An Osteopathic look at labor and delivery
I promised a few weeks ago a post on labor and delivery, so here goes:
The first thing to remember is that the osteopathic approach sees the body as being capable of self-maintenance and repair. It is in that light that we look at the woman in labor, not in a medical light.
The Osteopath sees pregnancy as a natural process (as we see all disease) which needs to be assisted, not managed. The end result of that process is labor and delivery. There is no difference which would automatically necessitate medical management just because the process is now ending.
The assistance of labor actually begins during pregnancy. Regular osteopathic treatments help the body adjust to the changes that are taking place, and prepare the body for labor. Specifically this includes making sure the pelvis is balanced, and the sacrum is free to move forward and back so that the baby’s head can pass through. But there are other important considerations. Labor and delivery is a very tiring process which can last more than 24 hours. The body needs to conserve energy and utilize it as efficiently as possible in order to make it through safely. Any other somatic dysfunctions which are present will take energy away from the situation at hand and make the body less efficient. For this reason it is helpful to have the whole body checked out and treated prior to delivery.
The initiation of labor is something the body does on its own, when the baby is fully developed and ready to enter the world. Modern medicine has no idea how to determine if the baby is ready to be delivered, yet they routinely “induce” labor for a multitude of reasons. Premature babies are at risk for a multitude of problems, most commonly respiratory distress, but also infections, heart defects, and developmental delay. Prematurity is usually defined as being born at less than 36 weeks, but any child delivered before the uterus spontaneously begins contractions is at risk for being premature. If you had a cake recipe that said to bake for 40 minutes, would you take it out at 38 or 39 minutes?
Once labor has begun, the best thing for women is to be as ambulatory as possible. This allows for natural spread of the pelvic bones (called the pelvic inlet) and allows the baby to “engage” or move head-first into the lower pelvis. For a woman who is having “back labor” caused by the baby’s head pressing against the sacrum, being upright may allow the baby to rotate to a more appropriate, less painful position. Osteopathic treatement aimed at the sacrum, pelvis, and especially the sacro-iliac joints (between the sacrum and the pelvis) may allow for more motion of the pelvis and sacrum and encourage proper positioning of the baby for descent through the birth canal.
As labor progresses the pain of contractions increases. During this difficult time, strong pressure over the low back may help reduce pain. A small study by RA Guthrie showed that inhibition of the back muscles can give 80-100% relief in 65% of patients. Most women will get relief from spending time in the water, preferably in a tub which allows almost complete submersion.
The final stage of labor, called transition, is the most intense, with contractions sometimes overlapping, and the pain is at its peak. During this time a skilled birth-assistant will be addressing the emotional and psychological well-being of the woman more than the physical aspects. Women need gentle support and constant reassuring that they can make it past this difficult time, and that each contraction is getting closer to the birth of their baby. Through confident coaching, the woman is now into the delivery phase.
After transition begins the pushing stage. For many women this is a relief, as it is a change from the difficulty of transition. The pushing stage can last from 30 minutes to 4 hours. During this time two important issues develop: First, the woman needs to stay hydrated, as she may be working for a while; Second, the woman needs to assume the most beneficial possible position for pushing. This will differ from woman to woman, and may change during the pushing stage for a given woman as the baby moves down the birth canal. Squatting, kneeling, either in the water or on the bed, are all positions that utilize gravity to assist with pushes. Laying on one’s back, also known as the lithotomy position, is the least beneficial position (except for maybe doing a headstand!), and is made even worse with forced flexion of the knees towards the head.
The reason the lithotomy position is least advantageous for pushing has to do with the shape of the pelvis. If you were to lay on your back, the pelvic outlet actually curves slightly upward (towards the front). If you bring your head up, as in most hospital beds, you curve the pelvis even more forwards. Finally, pushing the knees up towards the head induces even more forwards curve. All of this together makes the pelvic outlet smaller, and the baby has to do more work to pass through. This is one common cause for “prolonged pushing.” From an osteopathic perspective, as long as the woman is progressing and the pushes are effective, they should continue. If they become ineffective, the doctor needs to assess the situation to see if there may be a more advantageous position for pushing. It is not uncommon for women to change positions multiple times during the pushing stage.
Once the head is crowning, one or two more pushes are all that are required for birth. Episiotomies are largely unnecessary, and can lead to deeper tears of the perineum. Early cord clamping is not natural, and so should be discouraged. In fact, the most osteopathic approach would be to do very little for the mom and baby at that point, leaving them to bond skin-to-skin and even nurse. Of course, appropriate steps should be taken to make sure that neither is in danger.
I hope that this overview has given you an appreciation of a natural approach to childbirth. Unfortunately in America it is very difficult to have this type of birth attended by a physician, even an osteopathic one. This has to do with the rules and regulations set out by professional colleges (ACOG), insurance companies, and hospitals afraid of non-intervention. Your best bet is to look for a supportive physician or certified professional midwife who can help you on your journey. For more information on midwives, contact Midwives Alliance of North America.
February 11th, 2010 at 1:51 am
Your writing is very inspiring me. Thaks’ for sharing