Blog 6: What I want my daughter to know before becoming pregnant or in early pregnancy.

Let me begin with a disclaimer: I don’t have any daughters (I am blessed with 3 wonderful sons). However, as a childbirth educator of more than 30 years, I usually only meet pregnant women in their third trimester as they’re starting to prepare for birth. I often wish that I could have met them even before they became pregnant.

So I am writing this blog post with, what I believe, are a few important points to consider when planning a pregnancy or in early pregnancy. I know this is a vast topic and it’s not possible to cover everything, so I will include some links for those who want to research the topics further. Consider this the most basic information that you might not have thought about in order to have a healthy pregnancy.

There is SO much information on the internet and, coupled with specialized pages on Facebook and advice from girlfriends who have already made the transition to motherhood with a wide range of opinions (remember – they are opinions!!), we may feel daunted by all the things we might be made to feel we need to do, otherwise we might be harming our baby. That leads to guilt and stress – will that affect the developing fetus (more stress!!)? So – relax and enjoy your pregnancy. Look at the population of the world – women have done this before!!! Having said that, our world IS much more toxic than it was even when we were fetuses, so a little awareness of how to improve our health can benefit ourselves, our future children and our families.

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Firstly, and most importantly, you need to visit a doctor before starting to try to become pregnant.  it’s important to discuss with him/her at what point to stop using birth control and how long (if at all) you need to wait after stopping before trying to get pregnant. Stopping the pill a few months before starting to try to get pregnant will help you determine your cycle (do you have a 27 day or a 32 day cycle?) This will help you figure out when you ovulate and when you are most fertile. If you’ve been taking the pill for a while, your cycle could be different from the way it was before you started.

http://www.parenting.com/article/how-birth-control-could-affect-your-fertility?socsrc=ptgfb1509202

Depending on your ethnic background and medical history, your doctor may suggest testing for genetic disorders such as sickle-cell anemia or Tay-Sachs disease. He/she should also know about any genetic conditions in your family, such as a family history of Down’s syndrome, thalassemia or cystic fibrosis, to name just a few. If you do test positive as a carrier for any genetic condition, a genetic counsellor can help you determine how to increase your chances of having a healthy baby. This would include a blood test of you and your partner and, if a genetic disorder is present in either of you, options such as IVF may help to prevent a child from having this disorder.

Your doctor should know about any existing health conditions you may have, such as diabetes, asthma, high blood pressure, a history of depression, being overweight or underweight (or anything else that is relevant) and will be able to advise you regarding prescription or over-the-counter medication you are taking that might be contra-indicated during the pregnancy or in trying to conceive. For example, it is not safe to take some medications for acne when you’re pregnant. Even non-prescription drugs such as ibuprofen are best avoided in early pregnancy.

The concern is that taking certain medication might be teratogenic. A teratogen is an agent that causes birth defects and can include radiation, maternal infections, chemicals, and drugs. This can be a source of great stress to a woman, but there are, in most western countries, organizations that can help you determine if a particular agent is harmful during pregnancy.  Here is the link for women in Israel: http://www.health.gov.il/English/Topics/Pregnancy/health_centers/Pages/Tartology.aspx . For the US, consult: http://www.mothertobaby.org/  . If you live elsewhere, google your country’s resource.

Everything the mother ingests, puts on her skin or breathes passes through her system to the baby’s system. Although the baby is developing and growing during the entire period of gestation, the first three months are the most critical as this is when the baby’s body, including the organs, are formed. This is the period during which the woman should be most aware of what goes into her body. As she might not know that she is pregnant for the first few weeks, this caution is true also for women who are trying to get pregnant.

You may be given a blood test if your doctor thinks you might be anemic and to check whether or not you have antibodies for rubella. If not, you may be offered the vaccination for rubella, in which case your doctor will advise you how long to wait after being immunized before trying to conceive.

It’s also important for your husband/partner to get a check-up before you conceive to ensure that he doesn’t have any chronic illness or is taking any medication that might affect his sperm count or fertility.

Visit your dentist to make sure your teeth and gums are healthy. Current research links oral health to a healthy pregnancy. http://www.mouthhealthy.org/en/pregnancy/concerns?source=Morning_Huddle

Getting your body ready to grow a baby is important and may entail lifestyle changes. As I’ve said before, we live in a much more toxic world nowadays and this is an excellent time to develop awareness for healthy living for yourself and your partner as you prepare to transition to parenthood.

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Healthy Babies Bright Futures is an alliance of scientists and nonprofit organizations working to reduce exposures to neurotoxic chemicals in a developing baby. For more information, see https://www.hbbf.org/product-finder

While there are many articles about how to have an eco-friendly pregnancy, this might be a good place to start: http://www.mindbodygreen.com/0-15391/14-tips-to-minimize-toxins-if-youre-pregnant-or-want-to-be.html While following all of the recommendations listed in the link might be difficult or impossible, do the best you can to increase awareness and don’t drive yourself crazy.

Just because something is natural, it doesn’t mean that it’s safe. That includes herbs (also herbal teas) and supplements. For example, taking vitamins A and E in high doses can cause birth defects and you should not exceed the recommended daily allowance of these vitamins.

Folates are very important for the developing baby, particularly for preventing birth defects such as spina bifida and anencephaly, as well as other conditions such as autism. However, folate and folic acid are terms that are often used interchangeably, even though they are very different. For a detailed explanation on folate, including information on foods high in folate: https://ods.od.nih.gov/factsheets/Folate-HealthProfessional/

Another issue with folic acid supplementation is that as many as half of all pregnant women may not even be able to adequately absorb synthetic folic acid because of a common mutation of the MTHFR gene. In addition, while research has shown conclusively that folic acid is essential for the developing fetus, there is a possibility of a woman having too much folate: http://www.webmd.com/baby/news/20160511/too-much-folic-acid-in-pregnancy-tied-to-raised-autism-risk-in-study

I’m not trying to confuse you, just to raise awareness. It is most important to have enough folate in the early weeks of pregnancy, when you may not even realize you’re pregnant. Remember – the early weeks are when your unborn baby’s body and organs are developing. You should read these excellent articles: http://avivaromm.com/protect-your-babys-health-even-before-birth-5-important-tips-from-a-midwife-md and   http://avivaromm.com/nutritional-supplements-for-women  and discuss all these issues at your pre-pregnancy check-up with your doctor.

Certain foods may contain harmful bacteria, such as unpasteurized milk products, raw meat, undercooked eggs, deli meat and certain soft cheeses. In addition, contact with cat litter should be avoided. http://www.cdc.gov/parasites/toxoplasmosis/gen_info/pregnant.html

While studies on whether caffeine increases the risk of miscarriage have been inconclusive, most experts state that consuming fewer than 200 mg of caffeine (one cup of coffee) a day during pregnancy is probably safe.  As with all the topics in this post, do your own research to decide what’s best for you and your baby.

Caffeine, being a diuretic, interferes with the hydration and pH levels in the body and can create a level of acidity in the vagina that is not compatible with sperm. While some medical professionals indicate that one cup of coffee a day is ok, if a couple is having difficulty getting pregnant, then the pH balance may be relevant, in which case it may be helpful to cut out caffeine completely. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Moderate-Caffeine-Consumption-During-Pregnancy

Alcohol, drugs, cigarettes (including secondhand smoke) should also be avoided. While we don’t yet conclusively know the effect of cellphone use on a developing fetus, it may be prudent to cut down on cellphone usage and certainly never talk on a cellphone while it is charging. In addition, sleeping in an area where electric devices are plugged in or charging outside of a radius of 2 meters, is recommended.

Yet another thing to avoid is overheating, especially in hot tubs, saunas or hot baths. This is particularly important in very early pregnancy, as overheating has been linked to certain birth defects, particularly spina bifida. As the neural tube closes between 21 and 28 days of pregnancy, a time when you might not even know that you are pregnant, it is best to avoid overheating once you start trying to conceive. Even after you become pregnant and in later months, the baby depends entirely on you to dissipate heat (through your perspiration and respiration), so overheating should be avoided throughout the pregnancy. As exercise also raises the body’s temperature, it’s important for pregnant women to refrain from exercising in hot and humid conditions which would prevent the body’s system from dissipating heat.

The subject of nutrition is so vast, but so very important, if we abide by the dictum that ‘we are what we eat’. When it comes to fertility and conception, nutrition is of the utmost importance. As the man’s sperm is 50% of the genetic makeup of the baby, it is equally important for the man to be aware of what goes into his body.

During pregnancy, your body needs 300 more calories per day than it needed before pregnancy. It’s important to eat a balanced diet that includes lots of fresh fruits and vegetables, whole grains, lean sources of protein and to avoid unprocessed foods. It’s also important to drink plenty of water to stay hydrated and to avoid high sugar or artificially sweetened drinks.

Most pregnancy books include information on what foods NOT to eat during pregnancy, like raw fish, undercooked eggs, deli meats, etc. It’s important to check that out when starting to try to get pregnant. Here is a helpful guide to nutrition or what TO eat during pregnancy: https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000584.htm If you want to invest in a comprehensive book on healthy eating (and many other facts) during pregnancy, try this: http://avivaromm.com/books/the-natural-pregnancy-book

Exercise during pregnancy is important for both you and your baby. It can prevent excessive weight gain during pregnancy and can prevent or manage (together with nutrition) gestational diabetes. Exercising during pregnancy has also been linked to preventing hypertension, preeclampsia and preterm birth. It is also an excellent means of controlling stress, particularly as it releases feel-good endorphins. Check with your doctor before beginning any exercise routine once you are pregnant. You can continue whatever you were doing prior to getting pregnant, provided that you listen to your body’s signs. If you wish to begin exercising once you are pregnant, start slowly and increase intensity gradually, depending on how you feel.

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Swimming, yoga, walking and aerobics are all appropriate forms of exercise – provided that you feel good during and after exercising. Here are the current guidelines for exercising during pregnancy:

http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Physical-Activity-and-Exercise-During-Pregnancy-and-the-Postpartum-Period

While you may wish to stay with the Ob/Gyn you have been with since you started using birth control, his/her style of care may not be compatible with yours. If you are healthy and don’t have any medical issues, you may wish to see your family doctor or a midwife. In some places, midwives do routine prenatal care for low-risk, healthy pregnant women throughout the pregnancy. It’s important to know that your doctor’s philosophy of pregnancy will determine how many and which tests you have. Some women are happy to have every test suggested and others may want to have the minimum number, after determining that the pregnancy is normal.

Countless women ask me, towards the end of their pregnancy during the childbirth course I am teaching, why they needed to have so many ultrasounds during the pregnancy – in some cases, one at every prenatal check-up. When it comes to prenatal tests and ultrasounds, you actually do have a choice as to what you consent to during the pregnancy.  It’s really up to each woman to decide if she wants to have every prenatal test offered and to go to a doctor who does an ultrasound at every prenatal visit, or if she wants to choose which tests she does and do the early and late ultrasound scans (or none at all). She may decide to do only the non-invasive tests such as blood tests and to proceed according to the results (acknowledging that there are many false positives with certain tests). I’m not recommending any particular path to take – I’m merely raising awareness that each pregnant woman can choose her prenatal care according to what feels right for her and her partner.

Ultrasounds can be a useful diagnostic tool if a specific problem is suspected at any stage of pregnancy and is commonly used as a routine scan at around 18 – 20 weeks. If there is bleeding at any point in the pregnancy, a breech baby or twins are suspected, ultrasound can be useful for the woman and her doctor/midwife to make decisions as to her care.

Remember that the baby’s body and organs are developing in early pregnancy. As mentioned in the excellent link below, use the B.R.A.I.N. method to determine what is right for you. B = benefits, R = risks, A = alternatives, I = intuition, N = not now/never. http://sarahbuckley.com/blog/ultrasound-scans-in-pregnancy-your-questions-answered

A big incentive for writing this blog post is to help women find resources to deal with stress. All change, by its very nature, has the potential to cause stress, as it implies moving into unknown territory. Pregnancy is certainly such a time, as the article in this link demonstrates: http://europe.newsweek.com/how-calm-your-anxiety-during-pregnancy-315242?rm=eu . It’s too much information (including in this very blog post) that gets pregnant women all stressed out.

It is, however, important to know that it is only very significant levels of stress that really affect the baby long-term. That’s not usually what pregnant women experience, even if they are stressed about having a healthy baby, financial worries or tension at work.

It is, of course, not helpful to stress over how your stress might be affecting your baby. It can be very helpful, rather, to come up with techniques to cope with stress, even before you get pregnant. This is true for both you and your partner. Take a good look at what aspects of your life make you stressed. Can you take short ‘power breaks’ during your work? Can you and your partner work out household chores so you don’t feel exhausted?

It’s important to communicate your feelings to your partner. Share with him your fears and frustrations and see if he can help you deal with your stresses. Think about what you can do to help you unwind, whether it be exercising, practicing yoga, being in nature, reading, listening to music or taking a bath. Talking to your friends who have already had babies can be helpful before becoming pregnant and, once you are pregnant, connecting with other pregnant women can be help you realize that you are not the only one who might be feeling stressed.

Without trying to deny any of these feelings, mindfulness meditation can help you recognize your thoughts and emotions as passing ‘events in the mind’ and that ‘I am not my thoughts’. Starting a mindfulness meditation practice before or in early pregnancy can significantly help you deal with the stress of pregnancy. It can help you develop skills that can be very useful in childbirth as well as for parenting.

Some helpful resources for mindfulness meditation during pregnancy are: Mindful Birthing CD and App: http://www.mindfulbirthing.org/products/#cd

I can’t recommend these highly enough. I have trained with Nancy Bardacke and I, too, teach Mindfulness-Based Childbirth and Parenting courses. While I use my own CDs in my courses, Nancy’s are available commercially and are excellent and easy to use.

Here is another resource: http://www.givingbirthwithconfidence.org/blog/the-tool-thats-missing-in-prenatal-care

In order to give your baby the best start in life, it’s important that you do what you can to improve your own health and lifestyle even before you become pregnant. Once you become pregnant, find a good book on pregnancy and childbirth (though you probably won’t be interested to read the childbirth chapters for a while) and sign up to the Lamaze free e-letter with informative, evidence-based information for your pregnancy: http://www.lamaze.org/YourPregnancyWeekByWeek

Enjoy these unique moments as you prepare to create a new life in the world. It truly is an extraordinary time. And when you do become pregnant, savor each special moment as a new life grows within you.

 

Bio:

Rachelle Oseran (BA) became a Lamaze Certified Childbirth Educator in 1984 through the UCLA School of Nursing and has prepared more than 3000 couples for normal birth over the past 30 years. She is also a qualified MBCP (Mindfulness Based Childbirth and Parenting) instructor, a Birth Doula, certified by DONA International, a Fitness Professional certified by ACE (the American Council on Exercise), specializing in Prenatal and Postnatal Fitness and a Certified Yoga and Pilates Instructor.

She teaches a Lamaze-Accredited Childbirth Educator training course. Rachelle also co-founded and co-directed Great Shape/YMCA, the group exercise department of the Jerusalem International YMCA for 23 years and lectures in Israel and internationally on prenatal and postnatal exercise.

Rachelle was recently inducted as an FACCE (Fellow of the Academy of Certified Childbirth Educators) in recognition of her significant contribution in the field of childbirth education. She lives in Jerusalem, Israel, with her husband and 3 sons.

For more information, visit her websites at www.childbirtheducation.co.il and www.mindfulbirthing-israel.com, her Facebook page at Fit, Birth and Beyond – Rachelle Oseran or e-mail her at rachelleoseran@gmail.com

 

Blog 5 – MBCP – Mindfulness for Childbirth and Parenting.

Mindfulness. It’s probably THE catchword of the decade and its popularity is only on the upswing. What is it? What does it have to do with childbirth? How can I use it for parenting? How is it different from hypnobirthing?

Jon Kabat-Zinn, a molecular biologist who developed the hugely successful MBSR (Mindfulness Based Stress Reduction) program in the late ‘70’s, defines mindfulness as: “Paying attention, on purpose, moment by moment, without judgment”. Or, in other words, knowing what you’re doing while you’re doing it, or knowing what you’re experiencing while you’re experiencing it. (For a brief explanation from the man himself, you can watch a few very short videos):

What is mindfulness: https://www.youtube.com/watch?v=HmEo6RI4Wvs

Mindfulness: Liberation from suffering: https://www.youtube.com/watch?v=o14I-F2iI9U or any of his longer, more detailed videos (there are LOADS of them on YouTube).

Our culture values doing – the more, the faster, the better. In fact, many women say with a sense of pride how they are able to multi-task and get more things done simultaneously. But at what price? And who is suffering from this? Is this what I really want from my life? Why do I feel like my life is just passing me by and I’m exhausted at the end of each day?

Mindfulness is a state of being. Through specific meditation practices, we cultivate awareness of our physical bodies, our emotions and the thoughts in our minds from moment to moment. But mindfulness isn’t only sitting still with our eyes closed, focusing on our breath. Rather, through daily formal (mindfulness meditation) and informal practice (e.g. brushing our teeth mindfully), we cultivate our ability to be more aware of our bodies, thoughts and emotions in our everyday lives. It gives us the ability to be more awake to our experiences, to live more fully and joyfully and, according to many research studies, more healthfully.

We spend a great deal of time thinking about the future (very often this entails fear or anxiety) or stressing over something that has already happened, and very little time being in the present moment. Cultivating awareness in the present moment can help us realize that the past has already come and gone and thoughts about the future are just thoughts. In fact, one of the most important discoveries from practicing mindfulness is that “I am not my thoughts”. This can be extraordinarily liberating. It can help us look at a situation differently and respond with awareness, rather than simply ‘re’acting on auto-pilot the way we always have, which may not be in our best interests. In parenting, for example, it gives us new ways of responding when our toddler has a meltdown, even though we might just feel like having a meltdown ourselves.

Mindfulness Based Childbirth and Parenting (MBCP) is a formal adaptation of the 8 week MBSR program and combines MBSR and childbirth education. It was developed by Nancy Bardacke, Certified Nurse Midwife and mindfulness teacher who trained with Jon Kabat-Zinn. After 30 years of working with birthing women, she realized that learning to be in the moment not only helped the psychobiological process of labor and birth, it also helped women deal with pain, helped them relate to their partners on a deeper level, enabled them to be at peace with the labor experience they had and helped them parent with awareness and generosity, rather than out of fear, a sense of self-righteousness, or the desire to control. With all that in mind, she developed the MBCP program and wrote a book after teaching it for more than 10 years!

After reading her awesome book “Mindful Birthing – Training The Mind, Body, And Heart For Childbirth And Beyond” (http://www.amazon.com/Mindful-Birthing-Training-Childbirth-Beyond/dp/006196395X/ref=sr_1_1?ie=UTF8&qid=1410520146&sr=8-1&keywords=mindful+birthing ), I studied with her, training together with a dozen midwives and childbirth educators from around the world to teach this potentially life-transforming program. I have also been studying locally for several years with my MBSR teacher, Dr. Dina Wyshogrod (http://www.mbsrisrael.org/), who also trained with Jon Kabat-Zinn. Dina and I went to Rhinebeck, NY, this past June to participate in a professional retreat led by Jon and Saki Santorelli.

Those who know me, know that I have been a Lamaze Certified Childbirth Educator for 30 years and a teacher trainer for Lamaze International for the past 3 years. So does this mean that I no longer believe in Lamaze preparation for birth? Absolutely not. They are 2 very different paradigms, and I acknowledge the need to meet the different learning styles of expectant couples. In addition, only couples (that means BOTH partners) who commit to practicing the meditation techniques 30 minutes a day, 6 days a week for the duration of the course, are accepted to the MBCP course. It takes time and practice to cultivate a mindful state of being. I am aware that not all couples are willing/able to make this commitment.

While both Lamaze and MBCP courses cover the process of labor and birth, comfort and coping tools and partner involvement in the birth process, as well as preparation for breastfeeding and early parenting, Lamaze classes are more oriented to information as a tool for empowerment, while MBCP classes develop a ‘mode of being’. For example, in my Lamaze class we watch a carefully chosen birth movie (including many different births, with many different scenarios), to show how the couples use the same coping tools that we have learned in class. The philosophy behind Mindful Birthing, incorporating the attitude of ‘beginner’s mind’ (not being stuck on a particular outcome, but rather seeing every moment as new) means that we do not watch a birth movie, which may set up an expectation that the birth goes a certain way.

As I have been deeply influenced by practicing, studying and teaching mindfulness, I do incorporate some of the philosophy in my Lamaze classes, such as staying in the moment during labor. Both paradigms inspire women to have safe, confident and empowering birthing experiences. However, only through the specific meditation practices taught in MBCP classes can the laboring woman, with her partner’s support, enter a state of ‘being’ during labor. I am happy to speak to women and their partners to help them decide which course/paradigm would be most suitable to them.

MBCP teaching materials

MBCP classes include the foundational attitudes of mindfulness: Non-judgment, beginner’s mind, patience, trust (as self-reliance), non-striving, letting be, acceptance and compassion. Looking at any of these words, especially in relation to childbirth and parenting, will demonstrate that cultivating mindfulness is not easy. However, the practices – both in class and at home, together with the class discussion (known as ‘inquiry’) of the experience of the practice, help develop awareness for birth, parenting and give us skills for life.

I am often asked about the difference between hypnobirthing and mindfulness training. When your two-year-old throws a temper tantrum, instead of excusing yourself to listen to a CD or to come, through practice, to your quiet, peaceful place, through mindfulness practice, you are able to drop into the moment as it is occurring with awareness and respond to the situation with clarity and wisdom, rather than react with your usual auto-pilot behavior patterns.

While the deeply relaxed state that may be reached through training in hypnobirthing can be very helpful in labor, not all women are able to access it, or labor may unfold in a way that medical intervention becomes necessary for the mother’s or baby’s health. Some women feel a deep sense of disappointment at not having the labor go the way they had planned. The mindfulness attitudes of non-striving, non-judgment and acceptance can be very helpful in making peace with whatever arises.

New mothers often doubt their own instincts, saying that they don’t have any. They want to know which books to read and ask the opinions of other mothers through social media, without realizing that their child is unique and that often the situation is unique. Mindfulness training may give mothers and fathers new insight into their own parenting style, while responding to the best mindfulness teacher – their baby. Gloom and doom thoughts (fears about bad things happening) are seen as simply thoughts, which are not based on reality. The present moment is real. Fear is always about the future, which hasn’t yet happened.

When I teach the mindful communication practice to couples, I am always deeply moved as I notice that, in many cases, they are entering what is often unchartered territory – a deeper, more honest way of communicating. This can have far reaching effects on their relationship as a couple and on their parenting.

The MBCP program also includes a simple yoga practice (mindful movement) which is taught in class as one of the many mindfulness practices and which the couples then practice at home with guided instructions on a CD. This may alleviate the need to pay additional money to participate in a prenatal yoga class. (Yes, even though I, myself, teach prenatal yoga classes so I’m turning away potential clients!!)

There are 3 basic intentions to the MBCP program:

  • To offer systematic training in mindful awareness using the methodology and meditation practices found in the MBSR program.
  • To prepare expectant parents for birth and parenting through evidence-based information and mindfulness-based practices that promote the normal psychobiological processes of pregnancy, childbirth and the early postpartum period.
  • To lay the foundation for parenting mindfully.

We know that stress during pregnancy negatively influences the fetus. Mindfulness can greatly help women who have to deal with job changes, moving apartments or inconclusive prenatal test results, to name but a few of the many possible causes of prenatal stress. Preliminary research results have also shown a reduction of postpartum depression in women who practice mindfulness. This article published in the British Journal of Midwifery in 2009: “Mindfulness approaches to childbirth and parenting” explains in more detail the MBCP course and research findings: http://oxfordmindfulness.org/wp-content/uploads/Hughes-et-al-Mindfulness-Childbirth-Final-published-article.pdf

For more information about my MBCP classes (currently the only program of its kind in Israel), please see my website: www.mindfulbirthing-israel.com

I will end this post with a poem by Rumi, a 13th Century Sufi poet, that may help to convey the learning acquired through the practice of mindfulness meditation.

“Two Kinds of Intelligence” by Rumi

There are two kinds of intelligence.
One acquired, as a child in school memorizes
facts and concepts from books and from what the teacher says,
collecting information from the traditional sciences
as well as from the new sciences.

With such intelligence you rise in the world
You get ranked ahead or behind others
in regard to your competence in retaining information.
You stroll with this intelligence
in and out of fields of knowledge,
getting always more marks on your preserving tablets.

There is another kind of tablet,
one already completed and preserved inside you.
A spring overflowing its springbox.
A freshness in the center of your chest.
This other intelligence does not turn yellow or stagnate.
It’s fluid, and it doesn’t move from outside to inside
through the conduits of plumbing-learning.

This second knowing is a fountainhead
From within you, moving out.

Bio:

Rachelle Oseran (BA) became a Lamaze Certified Childbirth Educator in 1984 through the UCLA School of Nursing and has prepared more than 3000 couples for normal birth over the past 30 years. She is also a qualified MBCP (Mindfulness Based Childbirth and Parenting) instructor, a Birth Doula, certified by DONA International, a Fitness Professional certified by ACE (the American Council on Exercise), specializing in Prenatal and Postnatal Fitness and a Certified Yoga and Pilates Instructor.

She teaches a Lamaze-Accredited Childbirth Educator training course. Rachelle also co-founded and co-directed Great Shape/YMCA, the group exercise department of the Jerusalem International YMCA for 23 years and lectures in Israel and internationally on prenatal and postnatal exercise.

Rachelle was recently inducted as an FACCE (Fellow of the Academy of Certified Childbirth Educators) in recognition of her significant contribution in the field of childbirth education. She lives in Jerusalem, Israel, with her husband and 3 sons.

For more information, visit her websites at www.childbirtheducation.co.il and www.mindfulbirthing-israel.com, her Facebook page at Fit, Birth and Beyond – Rachelle Oseran or e-mail her at rachelleoseran@gmail.com

Blog 4 – What exercise advice should fitness professionals give to pregnant and postpartum women?

Yesterday (at the time of writing), I met with the Fitness Trainers and Exercise Instructors of Matti’s Studio in Jerusalem about what they should know about working with pregnant women and new mothers. I was invited by the owner who wanted her staff to give consistent advice to pregnant clients who were turning to them to have their fitness needs met. My hope is that more (in my fantasy world, I would say ‘all’) health clubs see this population as a source for future clientele. Professionalism and inspiring trust are excellent marketing tools and great ways to retain members.

As we didn’t have much time, we didn’t talk much about the numerous benefits of exercising during pregnancy. There’s loads of that on the internet (including this recent study that shows that exercising during pregnancy helps in fetal brain development): http://www.sciencedaily.com/releases/2013/11/131110204330.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Ftop_news%2Ftop_health+%28ScienceDaily%3A+Top+News+–+Top+Health%29 . I emphasized that it’s essential for a pregnant woman to get her doctor’s approval to exercise, even if she is continuing the same exercise routine that she has been doing for a long time. The problem with this is that, in Israel, many doctors don’t know that there are evidence-based, published guidelines about exercising during pregnancy, let alone what these guidelines say. Note that, in keeping with the Center for Disease Control’s recommendation for exercise for the general population, the most reputable guidelines for exercising pregnant women, those of the American Council of Obstetricians and Gynecologists (ACOG) say, “In the absence of either medical or obstetric complications, 30 minutes or more of moderate exercise a day on most, if not all, days of the week is recommended for pregnant women.”  (http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/Exercise%20During%20Pregnancy%20and%20the%20Postpartum%20Period.aspx ).  (These recommendations were ratified by ACOG in 2011 with no substantive changes). The Canadian guidelines go one step further and state that  “Women and their care providers should consider the risks of not participating in exercise activities during pregnancy”. (http://www.csep.ca/cmfiles/publications/scholarly/Joint_SOGC_CSEP_Guidelines.pdf ). That’s a far cry from the old recommendations that pregnant women MAY continue to do what they did before, and that they should limit the length of the most intense part their exercise session to 15 minutes and the intensity to a maximum of 140 beats per minute (those recommendations were discarded in 1994!). I hope that pregnant women who want to exercise will share these guidelines with their doctors and midwives who can then base their advice to pregnant women on current research.

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Of course, the most important consideration for a pregnant woman exercising is to maintain a favorable environment in the uterus.  Her exercise prescription should take into consideration what she was accustomed to doing before she became pregnant, how familiar she is with her new exercise prescription and how she feels when she does it (this will differ depending on the progression of the pregnancy and her energy level at that time). It is essential that the exercise prescription avoids any risk of injury, falling and abdominal trauma. What does ‘familiarity’ mean? While a woman with a normal pregnancy who hasn’t exercised before can begin a low impact aerobics program increasing exercise duration, frequency and intensity gradually, she should not be advised to join a spinning class! The intensity of her workout should be guided by the Rate of Perceived Exertion scale and the ‘talk test’ – she should be able to say a complete sentence at peak intensity.

The big controversy in prenatal exercise has been, for many years, exercising while lying on the back after the 16th week of pregnancy. Many instructors advise their clients that if they feel ok in this position, then a small amount of exercise on the back shouldn’t be a problem. I’m not sure what aspect of the sentence, “After the first trimester of pregnancy, avoid doing any exercises on your back” (ACOG 2011 recommendations) leaves room for interpretation. Even the current guidelines of the ACSM (American College of Sports Medicine) that previously had stated that a small amount of supine exercise may be ok, now state, “Exercising in the supine or prone positions should be avoided after the first trimester”.  That pretty much nixes a Pilates class after the 16th week, unless it is a class specifically for pregnant women, with modifications of positions. I wish more doctors encouraged their pregnant clients to exercise, but ignoring published guidelines is not a great way to inspire a doctor’s trust in a health facility or instructor.

While we talked about the usual issues of the importance of strengthening the upper back and stretching the iliopsoas muscles, I wanted to focus on the pelvic floor and the abdominal muscles. The big news flash is that we no longer recommend that pregnant women do 100 kegels a day! This will only lead to shortened pelvic floor muscles, not something a woman in labor will appreciate as she’s birthing her baby. The goal is now strength while keeping the length of the muscles, with exercises such as squats that work the gluteals (done with correct alignment). As so many pregnant women suffer from urinary stress incontinence (peeing every time they cough or laugh or sneeze), helping them develop awareness and the ability to contract the muscles before these stress triggers is a functional way of helping them with this potentially embarrassing situation.

So back to my all-time favorite subject – separated abdominal muscles. Many researchers have found that more than half of all pregnant women have abdominal muscle separation, classified as a width of 2.5 fingers or more at the largest point of separation, usually around the level of the navel. Can fitness professionals prevent this from happening during pregnancy and, if so, how? They can’t exercise on their backs after the 16th week and most pregnant women will place increased stress on the abdominal muscles when they are in the ‘all-fours’ position, so the critical issue of alignment needs to be the focus. While most fitness professionals follow the general caution that pregnant women should not exercise in this position, (planks, cat stretch, etc.), exercising in this position should be individually prescribed, based on the woman’s ability to engage the abdominal muscles against gravity.

A very effective exercise, reinforcing the concept of correct alignment, is done in the standing position. Have the woman stand with her back to a wall, with her heels, butt and head touching the wall, but with her shoulder blades drawn forward away from the wall by crossing her arms in front of her at shoulder height. On an exhalation, as she slides her ribs down, her shoulder blades will flatten against the wall. The flaring out of the ribs is often a cause of abdominal muscle separation that can easily be rectified with correct alignment.

When a new mom comes to exercise after giving birth, it is essential that her abdominal muscles be evaluated for separation, so that she can be safely guided to do the most effective exercises for her individual situation, otherwise a separation can be increased with incorrect exercise prescription. I would like to think that fitness professionals who work with pregnant women and new mothers share the same oath as physicians, “First – do no harm”.

While we talked about additional challenges and solutions for exercising pregnant women and new moms, the main emphasis of my talk was teaching correct alignment. It’s as easy as sitting upright on a strength training machine in the weight room, forward on the seat (not leaning against the back of the chair), with a small ball or yoga block between the knees to align the body and engage the core, which is so critical for pregnant women and new moms.

So thank you, Matti, for your professionalism in advancing your trainers’ knowledge about working with this population and for developing a policy of consistence. It is just too confusing for the public and doesn’t inspire confidence when different trainers offer conflicting advice. I hope more health clubs follow this example.

 

Bio:

Rachelle Oseran (BA) became a Lamaze Certified Childbirth Educator in 1984 through the UCLA School of Nursing and has prepared more than 3000 couples for normal birth over the past 29 years. She is also a Birth Doula, certified by DONA International, a Fitness Professional certified by ACE (the American Council on Exercise), specializing in Prenatal and Postnatal Fitness and a Certified Yoga and Pilates Instructor. She lectures in Israel and internationally on Prenatal and Postnatal Exercise.

Rachelle teaches a Lamaze-Accredited Childbirth Educator training course. She also co-founded and co-directed Great Shape/YMCA, the group exercise department of the Jerusalem International YMCA for 23 years.

Rachelle was recently inducted as an FACCE (Fellow of the Academy of Certified Childbirth Educators) in recognition of her significant contribution to the field of childbirth education. She lives in Jerusalem, Israel, with her husband and 3 sons.

For more information, visit her website at www.childbirtheducation.co.il ,  e-mail her at rachelleoseran@gmail.com  or contact her on +972-52-2342909.

Blog 3 – Why do I need to take a childbirth preparation course? Can’t I get all the information I need from the Internet?

You’re smart, you’ve read “What To Expect When You’re Expecting”, as well as the more sophisticated childbirth books by Ina May Gaskin, Janet Balaskas, Sheila Kitzinger, Pam England and others, you belong to the savvy pregnant and new mom Facebook groups and you know your way around the Internet. Like most women of childbearing age, you’re convinced that you can get all the information you need to prepare for your upcoming birth from the Internet. Right? Please read on to see why this could possibly lead to some very undesirable consequences for you and your baby.

How much time and energy do you spend on planning a vacation? Dare I ask the question how much time and energy you spent planning your wedding? Surely the way in which your baby comes into the world deserves the same, if not more, careful planning?  If it doesn’t matter to you what sort of birth you have and you are fine with the idea of going through the system, being cared for by those well-trained and experienced midwives and doctors who want a healthy mother and baby (but who work according to specific hospital protocols), then you probably don’t need to take a course.

However, if you want to know all of your options so that you can decide what sort of birth you would like to have, then you need a course that will explain your options. The cliché, “If you don’t know your options, you don’t have any” is totally appropriate in this context.

Helping couples integrate knowledge of normal physiologic birth and learning strategies to facilitate normal birth, understanding the impact of interventions on normal birth and promoting the attachment of mother and baby are a major focus in a good childbirth course curriculum. Knowing what questions to ask and how to have the type of birth you want (advocacy and informed decision making skills) are also key components of a quality course. For example, most hospitals routinely cut the umbilical cord immediately after birth unless the couple requests delayed cord clamping. What is delayed cord clamping? How does it benefit the baby? If it’s so beneficial to the baby, how come most hospitals routinely do immediate clamping?

While most midwives try to deliver the baby over an intact perineum (without cutting an episiotomy), many midwives still feel that it’s preferable to do a controlled surgical cut for a first birth. In many cases, the midwife won’t tell the woman that she is cutting and the woman doesn’t feel the cut as the baby is pressing on the nerves that numb the area. What is the evidence-based information regarding this issue? If you decide that you don’t want to be cut (unless it becomes necessary for your or your baby’s health and the baby needs to be born quickly), how can you try to avoid it? Is it only an issue of learning methods to stretch the perineum or do different pushing positions and techniques also reduce the likelihood of tearing?

A study published last year (http://www.ima.org.il/FilesUpload/IMAJ/0/38/19484.pdf ) and reported in Haaretz (a daily Israeli newspaper) http://www.haaretz.com/news/national/one-third-of-israeli-women-experience-post-traumatic-symptoms-after-giving-birth-study-finds-1.444401  found that “More than a third of new mothers in a study by Israeli researchers reported experiencing symptoms of post-traumatic stress disorder within one month after giving birth. These can include anxiety, irritability, difficulty sleeping and avoidance of stressful events (including doctor and hospital visits)”.

Although this is an Israeli study, the results could well be relevant to many other industrialized countries where hospital protocols often override the needs of individual women that reflect their core values.

A systematic review of 137 studies analyzing pain and women’s satisfaction with the experience of childbirth involving thousands of women in many countries concluded that “Four factors – personal expectations, the amount of support from caregivers, the quality of the caregiver-patient relationship, and involvement in decision making” are what constitute patient satisfaction in the birth experience. (“Pain and women’s satisfaction with the experience of childbirth: A systematic review” by Ellen D. Hodnett, RN, PhD, Am. J. Obstet. Gnecol, May, 2002).  This means that a woman’s satisfaction is determined more by the emotional care she received during labor than by the physical process itself, regardless of whether or not the woman used pain relief during labor and birth or even whether the birth was vaginal or by cesarean section.

Let’s look at the issue of ‘involvement in decision making’. A quality childbirth preparation course will help the couple navigate through the maze of hospital protocols in the specific location where they have chosen to give birth. While posts on Facebook groups will reflect the opinions of the women posting, a combination of evidence-based information and how to have your needs met in the location of your choice (advocacy) can only be found in a good birth preparation course.

Some women feel that they were bullied into taking medication or were spoken to in a humiliating or threatening way, (e.g. “With all due respect to natural childbirth, if you don’t get out of the shower now and agree to take Pitocin to speed up the labor, I will send you back to the admitting room because your labor is taking too long and we need the room for other women”). Not only can this abuse have an immediate negative effect on the labor but it can also have long-term effects on the self esteem of these women.

How many times have we all heard the comment, “The only important thing in birth is a healthy mother and a healthy baby”. Seriously? Even if it means that ONE THIRD of women will experience symptoms of post-traumatic stress disorder, potentially impacting their relationship with their spouse and baby (and possibly other children) to say nothing of their own self image? While certainly recognizing that the health of the mother and baby is of paramount importance, it is not the ONLY important thing, and right up there in priorities are the woman’s feelings of self worth and accomplishment, even if she chooses to take medication or if the baby is born by cesarean.  What is often overlooked and underestimated is the fact that a woman will remember her birth experience for THE REST OF HER LIFE.  She will remember not only the events of the birth, but also how she was treated and how involved she was in the decision-making process.

A big part of a quality childbirth preparation course is learning how to ask questions and to make her wishes heard in order to have the type of birth a woman wants, while maintaining harmony in the labor room. A student from one of my recent childbirth courses told me how her doctor wanted to use a vacuum as she had been pushing for a while and the baby was starting to show signs of distress. She asked the doctor if she could try pushing for another 2 contractions or if this was an emergency. The doctor said that he thought it was ok for her to push a bit longer as it was not an emergency. She then used upright positions and effective techniques and helped push the baby further down in her pelvis, before the doctor determined that he needed to use the vacuum to deliver the baby. After giving birth to a healthy baby, despite the intervention used, the woman was thrilled that she had pushed the baby down and had minimized potential harm to her pelvic floor and to the baby. She felt empowered and confident that her wishes had been heard, even though she needed to change her original birth plan according to the situation she faced in that moment.

If a woman feels positive about her birth experience, then those feelings carry over to mothering her baby and to her self esteem as a parent, even though, as we all know, those first few weeks of mothering a newborn baby are wrought with exhaustion and frustration. Why would we want to add to that already challenging situation symptoms of post-traumatic stress disorder?

I put the question of the need for taking a childbirth course over learning information about birth from the Internet to former students of mine. Yes, the population was skewed, but only women who have taken a course would know the difference. Here are some of the responses I received:

1) “Access to an expert and a live course was important for answering a lot of the ‘Why’s’. There is so much — often conflicting — information out there. The course offered a way to authoritatively sort through all the info (and pseudo-info), allowing participants to make their own informed decisions. Without it I think they’d be stuck (whether they were aware of it or not) using other people’s opinions and/or making uninformed decisions, possibly with undesirable consequences.”

2) “For me, learning about childbirth was not only about getting information but it was about the experience of coming to terms with my fears and expectations of birth through a process (group sessions, hearing from each other, and sharing our own thoughts).  This is something I couldn’t get from the Internet or books and it helped me enter labor in a more calm and positive way. Having you as our professional guide helped us to navigate what is mandatory, optional, and even not recommended when it comes to birth, as well as gave us a resource to turn to for later questions leading up to the birth and after.”

3) “I found it helpful to take a birthing course mostly because of the ability that you have to ask clarifying questions.  Online, and in books, people write from their own perspective.  You don’t always know if it’s research-based, and you run the risk of misinterpreting what they say.  It helps to have someone guide you through the process, so that you can ask clarifying questions, and understand the ‘source’ of the information better. Secondly, it’s important because you don’t necessarily know the breadth of information to ‘look up.’  A teacher can tell you about techniques, theories, and research that you, yourself, would never think to ‘google’.”

My wholehearted advice is – take a childbirth course, preferably with an independent educator (who is not restrained by the need to adhere to hospital protocol), who is able to give evidence-based information that will help you decide what type of birth is appropriate for you and will give you the tools to have that birth. Trust me, you can’t get the information you need from blogs (including this one!!!!). Take a course.

Bio:

Rachelle Oseran (BA) became a Lamaze Certified Childbirth Educator in 1984 through the UCLA School of Nursing and has prepared more than 3000 couples for normal birth over the past 29 years. She is also a Birth Doula, certified by DONA International, a Fitness Professional certified by ACE (the American Council on Exercise), specializing in Prenatal and Postnatal Fitness and a Certified Yoga and Pilates Instructor. She lectures in Israel and internationally on Prenatal and Postnatal Exercise.

Rachelle teaches a Lamaze-Accredited Childbirth Educator training course. She also co-founded and co-directed Great Shape/YMCA, the group exercise department of the Jerusalem International YMCA for 23 years.

Rachelle was recently inducted as an FACCE (Fellow of the Academy of Certified Childbirth Educators) in recognition of her significant contribution to the field of childbirth education. She lives in Jerusalem, Israel, with her husband and 3 sons.

For more information, visit her website at www.childbirtheducation.co.il ,  e-mail her at rachelleoseran@gmail.com  or contact her on +972-52-2342909.

 

Blog 2 – Squatting in labor – a new understanding of an old position.

We’ve known for years that squatting during the pushing stage of labor opens the pelvis and helps provide more room for the baby to be born. Research by Russell in 1969 looked at the increase in pelvic diameters from the squatting position in the second stage of labor.  He updated this research in 1982 and indicated that squatting increases the pelvic outlet by 1 cm. in the transverse diameter (side to side) and 2cms. in the antero-posterior diameter (front to back), resulting in an increase of 28% in area compared with the supine (lying on the back) position.

We are all born with the ability to squat. If you watch how a toddler bends to pick up a toy from the floor, she will squat. However, through years of sitting on chairs, our muscles have tightened up and we have lost the flexibility needed to squat. This position is taught in many childbirth education and prenatal yoga classes to regain some of the flexibility lost over the years and to get the woman used to it and to encourage her to squat during the pushing stage of labor – after many hours of labor and during contractions.

However, many midwives insist that they have anecdotal evidence to the contrary – that squatting does not open the pelvis and can even lead to a longer pushing stage and a difficult birth. The midwife will often encourage the birthing woman to change positions after seeing a lack of progress in the descent of the baby (the baby moving down through the pelvis).

So what is the truth behind this age-old position? My journey to finding the answer began when I attended the Midwifery Today conference in Costa Rica in 2007. I thought that, with the world’s most famous midwives all gathered together, this would be a wonderful opportunity for me to ask them about their experiences with birth in the squatting position. As I began to question them, I was puzzled by the answers – “The squatting position closes the pelvis, unless the woman has being doing it culturally”. What on earth does that mean? I continued my questioning and was amazed to find that not one single midwife I questioned deviated from this response!!!!! However, none of them was able to explain this further. It was just presented to me as a fact.

On my return to Israel, I realized that I had to make some sense of my findings, so I decided to look at the facts less from my role as a childbirth educator and doula and more from my many years of experience as a fitness professional.

The femur (thigh bone) inserts into the pelvis at the acetabulum, a cup-shaped socket in the pelvis. When the knees are open with the knees and toes pointed outward, the femur presses on the socket, causing it to draw the ischia (the sitting bones) closer together, making the outlet of the pelvis smaller. So that’s what the midwives meant by “squatting closes the pelvis”.

But what about the other part of their statement: “…unless the woman squats culturally”?  Let me back up a few years to explain this point from informal research I conducted many years ago. In 1986, Elizabeth Noble, the author of “Essential Exercises for the Childbearing Year” (compulsory reading for anyone involved in the field of prenatal/postnatal exercise) visited Israel. I met with her, together with some of my birth professional colleagues, and we showed her around the old Misgav Ladach Hospital (on Kovshei Katamon) in Jerusalem. She was most impressed. She told me that she had been invited to present a paper on Exercise During Pregnancy at a national conference for Ob/Gyns and midwives to be held a few months later, but was unable to return to Israel and asked me to fill in for her! I had attended her workshop in Los Angeles the previous year and she knew that I taught prenatal and postnatal exercise.

What a daunting task! I realized that I would need to present new and original findings, so I went to the English Hospital in Nazareth and Barzilai Hospital in Ashkelon to look at the effects of cultural influences on birth, particularly the use of the squatting position. In looking at the birth practices of women from Arab villages and Ethiopian women, I found that, even though they delivered in hospitals (the former in the lithotomy position and the latter on all 4’s), their births were very different from other Israeli women. They had fewer occipital posterior presentations (where the baby’s face is turned outwards instead of facing the mother’s spine) and shorter second stage labors. The midwives at these hospitals and I concluded that these differences were due to the use of the squatting position in their daily lives. While this wasn’t very scientific, it nevertheless indicated, anecdotally, that women who squat culturally are able to benefit from the squatting position for birth.

Now we come back to our current analysis, to try to understand the biomechanics of the pelvis with women who squat culturally. If anyone reading this blog has traveled in Asia or Africa, or even watched workers waiting for a contractor to pick them up for a building job, we see that, when squatting is a part of the culture, the position is with the feet parallel to one another and the knees and toes pointing forward. Squat toilets in Asia have a place for the feet that keeps them in a parallel position. This is very different from the squatting position taught in childbirth preparation and prenatal yoga classes, where the toes and knees are pointed outward.

Please don’t take my word for this, but try this yourself. In a standing position, with your feet a little more than hip width apart, place the fingers of each hand on your ischial bones (your sitting bones). You may have to dig deep to feel them in a standing position.


Now squat down, keeping your feet, knees and hands in the same position (feet and knees parallel, and fingers on your sitting bones). Most people will need to place a rolled up towel or a book under their heels, unless they have the flexibility in their ankles to place their heels on the floor.

Feet and knees forward, wider width between sitting bones

Feet and knees turned out, narrower width between sitting bones

Next – turn your feet and knees outward, and feel how your two hands are drawn closer toward each other. Now turn your knees and feet back to parallel, and you will feel that your hands move further apart from each other, meaning that there is a greater distance between the sitting bones, part of the outlet of the pelvis.

Feet (almost) parallel, knees parallel, wider transverse diameter at the pelvic outlet

Wider transverse diameter at the pelvic outlet, but narrower transverse diameter at the pelvic inlet

Feet and knees turned out, narrower transverse diameter at the pelvic outlet, but wider diameter at the pelvic inlet

Wider transverse diameter at the pelvic inlet, but narrower transverse diameter at the pelvic outlet

If you have a medical indication not to squat (e.g. knee injury, etc.), ask someone else who does not have such a medical indication to try it.

Now clearly, pregnant women in advanced pregnancy are, by design, unable to keep their feet and knees parallel to one another when their feet are hip width apart while squatting. They need room for their babies! Pregnant women should practice this position with their feet (parallel) wider than hip width apart, using something stable for support (against a partner/wall/bed/stable piece of furniture), or they can use one of the many modified versions of supported squats or a squatting stool (a type of birthing stool). They can also use a rolled-up towel under their heels. At the time when they will benefit most from this position, the final phase of the pushing stage of labor, their babies will be much lower down in the pelvis, so they will not feel that there is such a lack of space.

Supported squat with parallel feet and knees

Those of us who teach the hip squeeze as a comfort tool for active labor, know that we squeeze the butt cheeks and, by design, the lower part of the pelvis. This, in turn, widens the pelvic inlet, creating space for the baby to move down into the pelvis. During the pushing stage of labor (depending on how low in the pelvis the baby is lying), pressure on the iliac bones (protruding hip bones) widens the outlet of the pelvis.

By the same logic, the squatting position, even with parallel feet, would not be beneficial in early or active labor, but would be most beneficial once the widest diameter of the baby’s head has passed the ischial tuberosities, the narrowest part of the pelvis.  That’s when, according to the research by Russell cited at the beginning of this blog, the pelvic outlet would open substantially.

Another issue to consider is not practicing the squatting position for a lengthy period of time during the third trimester of pregnancy as it could cause the baby to enter the pelvis in a less than optimal position if the baby isn’t yet lying in the best position. A supported squat with the hips higher than the knees (against a wall or with a partner) would prevent this from happening, as would the full squat for no longer than 20 – 30 seconds. In any event, squatting with feet and knees parallel, in order to practice the position for the pushing stage of birth, is unlikely to cause the baby to engage in the pelvis as this position narrows the pelvic inlet.

Try it yourself and see if you notice any difference in the width between your sitting bones as you squat with your feet and knees turned out and with your feet and knees in a parallel position.

References:

  1. Russell, J.G.B., “Moulding of the Pelvic Outlet”, J. Obstet. Gynaec. Brit. Cwlth, Sept. 1969, Vol. 76, pp. 817-820.
  2. Russell, J.G.B., “The rationale of primitive delivery positions”, British Journal of Obstetrics and Gynaecology, Sept. 1982, Vol. 89, pp. 712-715.
  3. Pauline Scott, “Sit Up and Take Notice! – Positioning Yourself for a Better Birth”. Great Scott Publications, New Zealand, 2003.

Bio:

Rachelle Oseran (BA) became a Lamaze Certified Childbirth Educator in 1984 through the UCLA School of Nursing and has prepared more than 3000 couples for normal birth over the past 29 years. She is also a Birth Doula, certified by DONA International, a Fitness Professional certified by ACE (the American Council on Exercise), specializing in Prenatal and Postnatal Fitness and a Certified Yoga and Pilates Instructor. She lectures in Israel and internationally on Prenatal and Postnatal Exercise.

Rachelle teaches a Lamaze-Accredited Childbirth Educator training course. She also co-founded and co-directed Great Shape/YMCA, the group exercise department of the Jerusalem International YMCA for 23 years.

Rachelle was recently inducted as an FACCE (Fellow of the Academy of Certified Childbirth Educators) in recognition of her significant contribution to the field of childbirth education. She lives in Jerusalem, Israel, with her husband and 3 sons.

For more information, visit her website at www.childbirtheducation.co.il ,  e-mail her at rachelleoseran@gmail.com  or contact her on +972-52-2342909.

Diastasis Recti (separated abdominal muscles after birth)

Blog # 1

Abdominal muscle separation (Diastasis Recti) after birth

 

I decided to join the blogging world and this is my first blog! I agree – the internet is already saturated with information on every aspect of health, including pregnancy and birth issues. However, I am stunned that, while there are heaps of posts on a variety of subjects, some topics of great importance to childbearing women are dealt with quite superficially, if at all.

During my almost 30 years of working with pregnant and postpartum women as a Prenatal and Postnatal Fitness Specialist, a Lamaze Certified Childbirth Educator, Birth Doula and also as a Pilates and Yoga Instructor, I have been approached by women from all over Israel who cannot find any satisfactory answers to their problem of abdominal muscle separation after birth (diastasis recti). These women come to me after being told by a surgeon that the only way to draw these muscles back towards the midline of the body is through surgery. I know that this is not true as I, personally, have helped many women return their abdominal muscles to their pre-pregnancy state through individualized, targeted exercises.

So why aren’t other fitness professionals, physiotherapists or doctors dealing with this topic? Why are women coming to me in Jerusalem from Netanya, Tel Aviv, Kfar Saba, Raanana, Haifa, Petach Tikva, Rishon LeZion, etc.? This information is so relevant to so many women, that I decided to dedicate my first blog to this subject. However, this is still a blog, rather than a university course in public health, so it will deal with only the most important information that new (and not so new) mothers need to know.

The woman on the left has never had a baby. The right and left sides of her rectus abdominis muscle (otherwise known as the “six-pack muscle”), which runs vertically from her sternum to her pubic bone, are held together at the mid line of the body by the fascia (connective tissue) known as the linea alba.

The pelvis needs to widen to enable the baby to move through it during birth. As bones do not stretch, the body releases hormones during pregnancy to soften the connective tissue in order to widen the pelvis for birth.  These hormones (primarily relaxin and progesterone) affect all connective tissue in the body (not only the joints of the pelvis), including the linea alba. In addition, the linea alba may not be strong enough to withstand the force from the growing uterus on the abdominal wall, causing the right and left sides of the rectus abdominis muscle to spread apart at the linea alba. This is known as diastasis recti (see the woman on the right in the diagram).

This condition is more apparent in petite women, women carrying two (or more) fetuses, women with poor abdominal muscle tone, genetic factors and after a cesarean birth. During a cesarean, the abdominal muscles are not cut, but are rather separated with retractors which hold them apart while the surgery (and birth) take place.

It is normal to have a small separation during pregnancy and after birth. During pregnancy, about 30% of women develop diastasis recti, particularly in the third trimester. A woman may notice this if she sees a pyramid shape bulging between her abdominal muscles when she gets up from lying down in the bathtub (or from any supine position). According to a study published in the Journal of Women’s Health Physical Therapy in 2005, the occurrence and size of diastasis recti is much greater in non-exercising pregnant women than in exercising pregnant women. Women who have diastasis recti (DR) during pregnancy should do supervised abdominal exercises (mainly core stabilizing exercises) as certain standard exercises, such as sit-ups, will increase the separation. They should also lie down and get up by turning on their side first, bending their knees, and using their hands for support to lie down or to get up.

Most women have some separation in the first few days after birth, though this separation usually decreases by 1 – 4 weeks.

To check for DR (see photos above):

  1. Lie on your back with your knees bent towards the ceiling, keeping your feet and knees hip-width apart.
  2. Place 2 fingers 1 – 2 cms. below the navel, parallel to the waistband of your pants.
  3. Lift your head and feel how many fingers you can insert, widthwise, between your abdominal muscles.
  4. Lower your head.
  5. Repeat the check, but now lift up your pelvic floor muscles (see below), draw your navel towards your spine and slide your ribcage down towards your pelvis. Checking for a separation while activating your abdominal muscles is a more accurate check for DR.
  6. Repeat the check, while activating your abdominal muscles, 1 – 2 cms. above the navel.

A width of up to 2 fingers is normal. A width of 2 ½ fingers or more is considered a separation, or DR. Most women have a separation at the level of the navel, though some have a more extreme separation either below or above the navel.

All women after birth (whether vaginal or cesarean) should be checked for DR before resuming abdominal exercises. It is particularly important for women with DR to perform exercises to draw the muscles back to the midline before a subsequent pregnancy, otherwise the separation could be cumulative (it may increase with each additional pregnancy).

If you have DR, please see the following clip for some basic exercises to help return the muscles towards the midline of the body:

http://www.youtube.com/watch?v=470ndTV1khA&feature=youtu.be

Of particular importance if a woman has DR, is awareness of the pelvic floor muscles. The layers of muscle and other tissues that form the pelvic floor stretch like a hammock from the tailbone (coccyx) to the pubic bone. While there are many ways to activate these muscles, for now it is important to learn the following pelvic floor exercise (to be performed in any position where the buttocks and thighs are relaxed):

  1. Inhale. While you exhale, tighten the muscles around the urethra and vagina as though you are stopping the flow of urine. Keep them contracted. (Although it may be helpful to check that you are doing this correctly in the toilet by stopping the flow of urine, after identifying the muscles, don’t do this exercise while urinating, as withholding urine in the bladder can cause a bladder infection).
  2. Inhale. While you exhale, tighten the muscles around the anus, as though you are trying to control diarrhea. Keep them contracted.
  3. Inhale. While you exhale, bring the front and back parts that you have contracted towards each other and draw them up as though you are lifting them up deep inside your body.
  4. Breathe normally, without contracting the muscles of your buttocks  (gluteal muscles) or thighs, for about 5 seconds.
  5. Slowly release the muscles (rather than dropping them down).
  6. Rest and repeat several times.

While doing any abdominal exercise, lift the whole area up as one unit during the “work” part of the abdominal exercise, and relax the whole area during the rest phase.

Many new moms are so weak in their abdominal and pelvic floor muscles that, while doing any abdominal exercises, they bulge out these muscles rather than drawing them in. If you always activate your pelvic floor muscles (by just lifting the whole pelvic floor up, rather than doing the isolated exercise as described above), you will notice that you will also feel some slight activation in your lower belly. What you are doing is gently contracting your transversus abdominis muscle (TA), the deepest set of abdominal muscles, as the TA works in synergy with the pelvic floor muscles. This means that, when you lift up your pelvic floor muscles while doing any abdominal exercise, you cannot inflate your abdominal muscles (the incorrect way of doing abdominal exercises) as you are automatically working your TA, which serves to draw the belly inward. The TA muscle can (and should) be further activated with targeted exercises.

Activating the pelvic floor muscles and the TA muscle is the most important first step in resolving the problem of separated abdominal muscles.

The two exercises I have included in the video clip (the corset exercise and the see-saw or pelvic rocking exercise) are basic exercises to begin to correct the problem of DR. In addition to these exercises, it is important to learn stabilizing exercises, i.e. learning to control the abdominal and pelvic floor muscles while moving the arms and legs in certain directions. It is always advisable to exercise under the supervision of an experienced fitness professional who understands the problem of DR and is familiar with ways in which to solve the problem.

Certain exercises should be avoided if you have DR:

  • Regular sit-ups (or any exercise lifting the upper body against gravity) without supporting the abdominal muscles
  • Diagonal curls that activate the oblique muscles against gravity
  • Extreme rotation (twisting) of the upper body
  • Exercises that excessively stretch the front of the body (e.g. lying on your back over a large exercise ball, excessive backbends as in yoga or Pilates, etc.)
  • Severe coughing without supporting the abdominal muscles

Most of the women who come to me with DR come for aesthetic reasons – they don’t like the belly bulge that they have and they’re embarrassed by people asking them when they’re due to give birth! However, if the problem of DR is not corrected, it may very well lead to additional problems such as lower back pain which can become quite severe.

For a personalized consultation, please call me at 052-2342909 to schedule an appointment.

Testimonial:

http://www.tapuz.co.il/forums2008/viewmsg.aspx?forumid=331&messageid=159500536&r=1

(Following is a summary of the testimonial, translated from Hebrew, from the above link):
“I had a serious (abdominal) separation after the birth of twins. I tried physiotherapy but it did not really help. Meanwhile, four months ago I gave birth to another baby. This time I told myself I would opt for surgery if there was no alternative. I was referred to Rachelle through an internet forum. I went to Jerusalem specifically to meet with her and … within a month and a half of doing the exercises she taught me, my separation of four fingers was reduced to two fingers. I must add that I’m not really the sports and fitness type, but the exercises are not physically difficult. It’s important to do them correctly and to do them regularly. It is quite shocking that at physiotherapy and at the postnatal exercise class I attended nobody talked about the problem of separated abdominal muscles. Lots and lots of thanks! Keep referring to Rachelle – she is an amazing woman and a true professional.” Shirley, mother of 3.

Bio:

Rachelle Oseran (BA) became a Lamaze Certified Childbirth Educator in 1984 through the UCLA School of Nursing and has prepared more than 3000 couples for normal birth over the past 29 years. She is also a Birth Doula, certified by DONA International, a Fitness Professional certified by ACE (the American Council on Exercise), specializing in Prenatal and Postnatal Fitness and a Certified Yoga and Pilates Instructor. She lectures in Israel and internationally on Prenatal and Postnatal Exercise.

Rachelle teaches a Lamaze-Accredited Childbirth Educator training course. She also co-founded and co-directed Great Shape/YMCA, the group exercise department of the Jerusalem International YMCA for 23 years.

Rachelle was recently inducted as an FACCE (Fellow of the Academy of Certified Childbirth Educators) in recognition of her significant contribution to the field of childbirth education. She lives in Jerusalem, Israel, with her husband and 3 sons.

For more information, visit her website at www.childbirtheducation.co.il ,  e-mail her at rachelleoseran@gmail.com  or contact her on +972-52-2342909.