August 17, 2005
Volume 7, Issue 17
Midwifery Today E-News
“Prenatal Exercise”
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The Art of Midwifery

I twist a diagonally folded bath towel into a very tight roll and coil that into a ring for the new mother to sit on when breastfeeding.

Gloria Lemay, Vancouver, British Columbia, Canada, from "Midwife's Guide to an Intact Perineum," Midwifery Today Issue 59


ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.

MIDWIFERY TODAY ISSUE 59 (Theme is Prenatal Care)
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Research to Remember

A study ruled out breastfeeding as a means for mother-infant transmission of hepatitis C virus (HCV). Breastmilk samples and serum samples from 73 breastfeeding mothers with HCV were taken within approximately one week of each other. Serum samples from the women's 76 newborns were taken during the first week of life and again when they were between one and three months old. All the infants were breastfed. All maternal serum was found positive for HCV antibodies; none of the breastmilk samples were confirmed positive for HCV RNA. Seventy-five of the infants tested negative with each test, and one tested positive for HCV RNA at 27 days old. It took three to 28 months for the infants to lose maternal antibodies.

American Family Physician, March 1, 2000


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Prenatal Exercise

During pregnancy, the weight of the growing uterus causes the spine to overload every day. The stretching pelvis adds risk of injury to the spine, and also weakens core muscles. Building core stability is essential before, during and after pregnancy. The "core" consists of all the muscles that support the spine. "Stability" refers to the capacity of the body to maintain and/or return to a state of equilibrium.

With repetitive strain and injury to deep muscles, as well as weak abdominal muscles, the body compensates by developing movement patterns to protect the injured muscles and restore equilibrium. Instead of stimulating the deep muscles to provide stability to the spine, the nervous system recruits the superficial muscles. This can lead to muscular tension, further injury and weakening of the core. To change the pattern, an individual must increase awareness and move the spine slowly and consciously. This activates the movement centers of the brain and helps retrain the deep muscles to become the first responders in establishing core stability.

As long as the spine is aligned and deep muscles activated, weight is evenly distributed through each spinal disc, which is the ideal shock-absorbing position. In this way, the spine can carry heavy loads without damage.

Deep muscles typically form bundles, which attach from one vertebra to another, from one vertebra to several vertebrae or from the vertebra to the rib cage. Small muscles located close to the bone exert little force and are constantly working to maintain or recover proper alignment. Located closer to the skin, superficial muscles are larger and more powerful and span greater distances than deep muscles. Superficial muscles in the torso help perform large movements requiring full range of motion as well as actions of the spine. Many people have back problems because they have underdeveloped deep muscles in the torso. When a person with underdeveloped deep muscles tries to maintain an erect posture, the superficial muscles take over, which causes them to spasm or create discomfort.

The following yoga poses for expectant and new moms will strengthen and stabilize the core as well as reduce lower back discomfort.

Hugging Baby

  1. Comfortably sit, stand or lie on the back (first trimester and postpartum women only). Perform a posterior pelvic tilt and hold this position.
  2. Inhale deeply, expanding the belly. During the exhale, pull the belly button toward the spine. Repeat 12 times, rest and repeat again 12 times.

Rounded Cat Stretch

  1. Got to hands and knees position; make sure back is straight.
  2. Inhale. On the exhale, tighten abdominal muscles, tuck chin in and round the back. Inhale, returning the back to tabletop position.
  3. Continue for 12 breath cycles, then rest in "child's pose" (see next pose).
  4. Repeat for another 12 breath cycles.

Child's Pose

  1. Sit on knees with buttocks resting on heels. Extend ankles. Position knees a comfortable distance apart to accommodate the abdomen. If this is not comfortable, get into a tabletop position with buttocks over knees and arms under shoulders.
  2. Keeping arms shoulder-width apart, reach forward with palms on floor. Pull shoulders back away from ears. Tuck chin in and rest forehead on floor.
  3. Breathe deeply into the back and sides of torso.

Balancing Sunbird

  1. Get into tabletop position, with flat back.
  2. Stretch right leg behind you, and keeping back straight, raise heel to level of buttocks or below. Keep abdominals engaged to support the lower back.
  3. Bring right leg in and repeat exercise on left side.
  4. Bring left leg in and rest in child's pose.
  5. Return to tabletop position and straighten right leg behind you, raising heel to level of buttocks or below.
  6. Shift weight onto right hand and straighten left arm next to left ear. Balance in this position. Continue to breathe normally and use the muscles to abdomen to support back.
  7. Bring leg and arm in and repeat on opposite side.
  8. Rest in child's pose.

Flamingo

  1. Standing in good posture, take arms out to the side at shoulder level and step forward onto the right leg.
  2. Bend the left knee and balance.
  3. Keep abdomen engaged to support torso and reduce arching of lumbar spine. Hold for eight breath cycles.
  4. Return to standing position and repeat on other side.
  5. Repeat on both sides and try to reach arms above head with palms together to make it more challenging.

Sitting Spinal Twists

  1. Sitting comfortably on chair or floor, keep back straight with abdominal muscles engaged. Do not lean back in chair.
  2. Stretch arms overhead, bringing palms together and hooking thumbs. Arms should be pressing ears. If not, tuck chin in more to bring head between arms. Feel a stretch from hips to fingertips.
  3. Extend arms out to sides as you turn torso to the right. Continue to breathe deeply and rhythmically.
  4. Turn torso back to center, bringing arms overhead, then rest on things.
  5. Stretch arms overhead again with palms together. Open arms out to shoulder level and turn torso to the left. Hold as long as comfortable, then return to center.
  6. Repeat on each side, resting in between.

Editor's Note: This article by Bonnie Berk, RN, discusses in detail the lumbar spine, including the functions of psoas and abdominal muscles; the thoracic spine, and cervical spine. It also includes more yoga poses. Because of space limitations in this newsletter, this information was not included in this issue. The entire article is found in Midwifery Today Issue 59


Four major muscle groups comprise the front abdominal wall: the rectus abdominis, the outermost muscle that runs down the middle from breastbone to pubis; the external obliques, which run downward from the rib cage to the pelvis; the internal obliques, which cross underneath the externals and run diagonally upward from the pelvis to the rib cage; and the transverse abdominis, the deepest abdominal muscle that wraps like a corset around the middle.

The rectus abdominis is the main support system for the back. During pregnancy, the muscle changes in two ways. First, it elongates as a result of pressure from the expanding uterus. Then, conversely, the lower back muscles become shorter, which can cause backaches. The pressure of the uterus against the rectus abdominis may cause a diastasis—a separation of the muscle at or around the navel.

It is very important that women do abdominal exercises correctly; otherwise, the diastasis can become larger. Not all pregnant women get a diastasis, as is commonly believed, nor does it automatically go back together after birth.

Before a mother can strengthen the transverse abdominis in preparation for pushing, she must learn how to use the transverse muscle while breathing. With belly breaths, air is taken in through the nose, expanding the belly (transverse muscle goes forward). The air is then exhaled through the mouth as the belly (transverse) is brought in to the spine. Each exercise should begin with a belly breath so the transverse muscle is pulled in on the exhale, or working, part of the exercise.

The Elevator

Sit cross-legged on the floor or in a chair with support; the back should not move during these exercises. Because the action of the muscle is forward and backward, it works best to imagine the transverse muscle as a sideways elevator with five floors, using the belly button as the focal point. First floor is when the transverse is in a relaxed position; fifth floor is when the belly button "touches" the spine. When doing the exercise, remember to count because it forces one to exhale, which in turn forces one to breathe. The exercise begins with a belly breath, then the belly button is brought toward the spine where it is held for a count of 30. Close the eyes and visualize the belly button going out the back of the spine, or to the sixth floor, for the count of five. Conclude the exercise with another belly breath.

Contracting (Squeeze and Release)

Bring the transverse to the third floor. Then pull the belly button back from the third floor to the fifth floor. The emphasis is on the backward, squeezing, movement. Begin by doing 25 of these exercises, and work up to 100 repetitions three to five times daily. A set of 100 should take about one and a half minutes.

While doing this exercise, women can put one hand on their bellies and one hand on their backs; they should feel the exercise in their backs. When they become stronger, they should try to make the movement smaller by bringing the transverse from fourth floor to fifth floor. By delivery time, they should be able to pull the belly button from the fifth floor to the sixth floor 100 times, at least five times daily.

The transverse is attached to the recti, so every time clients do the contracting exercise they bring the recti back and together. It's important that the transverse be in or at the fifth floor, on the work of everything the women do. For example, when standing they can bring the belly button to fifth floor and hold it there. This not only strengthens the transverse and recti but also prevents any diastasis from becoming larger.

Caution: if women are doing something and cannot hold the transverse muscle at fifth floor, they shouldn't be doing that particular activity.

Julie Tuplar, RN, excerpted from "Back to Basics," Midwifery Today Issue 33


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I am hoping for a homebirth, but an ultrasound at 17 weeks indicated partial placenta previa. In my first pregnancy I was told I had low-lying placenta and that it wasn't a big deal. Is partial previa the same as low-lying placenta? My homebirth midwife doesn't seem too concerned, but she wants to look at a copy of the u/s report and plans to have another scan at 30 weeks. Does this mean there's a good chance the placenta won't migrate, or is she just being careful? How far away from the cervix does the placenta need to be in order to have an uncomplicated vaginal delivery?

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Question of the Week

Q: I have a client who is 32 weeks pregnant and has developed mild choleostasis. She now has it under control with the help of herbs, B vitamins (choline), Sam-e and improved nutrition. Most studies regarding the relationship of stillbirth and fetal distress to this condition seem vague. Has anyone worked with choleostasis, and if so, what have the outcomes been?

— H.M.


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


Question of the Week Responses

Q: What experiences have midwife readers had with shoulder dystocia and brachial plexus injuries? What techniques have you used successfully and unsuccessfully to relieve shoulder dystocia? Have you ever seen a brachial plexus injury where there was no shoulder dystocia, the delivery was textbook, but still an injury?

— Tanya

A: I have seen a brachial plexus injury without dystocia one time as a labor and delivery nurse. There are some theories out there that some brachial plexus injuries occur before birth.

Regarding dystocia techniques, if I expect a large baby, I talk to the mom before pushing and let her know that after the head delivers I want her to keep pushing unless there is a nuchal cord or meconium. I don't let the shoulders restitute if I can help it, as restitution makes the diameter slightly larger. When I think the baby is large, I rarely suction because most babies don't need it. Even if there is a nuchal cord, often times the mom can push the anterior shoulder under the pubic bone before restitution, and then you can have her stop pushing and reduce the cord. This method has worked well for me so far. However, reality is that you often cannot predict a dystocia and have to rely on standard maneuvers to resolve it.

— Julie Butts, CNM, Coos Bay, Oregon

A: While evaluating [the Pink Kit] I began to try out positions on my own to see which position I felt more "open" in. I discovered several positions that I feel sure would have opened my own vagina and changed my own shape enough to let my son pass through uninjured. Each mother and baby have unique sizing and fits and will require a positional change unique to that very moment. Hands and knees and standing are two of the positions I have seen used in dystocia resolution without injury.

Confidence and flexibility are essential. Of course, a more experienced midwife should share about the next step in resolution if positional changes do not work.

It is my understanding that breaking the clavicle allows for passage of the shoulder and leaves only a broken bone which will heal, as opposed to a lifelong injury.

Dystocia resolution is near and dear to me—thank you for asking this question. I look forward to reading replies and can offer mother-to-mother support to anyone with a child who has experienced a brachial plexus injury (Erbs Palsy).

— Mary Rainer, homebirth assistant, Fort Pierce, Florida mom@bellsouth.net


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A: In case of shoulder dystocia one shoulder is caught above the pelvic bony inlet. The length of the conjugata vera can be increased by 3/4 inch by stretching the hip joints, like when a woman is standing in a straight up standing position. This also guarantees the baby's own weight taking care of its body coming down without any pulling on the neck and brachial nerve. It comes from a very old technique by which a woman is laid hanging backward over the edge of a table with her legs hanging down freely. The Arabs in Spain some 500 years ago were familiar with it as a method to widen the pelvic inlet in order to promote engagement of the baby's head. Later when the English came to Spain they called it the Walcher's Position. Nowadays it has become rare when there are ample facilities to have a cesarean section. The true Walcher's Position is very uncomfortable of course, but the idea is to illustrate that one still can play with the measurements of the pelvic inlet in order to resolve a shoulder dystocia without doing any harm to either mother or baby.

— Gre Keijzer, midwife


Learn more about how to handle shoulder dystocia with our Shoulder Dystocia Handbook.


Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


Think about It

Midwifery is a spiritual act. Being with woman is more than just a physical presence. It requires attending to and respecting the magnificent energy and holiness at every birth.

Midwifery is a social act. Being with woman often involves members of the birthing mother's family, her partner's family as well as friends.

Midwifery is a multicultural act. Women from many different cultures call on a midwife for assistance. A midwife may be asked to participate in birthing ceremonies such as sprinkling water from the Ganges River on the baby's head as it emerges into the world or "laying hands" on the pregnant belly as God is called upon to be present.

Midwifery is a physical act. The physicality of birthing and assisting with birthing is second to none. There is blood, sweat and tears. There is grunting, moaning, pushing, holding, supporting, watching and waiting.

Midwifery is an emotional act. I have never been so deeply touched as I have with my own birthings and those I have had the blessing to attend, either as midwife, assistant, nurse, photographer or friend.

Midwifery is an act of faith. It is faith in the ability of a woman's body to do what it was created to be able to do and faith in the process of birth itself.

Chantal Molnar, excerpted from "Woman's Work," Midwifery Today Issue 69

What is midwifery to you? Write to E-News and share your thoughts with more than 12,000 readers around the world! mtensubmit@midwiferytoday.com

MIDWIFERY TODAY with the theme of "Midwifery Knowledge": Issue 69


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