and though obstetrics is among the best money-makers for hospitals, childbirth is the only event that occurs there that is not related to illness or trauma.

The real question is, why not remove birth completely from the pathology-centered hospital model? Why not redesign birth territory to maximize best outcomes, minimize intervention, and replace the present medicalized view of birth as a disaster waiting to happen with the more normative, expectant-management, midwifery view? Move the whole shebang, from the waiting room to the surgical suite, out of the hospital and back into the community where it belongs.

Why not indeed. The major obstacle to any redesign of the territory of birth is resistance from the field of obstetrics. The American Congress of Obstetricians and Gynecologists (which recently changed its name from the American College of Obstetricians and Gynecologists, reflecting a major shift in interest from academics to politics) has a 23-member lobbying arm, “OB-GYNS for Women’s Health PAC”, which describes itself on its web site:

Ob-Gyns for Women’s Health and Ob-Gyn PAC help elect individuals to the U.S. House of Representatives and Senate who support us on our most important issues. Individuals who understand the importance of our work, who care about the future of our specialty, who listen to our concerns, and who vote our way. In only a few short years, Ob-Gyn PAC has helped elect ob-gyns and other physicians to the U.S. Congress, and has become one of the largest and most influential physician PACs in America.

Only five of the 23 members are women; all ten of its board of directors are men. Current issues occupying the group are “Stopping Medicare payment cuts, ensuring performance measures work for our specialty, preserving in-office ultrasounds” (though there are still no long-term studies on the effects of ultrasound on the developing fetus, or on women, for that matter); and “winning medical liability reform,” which means limiting liability for malpractice.
Meanwhile,  the Medicaid Birth Center Reimbursement Act – Senate Bill #S.1423 (House Bill HR 2358) – is not on the list of bills that ACOG supports, even though this expansion of birth territory would probably better outcomes, and certainly cost less than the hospital OB model.

The only bad thing about “Birth Territory and Midwifery Guardianship” is that obstetricians will not read it.

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Baby it hurts: birth practices and postpartum pain

November 6th, 2009 by avatar

Ask a bunch of expectant women what worries them about labor, and chances are many of them will say, “the pain.”  Much is made about pain in labor. Women prepare for it, nurses constantly assess it, anesthesiology departments exist to eliminate it, and so on. But while there are many experiences of labor pain, just about the only universal truth about it is that labor pain ends once the baby is out.

FACES Pain Scale

But a 2008 report from Childbirth Connection suggests that, for many women, pain is an ongoing problem after birth. The report also suggests that two common labor interventions – cesarean surgery and episiotomy – are highly associated with ongoing pain.

According to their national survey of mothers, reported in New Mothers Speak Out, 22% of mothers who gave birth by cesarean said that pain interfered “quite a bit” or “extremely” with their daily activities in the first two months. That’s compared to only 10% of women who had vaginal births. Mothers who had vaginal births without episiotomies were the least likely to report that pain interfered at all with daily living. Episiotomy also increased the likelihood of painful intercourse in the first two months.

At six months, nearly 1 in 5 (18%) of mothers who had a cesarean still experienced pain at the incision site, versus only 2% of women who had vaginal births reporting continuing problems with perineal pain.

The Childbirth Connection survey did not ask about endometriosis, a common cause of chronic pelvic pain, but a growing number of case reports strongly suggest that cesarean surgery is associated with new-onset endometriosis.

ResearchBlogging.orgThis week I happened upon a study that reveals another aspect of labor and birth care that may affect postpartum pain. Researchers analyzed data from nearly 13,000 UK mothers of singleton, term, live-born babies. Participants were recruited into the study prenatally and answered questions about back pain in two postnatal surveys – one at 8 weeks and another at 8 months. The researchers set out to find out if mode of birth (spontaneous vaginal, instrumental vaginal, elective cesarean, or unscheduled cesarean) affected the likelihood of postpartum back pain. They concluded that it did not.

But here’s an interesting gem that I almost missed [emphasis mine]:

A higher proportion of women who had an emergency caesarean section reported 8-week postnatal back pain compared with those who delivered spontaneously… Adjusting for the factors associated with emergency caesarean section and back pain decreased this association. By 8 months, the prevalence of back pain fell, but remained higher amongst emergency caesarean sections. Epidural analgesia and ‘in preferred position in labour’ were the two most influential confounders.

What does this mean? I had to go back to an earlier study that reported outcomes from the same dataset in order to figure out what “in preferred position” was referring to.  It turns out researchers asked women how much of their labor was spent in their preferred labor position. Options were, “no/hardly,” “sometimes,” or “always.”  The results of this earlier trial showed that being in the preferred position in labor reduced the risk of cesarean surgery. The fact that the researchers in the new study controlled for it tells us that being in one’s preferred position in labor also was protective against postpartum back pain. It also tells us that having an epidural in labor increased the likelihood of postpartum back pain, although this finding has been inconsistent in other studies.

What other labor and birth practices could affect postpartum pain? What about skin-to-skin contact after birth? Only one tiny study involving only 20 mother/baby pairs has looked at whether skin-to-skin care affects nipple soreness and it did not find an association. Another small study (not published but included in the Cochrane systematic review) looked at breast engorgement pain and did find that skin-to-skin contact was protective. A much larger body of literature shows that skin-to-skin contact in the hour or so after birth increases the duration of breastfeeding, which lends additional support to the possibility that skin-to-skin care reduces breastfeeding-related pain (a common cause of early weaning).

Another Cochrane systematic review tells us that upright pushing positions are associated with a much lower rate of episiotomy. Although no study has evaluated pushing position and its direct effect on postpartum pain, anything that reduces episiotomy will in turn reduce postpartum perineal pain and painful intercourse.

In the same vein, practices that reduce operative delivery will in turn reduce postpartum pain associated with these modes of birth. These practices include letting labor begin on its own, providing continuous labor support, and reducing the use of interventions such as epidural analgesia and routine continuous electronic fetal monitoring.

It seems to me that we overemphasize the physiologic pain related to labor and completely ignore the pathological pain related to interventions and injuries in childbirth, many of which could be averted.  My question to my readers is this: how do we reframe the conversation about childbirth-related pain to look more holistically at pain throughout the childbearing year and beyond?

Moore ER, Anderson GC, & Bergman N (2007). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane database of systematic reviews (Online) (3) PMID: 17636727

Gupta JK, & Hofmeyr GJ (2004). Position for women during second stage of labour. Cochrane database of systematic reviews (Online) (1) PMID: 14973980

Moore ER, & Anderson GC (2007). Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status. Journal of midwifery & women’s health, 52 (2), 116-25 PMID: 17336817

Patel RR, Peters TJ, & Murphy DJ (2007). Is operative delivery associated with postnatal back pain at eight weeks and eight months? A cohort study. Acta obstetricia et gynecologica Scandinavica, 86 (11), 1322-7 PMID: 17851815

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Healthy Birth Blog Carnival: Walk, move around, and change positions throughout labor

October 28th, 2009 by avatar

On the heels of our successful “Let Labor Begin On Its Own” Carnival, here is our second Healthy Birth Carnival! This time the theme is Lamaze’s second Healthy Birth Practice: Walk, move around, and change positions throughout labor.

Every single one of these posts is great, and on top of some really thoughtful writing, I’m also excited about the amazing photos, illustrations, and videos our contributors used to show laboring women using various positions and movements. It’s so nice to see active birth rather than the conventional images of women passively laboring in bed connected to a bevy of tubes and wires.

Let’s get moving!

Two phenomenal posts show how important movement is in VBAC labors. Kristin at Birthing Beautiful Ideas writes about how she “moved and grooved” to a healthy VBAC, and the labor and birth nurse at NursingBirth offers another powerful story of how movement and great labor support helped a mother achieve a healthy and triumphant VBAC in the hospital.

Jill at The Unnecesarean points out that, “For first time mothers who have had no exposure to a birth, the time between, ‘I felt a contraction!’ and ‘I have to push!’ is often a total mystery.” She demystifies the in-between time with a plethora of selections from women’s birth stories that illustrate how movement helps.

Wendy at Aruban Breastfeeding Mamas offers “Birthing Positions 101” to an island where women are too often restricted to the lithotomy position to birth, discussing the potential benefits and disadvantages of each position.

The Well-Rounded Mama brings us another incredibly thoughtful and thorough post, this time about the importance of movement in labor and how mobility restriction – and its harms – affect women of size disproportionately.

Do we need to show harms of restricting mobility in order to advocate for freedom of movement? I discuss how a “medical model” approach to research can actually be an impediment to change in my post, “Do we need a Cochrane Review to tell us that women should move in labor?

Carol Van Der Woude shares a story of how 1970’s technology inadvertently helped a woman birth vaginally after progress had slowed. In the course of getting out of bed and going to another part of the hospital to get an x-ray of her pelvis (yes, this was common practice 30 years ago!) the baby finally found the right fit through the woman’s pelvis and was born soon after. Carol’s post also offers a story of how plenty of patience and freedom of movement kept a home birth safely at home.

Jen at Pursuing Harmony shares another simple story of birth at home, in which she followed her instincts to find the right positions and movements to help labor progress smoothly. Lauren Wayne at HoboMama shares a personal story of using movement to give birth to a nearly 12 pound baby vaginally with no drugs. Her story illustrates both how home birth offers optimal freedom of movement and how mobility can be maintained even when a planned home birth results in a transfer to the hospital. Sheridan at Enjoy Birth shares another personal experience, and also answers a common question, “can I still move around if I am using hypnosis in labor?

The hospital bed can be a potent symbol to a laboring woman that she has no choice but to get into it. This summer, Henci Goer wrote a post here at Science & Sensibility about a pilot study showing that removing the labor bed from the hospital room entirely resulted in less use of oxytocin augmentation. But most women birth in environments with hospital beds, and some women need to stay in or near the bed for medical reasons, so Molly Remer brings us a fantastic handout,”How to Use a Hospital Bed Without Lying Down“. The Lamaze-Certified Childbirth Educator and student nurse-midwife at Hands for Catching points out, however, that the bed is not the only element of the conventional birth environment that keeps women from moving while Moms Tinfoil Hat shares a personal story that demonstrates that mobility is an all-too-common casualty of the cascade of interventions. All of these posts reinforce the relevance of Birth Territory, a new theory for labor care that emphasizes the role of the physical environment and individuals’ use of power in promoting optimal labor outcomes. Rixa Freeze introduced this theory in a recent post at Stand & Deliver. (Stay tuned, we’ll soon be featuring an interview with the researchers who developed the theory and a review of their book here on Science & Sensibility!)

And last but not least, the News Moms Need blog reminds us that moving our bodies offers health benefits in pregnancy and after giving birth, not just in labor. The blog also offers tips and guidelines for exercising safely while pregnant. Our bodies were made to move!

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Do We Need a Cochrane Review to Tell Us That Women Should Move in Labor?

October 25th, 2009 by avatar

I am reposting this post from the archives in anticipation of this week’s Healthy Birth Blog Carnival about movement in labor. It was one of the first posts I ever wrote, back before anyone was reading this blog. It’s also one of my personal favorites.

Earlier this year, media outlets shared the news of a new Cochrane review that concludes upright positions are beneficial because they shorten labor by about one hour. The birth blogs were buzzing about this, and the consensus is that we should feel delighted and vindicated to have the scientific evidence to prove what women and midwives have always known.

ResearchBlogging.orgCochrane reviews synthesize all of the research on a particular topic, and because the reviewers bring together and analyze all of the data from many studies, the study population gets very big. Big populations yield greater statistical power and often (but not always) more reliable findings.

Prior to this Cochrane review there was a large body of literature on movement in labor, including a good sized U.S. randomized controlled trial. There was even another systematic review! But this body of research never consistently supported the hypothesis that movement improved labor and birth outcomes. Now we have a Cochrane review, which is the gold standard for evidence-based practice.  So we can put the evidence-based “stamp of approval” on freedom of movement.

But, were we any less justified in endorsing freedom of movement before the Cochrane? Although studies have given us inconsistent results as to whether movement shortens labor or decreases the need for c-section, a few conclusions have been loud and clear from the literature since researchers began looking at maternal position and movement:

  1. Women prefer to move around, primarily because they experience less pain when they can move.
  2. Women who stay in bed usually do so because they are connected to machines or IV lines, and/or because a health care provider tells them to.
  3. Movement and walking are not harmful to the woman or the baby.

Freedom of movement is the thing that would happen if women did not have any interaction with a health care system or provider in labor. In other words, it’s the default state of affairs. Anything that we do in the name of “health care” to improve upon this normal unfolding of things is referred to as an “intervention”. In scientific research, researchers compare a control group, which should represent the default/normal, with an experimental group, which represents the intervention. The burden of proof should be on the intervention.

Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice. While many of us believe that encouraging a laboring woman to move when and how she wants to is healthier and safer than making her stay in bed, waiting for evidence that it produces better health outcomes is putting a burden of proof on normal birth that has never been applied to routine intervention. Besides, lack of evidence of harm, less pain, and maternal satisfaction are valid and important outcomes in and of themselves, and provide the justification we need to reject routine policies and practices that restrict maternal movement.

Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, & Styles C (2009). Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews (Online) (2) PMID: 19370591

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Calling All Bloggers (Again)! Healthy Birth Blog Carnival #2

October 12th, 2009 by avatar

Last week, bloggers weighed in on different aspects of how labor begins and provided what I think is a treasure trove of evidence and wisdom on the subject. Now we’re ready to move on to Lamaze’s second Healthy Birth Practice:

Walk, move around, and change positions throughout labor

Here are some Lamaze resources to get you thinking about how movement affects labor and birth.

Participation in the Healthy Birth Blog Carnival is easy:

1. If you are a blogger, write a blog post on the Carnival theme (Walk, move around, and change positions throughout labor). Post it on your blog by Sunday, October 25. Make sure the post links back to this blog post, to the Healthy Birth Practice Paper, or to the Mother’s Advocate video. You may also submit a previously written post, as long as the information is still current.
2. Send an email with a link to your post to amyromano [at] lamaze dot org.
3. If you do not have a blog but would like to participate, you may submit a guest post by emailing it to me.
4. I will compile and post the Blog Carnival here at Science & Sensibility the week of October 26.

Last week, bloggers weighed in on different aspects of how labor begins and provided what I think is a treasure trove of evidence and wisdom on the subject. Now we’re ready to move on to Lamaze’s second Healthy Birth Practice:

Walk, move around, and change positions throughout labor

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