The Doula and the Partner:
How They Work Together to Help the Birthing Woman
by Penny Simkin, P.T.

I ran across this article that discusses the myths and realities of doulas and how they work with the birth partner to support the birthing woman. It was part of my doula training, and I think it's a wonderfully informative article.

Mother's Last Skin-to-Skin Goodbye Saves her 20 oz. Baby

"When Carolyn Isbister put her 20 oz. baby on her chest for a cuddle, she thought that it would be the only chance she would ever have to hold her.

"Doctors had told the parents that baby Rachel only had only minutes to live because her heart was beating once every ten seconds and she was not breathing. "

Click here to read the rest of this miraculous story.

Cesarean Birth and SIDS

If you or someone you know is considering scheduling an elective c-section, you should know that:

"Studies have shown that infants born through elective cesarean section may be at greater risk for SIDS."

RT for Decision Makers in Respiratory Care: Cesarean Birth and SIDS

The above article cites several studies that have been done about cesarean section and SIDS, and there are some alarming findings. I'll list in a nutshell what I consider key information from the article:

What is an Elective Cesarean Section?

"A mother may undergo cesarean section electively or as the result of an emergency. In an elective cesarean section, no labor takes place. This option may be chosen for several reasons, such as to avoid the risk of labor-induced uterine rupture if a mother has undergone previous cesarean sections; as a personal lifestyle choice; or if mother has tocophobia (severe fear of labor). An emergency cesarean section, on the other hand, takes place after labor has begun. It is performed in cases of fetal distress; prolonged, unprogressive labor; breech birth; or if the mother’s life is in danger."

Why is there a higher risk of SIDS for babies born via elective c-section?

"Because of the suspected role of sleep apnea in SIDS, infants are considered at greater risk for SIDS if they have symptoms of (sleep) apnea. These respiratory alterations are more pronounced if the infant is delivered by an elective cesarean section" because of two main factors:

• Gestational age at the time of birth. Elective cesarean sections are more likely to be done at 38 to 39 weeks gestation, whereas emergency cesareans are more often done at 40+ weeks gestation. The gestational age has an impact on the infant's respiratory health. Babies that are born before 40 weeks are more likely to have respiratory problems, which can cause sleep apnea, increasing the risk of SIDS.
  
• Compression. In an elective cesarean there is no trial of labor, so the baby doesn't experience any contractions. In labor the contractions have been found to compress on the baby's body in such a way that it prepares the infant's lungs for breathing outside of the womb. Babies delivered by c-section with no labor contractions don't have this vital preparation. The article details a study done on baby rats in which they tested the impact of compression on respiratory health, and the findings are clear that compression is very important.
  

I'll share some of the facts from the rat study involving compression:

• The group of rats that were given compression initially had 5 breaths/min and it increased to about 20 breaths/min during the hour in which this group of rats were observed.
• One group of rats that were not given any compression (but had cooling) had a significantly reduced respiration rate immediately after birth (about 1–2 breaths/min) and had a smaller increase in the rate of respiration to about 3–4 breaths/min by 1 hour. The other group that had no compression (but had cord clamping) all died within an hour of observation.
• In one group of rats that had no compression only 23% of the rats were breathing by 1 hour.
• In the groups of rats that involved compression, 100% of the rats were breathing by 1 hour.
  

What can you do to lower these risks?

• Avoid an elective cesarean section. Plan to birth your baby vaginally, if possible. If you do plan to have a c-section, you may want to consider doing a trial of labor by allowing your body to labor and experience contractions and give the baby important compression before the surgery is performed. According to the article, "even a short duration of labor seems to stabilize a neonate’s respiration after birth."
• Schedule your cesarean section at 40 to 42 weeks gestation. This will give your baby more time for the lungs to develop properly before birth.
• Send your infant to the NICU if your baby was delivered by elective cesarean. This would likely be a decision made by your care giver, but it could improve the baby's chances of survival because respiration patterns could be closely monitored and periods of apnea avoided through the efforts of NICU workers.
  
• Use a home apnea monitor on the infant if your baby was delivered by elective cesarean. "Ideally, an apnea monitor could prevent an infant’s apnea from progressing to SIDS. The monitor sounds an alarm if it detects a prolonged episode of apnea, hypoxia, or bradycardia, at which point parents can arouse their infant or do cardiopulmonary resuscitation if necessary."

The article also states that more studies are needed on this subject, and I agree.

CDC Says Cesarean Triples Neonatal Death Risk

The following article offers some surprising facts about cesarean section increasing the chances of neonatal death, regardless of the risk factors of the mother and baby:

July 29, 2009, by Misha Safranski

"While the increased risks of cesarean section to neonatal and maternal health have long been known, an even more grim issue came to light in a study released in the September, 2006 issue of Birth Journal. The CDC conducted research on cesarean section and neonatal mortality, expecting to find that the neonatal mortality rate (defined as death within the first 28 days of life) following cesarean section correlated directly with medical complications of the mother and baby. What they found, instead, was that regardless of risk factors, babies born by cesarean section face a risk of death nearly three times that of vaginally born babies.

"MacDorman, et al. analyzed national birth and death data for 5,762,037 live infants and 11,897 neonatal deaths, for the years 1998-2001. The purpose of the study was to examine the neonatal outcomes of primary cesarean delivery in women who had no other known complications or medical risk factors. The logical result of this examination would seem to be comparable neonatal mortality rates among cesarean and vaginally born infants. In fact, what the results show is that cesarean independently raises the risk of neonatal death by almost three-fold - .62 per 1000 deaths among vaginal births versus 1.77 per 1000 infant deaths among cesarean babies.

"Even more astounding than the simple fact that cesarean section raises the risk of infant death - regardless of the reason the cesarean was performed - is that even when the researchers adjusted for sociodemographic, medical and congenital factors, and removed infants with APGARs under 4, the risk of death was only reduced "moderately". A stark difference in the death rates between cesarean born infants and vaginally born infants remained even with no medical explanation.

"We aren't talking about babies dying from the few, rare complications that can arise in childbirth. We're talking about healthy, low-risk mothers electing for a primary cesarean section with no medical indication resulting in a nearly three times higher rate of death than those who have a vaginal birth.

"According to Marian MacDorman, the CDC's study leader, "These findings should be of concern for clinicians and policymakers who are observing the rapid growth in the number of primary Caesareans to mothers without a medical indication."

"While the findings of this research on cesarean and neonatal mortality were reported by major media outlets upon its release, publicity for the issue quickly waned. It is evident that care providers and mothers have continued to discount the disturbing results of the CDC study on neonatal mortality and cesarean, as the rate of surgical delivery has continued to climb to a record-breaking high of 31.8% in 2007, up from 31.1% in 2006.

"The World Health Organization recommends no more than a 10% cesarean rate in developed countries, based upon research indicating more harm than good to both mothers and babies when the cesarean rate tops 15%. Until mothers and obstetricians start taking the risks of elective cesarean section seriously, we will likely continue to see tragic consequences of the interference of surgery in childbirth."

Click here to access this article on Associated Content

Operation Special Delivery: Free Doula Services for Military Families

Operation Special Delivery: A Hand to Hold 'Til They All Come Home

"Operation Special Delivery (or OSD), provides trained volunteer doulas for pregnant women whose husbands or partners have been severely injured or who have lost their lives due to the current war on terror, or who will be deployed at the time that they are due to give birth."

"Why military moms? Because OSD believes that no one should give birth without support, especially the women who are giving birth while these fathers are making such a great sacrifice for our country and our freedom. We just want to try to give back in appreciation."

OSD has 600 volunteer doulas. Please visit their website (link at the top of this post) for more information.

The Guide to a Healthy Birth

I recently ran across a website for a group called Choices in Childbirth.
Their objective is to help educate women so they can make informed choices in their maternity care. They have a pdf e-book that can be downloaded for free:

The Guide to a Healthy Birth

The above link will take you directly to the 2009-2010 edition of the guide. There is also a 2008-2009 edition available. If you happen to live in New York or Philadelphia, there are guides available specifically for those areas as well.

Breech Presentation: Risks and Options

After the birth of my fifth child ended with a surprise breech delivery at home, I decided to look back in my books and learn more about breech presentation and the risks and options available.

At prenatal visits, the doctor or midwife routinely checks the position and presentation of the baby by palpating the mother's belly. As the due date approaches, most babies assume a presentation with the head down, called cephalic position, prepared to descend into the birth canal with its head pushing through for birth. About 3% to 4% of babies don't move into a head-down presentation, and it's called a breech presentation. There are three types of breech presentation: frank, complete, and incomplete.

• Frank breech is when the baby is presenting with its buttocks in the birth canal. The legs are generally extended up with the feet by the baby's head.
• Complete breech is when the baby is in a normal fetal position (sitting cross-legged) but the baby's rear end is presenting over the birth canal.
• Incomplete breech includes kneeling and footling positions. The baby's knees may be bent with the knees presenting over the birth canal, or one or both feet may be down.
  

Vaginal delivery of a breech baby can be safe, but there are some risks involved, which can include:

• Cord prolapse: This occurs when the cord is swept into the cervix, because the baby's feet or buttocks don't completely cover the cervix to prevent this. This can happen if the membranes rupture in a gush and the cord comes down as the fluid comes out. This is dangerous because the cord can be compressed during contractions and cut off vital oxygen and blood supply to the baby. The risk of cord prolapse is much less with frank breech position, because the buttocks are about the same size as the head and can fill the pelvic area enough to prevent the cord from slipping down.
  
• Prolonged delivery or fetal distress: The feet or buttocks can be delivered before the cervix is complete and may not allow the cervix to open all the way to deliver the head. This can lead to fetal distress or delayed delivery of the head.
• Spinal cord injury: This is rare, but can occur if the baby's neck is hyper-extended (the baby looking upward). A baby in this position is sometimes referred to as a "stargazer" and can be detected if an ultrasound is done to determine the baby's position. Experts agree that stargazers have the best outcomes when delivered by cesarean section.

What You Can Do
Most babies assume their birth position by about 36 weeks gestation. Some turn later, even in labor. Ask your care provider to pay extra attention to the position of the baby at 36 weeks and later. If your baby is found to be in a breech position, you can try these methods at home to encourage the baby to turn:

• Open knee-chest: From a hands and knees position, move your knees backward and outward and lower your head and chest to the floor or bed. Make sure your buttocks are high in the air and your thighs are angled away from your belly so that your knees are slightly behind your buttocks. Try to stay in that position for 30 - 45 minutes, or as long as you can. Your partner can help you maintain the position by kneeling next to you, facing your head, placing his or her hands on your shoulders, and pulling up and back slightly. After using this position it can be helpful to go for a walk, crawl on the floor, or dance in a swaying motion. By alternating the downward and upward positions (i.e. knee-chest, walk, knee-chest, walk, etc.) you can encourage the baby to move out of a unfavorable position and into a favorable position.
• Breech tilt position: The concept is to get your hips higher than your head. Lie on your back with your knees bent and feet flat on the floor. Have your partner help place pillows under your hips, enough to raise your hips 10-15 inches higher than your head. Stay in this position for about 10 minutes, 3 times a day. You can also use an ironing board or other flat board in a tilted position to do this.
• Sound: Research shows that a fetus will respond to sound. Have your partner talk to the baby with his or her head in your lap, or place headphones with pleasant music just above the pubic bone. The concept is that the fetus could turn to get its head closer to the familiar or pleasant sound.

Medical Care:
A doctor or midwife can perform an external cephalic version, or ECV, to try to turn a breech baby. An ultrasound is usually done prior to the version to verify the baby's position. A medication can be given to help relax the uterine muscles, but it is not necessary. A non-stress test is often done before and after the procedure to check the baby's well-being, and fetal monitoring throughout the procedure is common. If fetal distress is detected, the procedure will be stopped. Depending on the caregiver performing the version and the amount of pressure used, it could be quite uncomfortable. It's a good idea to have your birth partner come with you and help you practice your birth comfort measures such as focused breathing. External version has a success rate of about 60%. If the version is unsuccessful, your care giver will discuss your delivery options with you.

Vaginal delivery versus Cesarean Section:
Up until the 1970's breech babies were routinely delivered vaginally. Doctors were trained how to handle them and it was a common practice. However, as c-sections became increasingly widespread, doctors came to rely more upon surgery as the preferred birth method for breech babies. Doctors now are not trained to deliver breech babies vaginally, and most women with breech babies are limited to cesarean section.

The best candidate for vaginal breech delivery is a woman with a full term baby of average size who is in frank breech position. This is because the buttocks are the same size as the head and can prevent cord prolapse. Frank breech is the most common breech position.

If you desire a vaginal birth, it would be good to discuss the possibility of vaginal breech with your care giver. Your care giver may or may not be comfortable attempting a vaginal breech delivery, and it would be good to know this when selecting your care giver in the beginning of your pregnancy, if possible.

Personal note: We didn't know my baby was breech until I started pushing. There was no preparation I could have made. However, I don't consider the breech position to have been a complication in my baby's birth. We had birth professionals with us who had the training and experience necessary to guide us in the birth of our baby, and I was able to birth him vaginally in the birth tub at home. The water enabled my baby to manipulate his body to assist in his own delivery, and I don't think he could have done that if we had been out of the water. I feel that my overall calm approach to the birth helped things go much more smoothly than they would have if I had been afraid. It's important to prepare yourself physically, mentally and emotionally for your baby's birth, and be prepared for the unexpected. It also helps to have a good support team! Click here to read my breech home birth story. The video below is not of my own baby's birth, but it's a wonderful example of a breech water birth.



For more information about breech presentation, or any other pregnancy or birth topic, please see The Thinking Woman's Guide to a Better Birth by Henci Goer, and Pregnancy, Childbirth and the Newborn, by Simkin, Whalley and Keppler.

The Birth Wars: Who's winning the home birth debate?

The Birth Wars: Who's winning the home birth debate?

This is an excellent article that details the home birth debate between the medical community and those who are pro home birth. I found it to be very interesting and informative. I would recommend this article to anyone who is interested in learning more about the pros and cons of hospital vs. home birth, and the research studies (or lack thereof) that are behind the claims on both sides of the issue.

Two Hundred Hospitals Nationwide Will Replace Formula Sample Bags with Breastfeeding Support Sample Bags

"This month, 200 hospitals across the country are replacing their formula discharge bags and samples with the country’s first breastfeeding support promotional discharge bag.

"The “Healthy Baby Bounty Bag” contains product samples, coupons, and information that support and encourage breastfeeding without a packet of formula and without conflicting and contradictory messages about breastfeeding. Hospitals including UCLA Medical Center, Children’s Hospital in Boston, Mount Sinai Medical Center in New York City, and Exeter Hospital are among the first to distribute Healthy Baby Bounty Bags to new moms."

Click here for the article on growingyourbaby.com and for a list of the items in the bags.

Visit www.cottonwood-kids.com/gift for all the details.

Click here if you want to contact Cottonwood Kids They're a small company, and they can use lots of support and word of mouth to spread the word about the good work they're doing!

Breastfeeding Cafe in Salt Lake City

The Breastfeeding Café runs August 1 - 31 at the Main Library in downtown Salt Lake City. At this year's Breastfeeding Café new and pregnant mothers will find classes, discussions and instructions on this normal and healthy practice. All classes and events are free!

"It provides optimal nutrition for your baby, and can quickly calm a fussing child. Unfortunately, breastfeeding is not really the norm in our society and women are often encouraged to give it up sooner than they should. But, many Utah moms and health professionals say breastfeeding can literally save the day, and have plans to show what they mean at this year's Breastfeeding Cafe."

"One example of how breastfeeding saved the day is this harrowing story from Oregon. After nine days of waiting in their car, snowbound in the wilderness, Kati Kim and her children were rescued. Remarkably, Kim's 4-year-old and 7-month-old daughters survived the ordeal because Kim was able to breast-feed both of them."

"it's important for moms to understand that even small inconveniences, like delayed appointments, power outages or car problems can upset the family feeding schedule. Breastfeeding is the healthiest and easiest solution to those trying days."

Click here for the Breastfeeding Cafe 2009 Calendar

Click here for the whole article

See www.utahbreastfeeding.org for more information or to volunteer.

You can find more information about breastfeeding at www.babyyourbaby.org. Or, you can call the hotline at 1-800-826-9662.