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29 May 2018

How do I know my baby is growing well and is healthy?

There are several ways to measure how your baby is growing:

  1. measuring your bump with tape measure
  2. measuring your bump with fingers
  3. estimating your baby's weight with an ultrasound scan
  1. Measuring your bump with tape measure

Measuring the height of your uterus helps determine if your baby is growing normally at each stage of the pregnancy. The term for measuring your uterus is called the symphysis-fundal height. This means the midwife will feel for the top of your uterus (ie the fundus) and using a tape measure will measure from the top of the fundus down to the bony part of your pubic

At about 13-14 weeks, the top of the uterus is usually just above the mother’s pubic bone. At about 20-22 weeks, the top of the uterus is usually right at the mother’s bellybutton (umbilicus). At about 36-40 weeks, the top of the uterus is almost up to the bottom of the mother’s ribs. Babies may drop lower in the weeks just before birth as they go into the pelvis and this may decrease the fundal height.

In terms of centimetres, measurement of the symphysis-fundal height will correspond to the number of weeks that you are pregnant, ie at 30 weeks pregnant your fundal height will be approx. 30 cms.

2. Measuring your bump with fingers

Some midwives will instead of a tape measure use their fingers to measure how many fingers above the umbilicus the top of the fundus is, ie 1 finger per 1 centimetre. The limitations for this finger method is that every clinician's hands are different and this can lead to a discrepancy in measurement. Measuring with a tape measure overcomes this problem.

As healthcare professionals, we need to take into account your and the baby’s father’s genetics – taller parents will tend to mean a taller baby, and vice versa. Also important is having continuity of carer – ie the same person measuring the fundal height. Having the same person measure your bump at each appointment will mean they are best placed to pick up any discrepancies. In the hospital where I worked at, we looked at if your bump measures more than 2 cms smaller or larger than your gestation (number of weeks) then you may be referred to get an ultrasound scan.

3. Estimating your baby's weight with an ultrasound scan

Another way you to find out how well your baby is growing is through an ultrasound scan. The sonographer will measure the femur length, head circumference amongst other measurements. This is then plotted against the average for that gestation. These measurements can be seen in your ultrasound scan report and for normal results you are looking for the black dot (•) to be anywhere along the line – like this |-----•---|. If the dot is on the left side of the lines then your baby’s growth is on the smaller side • |---------| or if it is on the right side of the lines it is on the larger side |----------| •

Using these measurements, the baby’s weight can be estimated. However, keep in mind that the further along in your pregnancy you are the more difficult it becomes for the sonographer to accurately perform measurements. This leads to overestimating a baby’s growth and can lead to unnecessary worry. According to a 2016, an analysis of the outcomes of 64,030 women shows that the practice of estimating the baby’s weight before it is born is associated with an increased chance of the woman having a caesarean section.

  • 18.5% of women who had their baby’s weight estimated by ultrasound and documented in their notes had a caesarean section
  • 13.4% of women who had their baby’s weight estimated clinically (estimation by a midwife/doctor feeling the baby with their hands) and documented in their notes had a caesarean section
  • 11.7% of women whose baby’s weight was not estimated/documented had a caesarean section

Midwife and author, Sara Wickham, states that we must not underestimate the effect that our human perceptions have on decisions. If clinicians think and see documentation that the baby might be larger than average they might be quicker to suggest a caesarean section. What concerns Sara is when women are not told about the possible risks and benefits of this type of screening (measurement) before it is performed on them and then documented in their notes.

The national guidance for the UK (NICE 2008) also suggests that ultrasound estimation of fetal size for suspected large unborn babies should not be undertaken in a low-risk population.

Sara says “given the ramifications of this screening test, not to mention the fact that our estimation of fetal weight is often not that accurate… we need to give some serious thought to whether it is justifiable to continue such a practice or whether it might be something that women should be informed about and asked about before it is performed”.

Would you prefer to be asked whether you want to know the estimated size of your baby? Would you find it helpful to know for yourself what your baby’s estimated weight is at each antenatal appointment? Or would you only rather know whether the baby is growing smaller or larger than average and then get further screening tests?

If you would like further reassurance or information I offer one-off antenatal appointments at home where we can fully discuss your situation and your options – you can book an appointment via the contact form.

References:

Froehlich, RRJ, Sandoval, G, Bailit, JL et al, for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network (2016). Association of Recorded Estimated Fetal Weight and Cesarean Delivery in Attempted Vaginal Delivery at Term. Obstetrics & Gynecology 128(3): 487-94. doi: 10.1097/AOG.0000000000001571

NICE (2008) Clinical guideline 62 – Antenatal care for uncomplicated pregnancies. National Institute for Health and Care Excellence (updated 2017)

 

24 April 2018

The labour process can be a marathon!


Did you watch the London marathon on Sunday? I'm a big fan and am usually on the street cheering the runners on, however, this year I was teaching a class. So, I'd like to explain how the London marathon is similar process of going into labour. This isn't meant to scare you at all, in actual fact it is meant to make you in awe of your body's capabilities.

They say that the level of energy your labouring body expends is the same as a marathon runner. Sometimes the early niggling phase of labour can be long and perhaps it ramps up to established labour and then stops and restarts again. This is called a long latent phase. 

This can leave you exhausted - a bit like when a marathon runner hits "the wall". So, as with any long-distance runner, it is important to look after yourself. Here are some tips if this happens to you:

  1. Trust the process - know that this is common and your body is getting ready for the event in its own way.
  2. Stay well nourished - important to keep your energy levels up. Labour is taxing on the body and if you don't eat much your body will start breaking down its own fat reserves. This will show up in your urine test as ketones (a side effect of breaking down fat). Perhaps you won't feel like eating big meals as it can be common to feel nausea and vomit. So, instead have small light snacks.
  3. Keep hydrated- keep sipping water or energy drinks. Perhaps not gulping down liquids as this may make you feel queasy and if you have too much water then you may suffer from low sodium levels.
  4. Go to the toilet- keeping your bladder empty: will prevent damaging the nerves around the bladder, and will mean your baby's head can descend further down into your pelvis.
  5. Try to rest - try and sleep if possible, you'd be surprised how many women are able to sleep in between contractions! If you can't lie down, try leaning over a your birth ball or pillows. If sleep doesn't come then try having warm baths, massages.
  6. Listen to your body- you may be told to keep mobilising, walking or bouncing on your ball to get labour moving on, but if you feel like resting, go with your instincts - you want to save your energy for later.
  7. Don't obsess over numbers- try not to pay attention to how many centimetres your cervix is dilated. If you are being examined vaginally, ask your midwife to tell you if your cervix is thinning or whether the baby's head has moved down. Both of these are also indicators that the labour is progressing - cervix dilation isn't everything!
  8. Remember oxytocin- this amazing hormone helps to progress your labour. Get yourself some cuddles, massage and low mood lighting to increase your oxytocin levels and keep adrenaline at bay. 

If you’d like to sign up to my Yoga for Labour and Birth workshop (28th April at 13.15-15.15) where I show you a yoga sequence to practise during this latent phase. There are only a couple of spaces left. Please email me or book the workshop on the Yoga West workshop website

 

 

17 April 2018

Breathing during labour

During pregnancy yoga, we do several exercises to stretch the sides of your body to give more space for your lungs. We also do breathing exercises to help focus the mind and body, and to regulate our breathing rate and ensure we are getting enough oxygen to your lungs and to your baby.

Generally, the breathing techniques that I teach places emphasis on your exhale. I do this by getting you to visualise a white feather floating in front of your face or a golden thread coming out of your slightly-parted lips. The aim is to blow away the white feather or gold thread further and further away from you during a contraction/surge/wave.

Perhaps you have heard of Ina May Gaskin and her sphincter theory. She explains how the more the jaw is relaxed the more the cervix can dilate. Therefore, by keeping your focus on your exhale and making it longer than your inhale you can help to speed up your labour progress.

This reminded me of a conversation I had with one of my friends. She commented on how her labour was helped by whistling throughout her contractions. I thought that was fascinating at the time and did some research. I found that some hypnobirthing techniques encourage women to make a noise during the exhale which could be a “sshhh” noise or a deep exhale. Indeed, my friend used a whistling technique. I think that having this added sound can help you to focus your mind on something other than the intensity of the labour sensations. Making a noise during the exhale can also work to lengthen it and relax the muscles in the face and jaw.

If you are a practiced yogi you may find it useful to use your Ujjayi breathing. This is another way to create sound during the exhale. This breathing technique is sometimes called "the ocean breath". It works by slightly narrowing the back of the throat which constricts the passage of air. It’s important never to hold your breath during labour (or in pregnancy) as your body and your baby needs oxygenated blood.

Another breathing technique to lengthen the out breath is by counting. Inhale to the count of 3 and exhale to the count of 3 initially, but then gradually lengthen the exhale to the count of 5. You can count in your head or get your birth partner to help you count out loud. Alternatively, instead of counting perhaps focus on the sensation of cold air coming in through the nostrils and warm air leaving your nose and mouth.

If you’d like to sign up to my Yoga for Labour and Birth workshop (28th April) where I show you different breathing techniques to go along with each stage of labour please email me or book the workshop on the Yoga West workshop website

 

10 April 2018

The Importance of Making a Caesarean Plan

You might be thinking: ‘what’s the point of making a caesarean birth plan?’ Perhaps you know you definitely don't want one and are preparing for a vaginal birth. However, by making this plan it doesn't mean you are going to have a caesarean - you might not! And by making this plan it doesn't mean that you will thoroughly enjoy the theatre experience – you may not. It just means that you are better prepared and feel actively involved to cover this eventuality should it arise. 

Caesarean sections can be planned:

  • due to baby being in a transverse position (lying in a horizontal line across your uterus)
  • placenta covering the cervix
  • your choice

Or they can be unplanned, as a situation arises during labour (what you might call an emergency section):

  • if circumstances deviate from normal
  • if there are concerns for your health or your baby's health during pregnancy

An emergency c-section's name is a little misleading because it is not always an urgent/life-threatening situation. If this is so, then it is called a crash section.

There are many different reasons why a caesarean might be necessary or wanted, but I’m not going to go into them now. However, here are some useful tips to ensure you regain some control over a situation where you might feel you have no control over.

The Gentle, Natural or Woman-centred caesarean

This is a new type of caesarean that puts the woman back at the centre of her birth experience. Circumstances may dictate that this is the way your baby needs to be born, however, you can still make some choices around the environment and what happens to your baby immediately after birth. What constitutes a Gentle Caesarean?

  • the room is kept calm and quiet
  • all theatre staff are asked to stand at your head end while your urinary catheter is inserted to maintain your dignity and privacy
  • music of your choice is played (using your own headphones as one of my yoga student’s did, or ask the theatre staff to tune in the theatre’s radio to your preferred music station)

“when we were in theatre a radio was playing so I asked for it to be turned off and I put on my headphones and listened to your labour and birth playlist which I had downloaded. My son was pulled out of me to the ‘breathing ripples track which I think is what you often play at the end of your classes during shavasana” – Lucy, Acton

  • the screen is lowered during the birth so that you and your partner can watch your baby being born
  • you can still choose delayed cord clamping (as long as all is well with baby)
  • the ECG dots are attached to your back so as not to interfere with immediate skin-to-skin
  • your IV line to be placed in your non-dominant hand so it is easier for you to touch and hold your baby
  • ask the theatre staff not to tell you the sex of the baby, if you want to discover it or yourself

The above 8 points are not the ‘standard’ method of caesareans, so you will have to have a discussion with your care providers to see whether they can accommodate your wishes. Because it is not the ‘usual way’ of doing things you may be met with some disgruntled care providers. Don’t be afraid to consult different obstetricians or go to a different hospital, if your first obstetrician does not do certain elements of your gentle caesarean plan.

If your caesarean is done under general anaesthetic, you can include some other points for your plan:

  • ask for a film/photo of the birth to be taken of your baby being born. Being able to see the film/pictures afterwards can help it seem more real to you
  • ask for the baby to be placed for skin-to-skin with your birth partner

Remember that your birth experience will remain with you for the rest of your life and so it is important that you feel happy and your choices are respected. Studies have shown that feeling in control and respected during the birth experience have a huge impact on you and your family. Be prepared to negotiate with your care providers and find ones that will support you in your choices. Furthermore, you may never have to use your Caesarean birth plan, but I think it is good to have it for ‘just in case’.

 

Hayley and baby Indy
Hayley and baby Indy

 

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Birth Story: Becs and Marley

Becs begins by telling me how the events unfolded on a Sunday afternoon when she felt her waters break. What follows is her birth story as told by her to me. I have full consent to share her story.

There was a lot of expectation of having the birth at the birth centre... And everything I’d been studying, reading, and working towards was going to be encompassed at the birth centre.

Becs went to the birth centre where the midwives confirmed her waters had broken. However, since she was not having any contractions/surges, she was told she couldn’t use the birth centre.

That was the first moment I realised that everything was going to go very differently to plan. People keep telling you to stay open to things not going your way, and in that moment, my whole world came crashing down.

After reviewing her options, she chose to opt for expectant management – waiting for labour to start naturally. Most women (90%) will go into labour naturally within 48 hours of the waters breaking.

She decided to wait for things to start naturally and in the meantime monitor for signs of infection. Throughout Monday she tried all sorts of things to kick-start the labour – from eating pineapple, long walks, yoga, raspberry leaf tea. Becs had already started to feel sporadic tightenings and felt like mentally retreating inwards. By Tuesday morning, her surges had ramped up and she felt the need to use a TENS machine to help. By midday, the surges came every 2 minutes, and she started to feel intense pressure down below. So she got ready to go to hospital.

It was quite hard to get into the car, and to try and find a comfortable position … I had my pregnancy pillow and was lying on my left side with my head out the window. So, the looks people were giving us when we stopped at traffic lights and I was surging hard! We had one guy roll down his window, clapped and said, “go on, go on, you can do it!”

Once in hospital, Becs was examined and found to be 6cm dilated! In the labour ward she was looked after by one midwife and her student. Becs chose to use a birth pool and experienced a huge relief from the warm water – “pure feelings of surrender, and floating felt incredible”. She used her breathing techniques to help ride through the surges. The midwives attending her encouraged her to listen to her body and push if she needed to. After 1 hour of being in the water, Marley was born and brought up to her chest.

What a feeling! Your attention is diverted to something so much greater and what you have in your arms. I first sniffed his head – that beautiful baby smell!

One aspect that Becs found she was not prepared for is the checks that happen after the baby is born, ie checking for perineal tears, which felt very invasive. The gas and air really helped during this part. Both Becs and Sam (partner) are huge Bob Marley fans.

Bob Marley playing in background really helped. The midwives were singing along whilst doing the check-ups.

All in all, it was an amazing experience not only for the new parents but also for the midwives. This was the first water birth that the student had witnessed! Both the student and the experienced midwife felt privileged and commented how it gave them hope that birth doesn’t always have to be completely medicalised.

Rebecca: Was there any part that was challenging?

Becs: I think the challenging part for me was just keeping my focus. As the surges start to intensify, as your body starts to open, it gets more and more challenging to maintain the focus to your breath and to work through those surges. I felt like I had to drop a lot of my own ego and drop a lot of my own layers to reach that point, to get really deep into the intuitive side of myself.

Rebecca: How did you overcome this?

Becs: You have to trust the process. You have to trust that you do have it within you to dig deeper. You have to trust your baby and you have to trust your birth partner. It was really important for Sam to understand the breathing techniques. Find what anchors you, find what grounds you and make sure your partner knows what that is.

An important factor is having control over the birth environment you create. For Becs this was her birth playlist, muslin cloths with lavender oil, her breathing techniques, and having a wonderful birth partner in Sam who encouraged her when she felt like giving up. Having someone you trust is imperative.

Rebecca: Name 3 things that you learnt about in pregnancy that you found really useful and helped in your labour.

Becs:

  1. Breathing technique– During pregnancy and anytime I felt overwhelmed or needed a breather I would use these techniques: in-breath for 4 and an out-breath for 6, and also relaxing every single part of your body. On a few occasions, Sam helped count me in if I lost the focus, but it was mainly an internal thing.
  2. Mantraof “trust”– Trust became an important mantra for me to have. Having faith in yourself is important, having faith in the baby and the midwife.
  3. Yoga– I would be absolutely nowhere without yoga. Being able to move your body is a beautiful thing. No matter how small the movements are or how big, whatever it is you need to do on that day, just make the time to move your body – it definitely needs it and definitely helps you tune in.

Rebecca: and you practiced right up until the birth?

Becs: Yes I was practising all through the labour. I was doing all fours, hip circles, cat cows – really helped with the spine.

Rebecca: Any tips that you’d give to other women who are expecting their first baby?

Becs: One thing that we have done, which seems like such a trivial thing, is cook food and freeze it. He [Marley] came early so we still had another week on our schedule to do cooking and freezing but we managed to get a good 20 meals in the freezer.