Monday, December 22, 2008

"She's got good birthin' hips"!

She’s got great birthing hips”! Have you heard that one before?
I see the following questions all over the net:
My hips are small, (insert measurement size) can I give birth naturally?
I know a women with really wide hips, and she ended up with a cesarean - what happened?
If you have big hips is child birth easier?
Can a woman's hips be too small for a vaginal delivery?

These are not dumb questions. The idea that a woman’s hip size has everything to do with her ease of birth is not a new idea. It’s been a way of thinking for centuries, and it’s hard to shake a long standing myth.

Let’s break this down. First we need a nice picture. Thanks to the 20th U.S. edition of Gray's Anatomy of the Human Body, originally published in 1918 - we can safely use the following pictures because they are now public domain.
You see those Micky Mouse ears on that pelvis? That is the ilium, and that is what we think of as the hip bone. Now the ilium comes in all different sizes. But the size of that iliac area does not have anything to do with birthing babies. When it comes to birthing, it’s the size and shape of that round hole in the middle of the pelvis that counts - but keep reading, because there is more to that than meets the eye. The main hole in the middle of the pelvis is called the pelvic inlet. This is where the True Pelvis begins. There is much more to the anatomy of the true pelvis, but I’m going to skip it, dare I bore you to death. The True Pelvis is what is measured during a medical assessment. Let’s pretend we are comparing two different women. The size of hip bones (the ilium and iliac crest) might be quite large, and in the other, they may be much smaller, but their pelvic inlet may be the same size. So we can’t go by the measurements of our waist - or the size and shape of our pelvis. But guess what else? Measuring the pelvic inlet is ALSO not a big help! Even with the help of x-rays, and presumably accurate measurements we cannot predict the passage of a baby through that pelvis. Here is it where it get’s *really* interesting.

What most people do not understand is that the pelvis is not an immovable structure. We tend to imagine the pelvis as something solid and some believe it is one giant bone. There are four joints that join different pelvic bones together. During pregnancy and labor the hormone relaxin softens and relaxes the ligaments that join the pelvic bones, allowing the pelvis to give and 'stretch'. Look at the above picture again - this time focus on where it says “pubic arch”. In between the two bones that meet there in the front lies a pad of cartilage. This is symphysis pubis. In some women there can become a pretty good gap there. It can be painful towards the end of pregnancy when this happens. However, my point is to show you that the pelvis can “open”. Look at the picture below and check out the ligaments attached to the various parts of the pelvis.

The story continues. There is one more thing we must consider. The baby. A baby’s head is made up of several bones - and they are made to overlap during birth. This is what causes molding. No one, not even a doctor, can tell a women how much the babies head will mold - or how much a woman’s pelvis will relax to accommodate that baby. The *only* way is to try it.

Women are told all the time that they have a pelvis that is too small. They end up with an automatic cesarean without a trial of labor, only to give birth to the next child - much bigger in size, vaginally. Just ‘google’ the many stories! The diagnosis of CPD (cephalopelvic disproportion - meaning babies head is too big compared to the size of the pelvis) is given out way to often - sometimes before the birth, and sometimes after a long labor followed by a cesarean. A long labor, and even a long pushing stage is not an indicator of a small pelvis/big baby. Often these same mothers give birth to their subsequent children who are much bigger. Labors stall for other reasons. This diagnosis gives women doubts in their bodies, and then they pass these doubts on to other women. A woman who is a size 20 and has a nice large hips is told she cannot give birth naturally to her 6 pound baby. She tells the woman who is a size 5, with ‘smaller hips’, and then this poor women doubts her ability to give birth. Next thing we know, we have women measuring their hips, and wondering if they will have a harder or longer labor - and they are scared of a baby bigger than X pounds.

I write this because there are so many women out there questioning their ability to give birth. I don’t know if doctors are afraid of lawsuits, or what - but why is there such an increase in this ‘problem’? I’m just really glad that there are women out there that go ahead and say “YES I CAN!”. It is because of these women that we know that this diagnosis is often wrong -perhaps to error on the safe side of a lawsuit.

Tuesday, December 16, 2008

Prodromal Labor

So you're having contractions around your due date, but you haven't actually produced a baby! Sound familiar? I'll bet some of you are already dilated (and/or effaced), but confused as to why this baby isn't sitting on the outside of your tummy yet!

Prodromal labor can be very confusing! Heck, it's not easy to remember the spelling either!

Prodromal labor is also known as "false labor".  Most women will say, "There's nothing false about what I'm feeling!" - and they are right!

Prodromal labor isn't all in vain. These annoying contractions condition the uterus, and prepare the cervix for dilation and effacement. In fact, sometimes the cervix may even dilate and efface as a result. It’s all about your body preparing for the big day. Let’s talk about the differences between prodromal labor and the real thing.

1. Prodromal ‘labor’ may begin hours or days (and do I dare say weeks?) before active labor. (If you experience more than 4-6 contractions in an hour and you are not in your 36th week yet, consider the prospect of it actually being preterm labor).
2. They may feel like Braxton Hicks contractions but sometimes they can be much stronger.
3. Unlike true labor, where contractions usually become longer, stronger and closer together, prodromal contractions are irregular in duration, length and intensity.  I tend to see moms complain that there is a pattern in how close they are together but they don't usually get stronger and closer together. 
4. They may have a pattern and show up about the same time every day (or night).
5. They will stop after a few hours.. (Okay, maybe longer than that for some of you!)
6. They may or may not be affected by your activity. Sometimes a warm bath will make them go away, and on other days, it may run it’s usual course - leaving you to wonder if *if it's really it this time*!
7. Your cervix may begin to dilate, and efface and you may lose your mucous plug. Nothing false about that!

Many women head to the hospital only to find out after a few hours that it was 'false labor'. In other words, the contractions stopped. You may have dilated, or effaced but everything came to a screeching halt. Being sent home can be emotionally confusing. You are left to wonder how you will know when it *is* the real thing. You might be embarrassed to head back up to the hospital the next time, and then you wonder about giving birth on the side of the road! (For those of you birthing at home, the scenario might be different of course...but for sake of time and length, I'll let you fill in your own scenario blanks).

Most women figure it out. It may take more than one trip to the hospital (or call to the midwife), but don't worry.. eventually you'll end up in true labor that will produce a real baby. Most care providers are used to this type of labor, and would rather you be seen if you feel the need, then miss your birth all together. Typically in true labor, the contractions will become stronger, longer (in length), and closer together. With prodromal labor, you may not see the emotional sign posts of labor.  Contractions are there, but aren't getting longer, stronger and closer together, so you may not see the physical and emotional things that come with real labor. 

Can you make them go away? Can you stop the contraction by changing your position? Will they slow down with a warm bath or shower? What about if you eat or drink? Now with Braxton Hicks contractions, these things will usually make them go away. The problem with prodromal labor is that sometimes these things can make them go away, but there's a good chance they will keep coming for a little while.  Go about your regular business. If it's night try to sleep.  If they do happen to keep coming, pretend you are in early labor.  Rest, eat and stay hydrated.  Time will tell if this is the real deal or another false alarm.  Either way, you need to stay rested up for when labor hits in earnest. 

Why does it happen? Although I don't have an evidence based answer for this question, I will tell you what I've learned from personal observations. There might be an emotional reason (perhaps a fear the mother hasn't quite worked through). Sometimes it seems like the body tries to do it's job, but our heads get in the way and talk us out of it. (The mind is a powerful thing ya know!). Once the mother faces her fears, or the fear is resolved, she goes into labor. Perhaps the fear connection is coincidental. It may also be that our bodies are just revving up for the big day, and needs a few practice sessions first. I've got a feeling that more often than not, its caused by the baby's position. It's like the body needs to use those contractions to align the baby's head just right. A positioning tool! I'm not talking about a breech baby, I'm thinking more along the lines of a posterior baby, or an acynclitic head. Once your baby has moved into a decent position to put proper pressure on that cervix, off you'll go!

Here's a tip: Spend some time on your hands and knees. At the very least, try forward leaning positions while sitting or standing. If your baby is truly posterior, you may be able to let gravity turn that head the way it should be for an easier birth. If baby is already in a good anterior position, he'll just stay that way, so it won't hurt anything to try anyway.

Finally, relax - and let your body do its work. You may find your labor easier, and perhaps a bit faster if you were blessed with prodromal labor. Take advantage of these contractions and practice your relaxation, breathing or whatever you plan to use to cope with labor.