WHAT is Postpartum Rehab, and WHY should EVERY mother have it?

By Sheri DeSchaaf, PT, DPT

http://www.shefitpt.com

Most women are familiar with the common postnatal recommendation of “no exercise for 6 weeks,” or until she is seen for her postpartum check up. But is doing nothing really the BEST way to restore a woman’s body and prepare her to care for a growing child, and all the responsibilities that come with it?

After any physical trauma, minimizing strain on healing tissues is crucial to allow the body to heal and recover, and the same applies to childbirth. After any comparable athletic trauma, rehabilitation (physical therapy) would be a standard part of the plan of care – helping the patient to regain mobility and strength, and educating them on what not to do to avoid reinjury, as well as what TO do to restore injured muscles, fascia, tendons and ligaments, and regain strength and stability. After any significant surgery, such as a rotator cuff repair or knee arthroscopy, patients are immediately referred to 6-16 weeks of structured rehabilition from a qualified physical therapist. I think we would ALL classify a C-Section as significant surgery, and yet no such referral is made – mothers are simply instructed to go home and “rest” for 8 weeks, then go back to doing “whatever feels good”.

You may be surprised to discover that there actually IS specialized phsyical therapy for women to repair their bodies after childbirth. However unlike in France, where every new mother is referred for 6-8 weeks of postpartum therapy, American doctors almost never refer to PT, leaving women to sort out the myths and somehow make it back to fitness on their own.

Women in American society often feel far too much pressure to get their pre-baby body back within months of childbearing. And while we must encourage women to REST during the early postpartum phase, we should also consider that:

  1. Women HAVE to use their bodies the minute the baby is born and every minute after that – to roll over, stand up, lift and carry a 6-10lb newborn, breastfeed for long periods in various positions, and often care for older children and tend to their normal daily duties, whether or not they are “exercising”.
    The deep core muscles that have been overstretched, overloaded, strained and torn during pregnancy and childbirth often do not simply resume their perfect pre-pregnancy function and coordination. They often require careful, intentional retraining to function normally again. This does not magically happen at the 6 week time point.
  2. Every move we make as a human body requires a functional deep core system. Even something as simple as rolling over in bed requires the effective coordination and activation of more than 10 different muscles, including the diaphragm, transverse abdominis, pelvic floor, multifidi, and more superficial spinal and abdominal muscles. We need these muscles to turn back on or get stronger after pregnancy (babies get bigger, helpers go home or back to work, older children forget you just had a baby…). The key is, how do you progress appropriately in this delicate healing period, to restore normal core function and begin strengthening while promoting tissue healing and preventing injury. This is where postpartum PT comes in.

After any injury, the first task is to assess the muscles that are most impacted and restore their normal mobility, tone, and activation. Pelvic PT helps women manage and navigate pain, identify any red flags, ensure that the pelvic floor, abdominals, and other core muscles are functioning well, and that mothers are educated on proper body mechanics, posture and breathing for postpartum tasks like breastfeeding and carrying baby. After the trauma of childbirth (with about 25% currently ending in surgery), pelvic floor therapists assist mothers in careful retraining of the muscles most impacted by pregnancy and birth – the pelvic floor, transverse abdominis, superficial abdominals, and diaphragm. They help restore proper posture and breath patterns to allow a woman’s body to function in optimal alignment, avoid injury, and prepare for return to “real exercise” like running, weightlifting, HIIT training etc.

If a woman goes home from her birth experience and does nothing to strengthen her deep core muscles, retrain her pelvic floor, restore normal posture and mechanics, then the likelihood she will NOT be ready to resume exercise at the 6 week mark is pretty high. On the flip side, if she goes home and gets antsy and frustrated and starts up with her “normal” core exercises again at week 3 or 4, she is likely to hurt herself and further damage the healing soft tissues of the pelvis and abdomen. There is a safe, intentional way to restore the core and return to exercise, and it is imperative that women who want to return to rigorous exercise after their 6 week clearance take the necessary interim steps to rebuild the pelvic floor and core muscles, retrain the appropriate postural responses and breath patterns, and learn how to move optimally prior to resuming impact exercise, heavy lifting, or aggressive abdominal exercise.

There are a few things that most women will find beneficial to begin as soon as you are physically comfortable doing them, as they are natural ways to promote initial retraining of the deep core. The first one is walking. As soon as you are physically able, start walking a little more each day, focusing on good posture and deep breathing. (If you have any increased bleeding or pain, stop the activity and consult your doctor/midwife.) Second, mind your posture and breathing. When you sit, sit up straight. When you stand, stand up tall. And at all times remember to breathe evenly, never holding your breath. As you practice your posture and breathing, focus in the gentle expansion of the abdomen and ribcage with inhale, and the gentle contraction of the abdomen and pelvic floor with exhale. This focused awareness will help you get back in touch with these muscle groups while also focusing on restoring normal posture and alignment to your body.

If you’d like to learn more about safe and effective return to fitness after pregnancy and childbirth, please join us June 16th with Dr. Sheri DeSchaaf, DPT for Bellies, Bladders and Beyond.

Riding the Postpartum Waves: Understand the wide range of feelings

By Rachel Rabinor, LCSW

http://www.rachelrabinor.com

Riding the Postpartum Waves: Understand the wide range of feelings that come with a new baby and how to let your community support you

Becoming a mother is the biggest transition a woman goes through in her adult life. We’re taught to think and plan for the birth: Will I have an epidural? Pitocin? Vitamin k? I’ll bring music, wear an eye mask… There’s such a huge range of considerations. But what about after the birth? We anticipate happiness, love, deep connection with our partner and an instant bond with our baby. How will we foster these emotions and experiences? Will they just happen? And what else might I expect?

When baby is up all night and your partner is snoring, how will that impact you? What about the emotions coursing through your body after a few weeks in the NICU—is it anxiety or the oxytocin you’ve heard so much about. Despite your text-book home birth that you planned to a T, you might find yourself crying uncontrollably for what feels like no good reason. The postpartum period can feel unpredictable to a new mother and even like a roller coaster at times.

So what does it feel like to be a mother? What is normal? In this workshop we’ll discuss the common range of emotions new mothers may experience. We’ll talk about the baby blues and if what you’re feeling is something more, like depression, anxiety or post-traumatic stress disorder.

We’ll also talk about some of the many (many) myths of motherhood that can contribute to feelings of guilt, fear or shame and strategies for cultivating more joy while coping with the challenges of motherhood.

Bio

Rachel Rabinor, LCSW is a psychotherapist and licensed clinical social worker. She has a private practice in Banker’s Hill where she specializes in reproductive and maternal mental health. She is passionate about supporting women (and those who love them) on their journey to and through motherhood. She has specialized training in treating pregnancy and postpartum mood and anxiety disorders, traumatic birth, infertility, miscarriage, loss, and early parenting. She believes in the healing power of community support and enjoys facilitating groups for new mothers and women experiencing infertility. Rachel is a member of ASRM, Resolve and San Diego’s Postpartum Health Alliance where she was the former training chair. She is often featured on podcasts and webinars, and regularly presents to local groups and organizations on topics of maternal mental health.

 

Diastasis Healing with Dr. Stephanie Libs

We were so fortunate at MothertoMother Midwifery this weekend to welcome Dr. Stephanie Libs to our Fourth Trimester Talk in the Garden.  Dr Libs is a chiropractor and owns her practice, Cafe of Life in San Diego.  She has a daughter and is expecting a second baby.  So she has personal and professional experience of the subject she shared with us: Healing the diastasis after having a baby.

I learned so much from Dr Libs. She is knowledgable, energetic and personable in her presentation.  I’m eager to pass on to my own clients all the tips Dr. Libs shared with us.

“Diastasis is when the linea alba (midline) separates from the rectus abdominis. During the second and third trimester the linea alba starts to thin due to babys growth. The linea alba is made of connective tissue which has little blood supply, and makes it difficult to heal”, according to Dr Libs.

To feel your own diastasis, use your fingertips when you are lying down and your head lifted to feel the separation of the muscles. It seemed like everyone in our group of mothers had a diastasis at least three finger tips wide.

Diastasis doesn’t just cause tummy bulging but actual back pain and even urinary incontinence.  It’s challenging to accept these changes in the body after having a baby.  It can even lead to some depression.   Women don’t realize they don’t have to accept these changes though.

A lot of women continue their entire lives with a gaping diastasis after childbirth and consider it to be normal.  But it’s not normal and there are some very simple things to do to heal the diastasis.  We discussed within our group that most care providers do not give instructions how to heal the diastasis after having a baby.  It’s unfortunate these instructions aren’t common knowledge because they can make a big difference for a woman’s comfort and her self-esteem.

How to heal the diastasis after childbirth

It’s possible to have a strong core after childbirth.  Those abdominal muscles can be knit back together to close the diastasis.  Here are a few highlights from Dr. Libs presentation.

Did you know bone broth and wheat germ oil are excellent for healing the connective tissue of the diastasis?  Yes, it’s true.  I will add here that organic gelatin powder is an easy and affordable alternative to bone broth.

“Crunches” and traditional abdominal work outs are the worst for healing the diastasis. I guess those “Abs of Steel” videos 30 years ago were counterproductive!  You can check for yourself if your work out is working against you.  Feel the diastasis when you’re working out and check if it’s more pronounced.  It should be getting smaller and closing together.  By the way it’s possible to place tapes on your diastasis to better support it’s closure.  Dr Libs can help you with this.

The best exercises for healing the diastasis are done with the umbilicus drawn in and the abdomen engaged as if bracing for a strike.  With this posture, mindfully sit down and stand up.  This should be your first abdominal exercise after having a baby.  Dr Libs says mindful baby wearing with the core engaged is another of the first postpartum work outs.  Don’t forget to breathe!

Never hoist yourself to sit up. This makes the diastasis worse!  Always roll to the side and then sit up when trying to heal the diastasis.  Twisting and leaning down are also a big culprit.  Avoid twisting when you reach down to pick up your child.

There are several progressive exercises to do to heal the diastasis.  They all involve lifting one leg at a time, never two. One is to lie down with your knees bent and feet flat on the ground. Draw in your umbilicus and engage your abs.  Now lift one bent leg at a time to a perpendicular position and then slowly lower.  This exercise is one of the first to do to heal and to close the diastasis.  There are several more as you continue your progress toward your mother strong core.  I recommend looking at youtube for demonstrations.

Most importantly, instead of thinking about trying to get your former body back, think about going forward, toward a stronger, wiser, mother body.  Work out wise and strong like a mother!

 

 

 

Cord Blood Collection and Homebirth

Cord blood collection is possible at your home birth.  Mother to Mother Midwives will help interested families collect cord blood at their Homebirth.

The stem cells in your baby’s umbilical cord blood are a valuable resource.  They are undifferentiated cells that can be used to treat many diseases such as stroke, heart disease, Parkinsons Disease  and Diabetes.  This could be a life giving donation from your baby to another individual and an early act of good karma..

Unfortunately, due to our current scientific limitations,  it is very unlikely the stem cells collected from your child will later benefit him or her.  The likelihood your child will benefit from his/her own stored stem cells is approximately 1/100,000.

It’s much more likely that these stem cells could benefit an ill family member or an anonymous individual in need.

There are two options for collection and storage of stem cells, private companies or local, community blood banks.

To collect stem cells for a family member, consider a private stem cell collection company such as Stemcyte. Such companies charge for collection and storage of your baby’s cord blood.

A practical option for those who want to donate to the public is the Community Blood Bank.  They will collect and store cord blood at no charge. Best of all, they match the donated stem cells to needy, sick individuals.  If your motivation is to help someone in need, blood banks are the best option.

Altruism aside, the individual most likely to benefit  from his or her own cord blood is your baby.  Allowing a baby to keep all of his or her own cord blood means he will receive all the benefits from the precious stem cells, red blood cells and platelets.

Delaying cord clamping for at least 30-180 seconds after birth results in higher concentrations of hemoglobin and hematocrit and blood volume during the neonatal period and less iron-deficiency anemia at 4-6 months of life.  There is also a correlation to improved neurological function for those who kept all their own cord blood.

For families who do choose to collect stem cells, our midwives prefer to delay cord clamping and cord blood collection for 30-180 seconds after birth before collection. This is a compromise between collecting all or none of the cord blood.

Mother to Mother Midwifery preferred method of cord blood collection is delayed clamping and collection. For families who choose it, this is a good compromise.

ohhh the vernix-Birth Photos

“The International Association of Professional Birth Photographers has announced the winners of their 2017 contest, and the photos they chose show the struggles mothers go through to bring new life into the world, and the sheer joy that follows.

We took your breath away with last year’s contest, and these new photos will leave you even more amazed. Each one tells a story of pain, perseverance, and finally, relief. They document a baby’s first moments of life, and a family’s first moments of unity.”

http://www.boredpanda.com/professional-birth-photography-competition-winners-labor-2017/?page_numb=12&utm_source=Epictexts&utm_medium=referral&utm_campaign=SBP

one of the many waterbirths

SO many raw images…careful if you are sensitive to images of cesareans. Many Midwife and Homebirth pics…tons of beautiful images.  Enjoy

Why a Doula? But we have a midwife…

One of the big questions that we get asked at Mother to Mother Midwifery during our interview process is ” Do I need a doula at our homebirth?”

The short answer?  Yes

We as midwives have very refined doula skills.  We know what words to use, what touch works, positions for you to get into, how to engage the father in the process, we know about aromatherapy, homeopathies etc….  We do all of the things that a doula does.

What we can’t do is provide that support continuously as a good doula does.

We ask that you have an extra person at your birth especially for first time mothers and you will frequently hear us say that we can provide some labor support but our focus is on the clinical aspects of labor, birth and postpartum.  We ebb and flow in our physical support, always on alert for you and the baby but we can’t always be hands on.  Often we need to conserve our energy and focus for the important moments of the baby’s emergence and the postpartum period.  This means that we may rest while you labor and we are doing other clinical things while you may need hip squeezes.

Do we need to pay for one?  That depends…

We have a regular and low cost doula list in the office.  You don’t need to pay for one but…

We encourage you to have someone who has experienced natural birth, ideally in a home setting.  We ask that the person have some labor support skills and some awareness of what it is to be on continuous call for someone.

That person could be a close family member or a friend as well.  As long as they possess the above, then you will have a solid team of support.

For 2nd and subsequent babies we just ask that you have someone that is not your partner there if your other kids are in the house with you.  Most laboring mother’s want their partner with them, not looking after the toddler, so the third person fills another role for the family.

It is one of our big topic at prenatal visits.

#keeptheoxytocinflowing #mothertomothermidwifery #homebirth

Sunshine supporting a laboring mother with belly binding and rebozo

Evidence Based Birth Practices

One of the goals of midwifery care is “Evidenced Based Birth Practices” which means that our care is guided by more than just our personal experiences and instincts.  We strive to provide what we think  is a blend of available science and technology as well as good old fashioned nurturing…

A webisie that families can reference when making decisions is
Evidence Based Birth
We feel strongly in this model of care that empowers families to make good decisions.

This article on GBS is something that we reference from the website…there are many informative articles and we invite you to explore  when making important decisions that impact your care.

 

ENJOY!

 

#homebirth #mothertomothermidwifery #Midwife #licencedmidwife #CNM #midwifeminds #evidencebasedbirth

NIPT: Early Genetic Testing

Non-Invasive Prenatal Testing (NIPT)

Introduction

NIPT analyzes cell-free fetal DNA circulating in maternal blood. It is obtained from a simple blood draw. It is a relatively new technology in prenatal screening and testing for trisomy 21 and other fetal chromosomal aneuploidies. It differs from the California State-sponsored Prenatal Screening program in the following ways:

NIPTCA Prenatal Screening
CostCost is based on your insurance; out of pocket max, $200Free with most insurances
TestsThe most common chromosomal disorders only: Down Syndrome (Trisomy 21) trisomy 18 & 13. Can also tell if your baby is a boy or a girl.  More advanced testing also available.Screening for chromosomal AND “mid-line defect” issues (spina bifida, Open Neural Tube Defects, gastroschesis)
Accuracy97-99% Sensitive and Specific (almost diagnostic)Accuracy varies: up to 90% accurate for Down Syndrome, 80% for ONTDs
TimingCan be done any time in the pregnancy from 10 weeks.Done at particular intervals; Final results available after 16 weeks

 

NIPT Test Characteristics

Genetic testing using cell-free fetal DNA

DNA from the fetus circulates in maternal blood. Unlike intact fetal cells in maternal blood, which can persist for years after a pregnancy, circulating cell-free fetal DNA (ccffDNA) results from the breakdown of fetal cells (mostly placental) and clears from the maternal system within hours. Fetal DNA detected during a pregnancy, therefore, represents DNA from the current fetus. Although only about 10-15% of the cell-free DNA circulating in maternal blood is from the fetus, it can be detected and measured. Quantitative differences in chromosome fragments in maternal blood can be used to distinguish fetuses affected with trisomy 21, and a few other fetal aneuplodies, from those that are not affected.

NIPT is currently offered by a host of companies:

Natera: Panorama

Sequenom: Materniti21

Illumina

We like NIPT because it offers families early testing for genetic diseases that can affect their choices in pregnancy- like early follow up care, education about place of birth, or opportunities to consider further testing.   The drawback with NIPT is that it does not test for “mid-line” defects which could also impact a family’s choices.  So we’re very careful when counselling our families about the wise use of this new emerging technology.  People DO love to find out early if it is a boy or a girl.  We enjoy their reactions, too.

 

Cesarean births affecting human evolution: The female pelvis is not to blame

Recently some British researchers came up with a dodgy, new spin on an old obstetric myth. They warn us that the high rate of cesarean births is afffecting human evolution.  They claim the female pelvis is shrinking through evolution.  They report, selection pressure from the overuse of cesarean deliveries is accelerating this evolutionary shrinking process. Consequently, more women now require cesarean births because the pelvis is too small and narrow to birth normally.

Rate of cesarean births is climbing

Researchers are baffled by how quickly the cesarean birth rate is increasing.  Their best explanantion for this phenomenon is evolutionary pelvic shrinking.

This isn’t a new conclusion, folks.  The size of the female pelvis has always been the scapegoate for complicated deliveries.  The original diagnosis for cesarean delivery was cephalopelvic disproportion.  Translation is the pelvis is too small to fit the baby.

It’s possible that high cesarean rates will lead over time to the an evolutionary smaller pelvis, but the size of the pelvis is not the cause of the high rate of cesarean births.

female pelvis

The pelvis is not the problem

The truth is, the size of the pelvis is not too blame for the high rate of cesarean births.

In fact cesearen rates for women who plan to birth at home in the U.S. have remained a steadily low below 10%. This proves the problem is not the pelvis.

Its imperative to lower the cesarean birth rates but not by blaming the female pelvis.

The Brits were on the right track two years ago when they announced their campaign to steer low risk women away from birthing in the hospitals.

In an effort to lower the rate of interventions and cesareans, in 2014 Great Britain’s National Institute for Health Care Excellence (NICE) recommended that women with low risk pregnancies are better served by giving birth at home.

More than half of cesareans are unnecessary

In our modern, developed countries the cesarean birth rate is more than twice what it should be. According to the World Health Organization, the ideal cesarean rate should be 10-15% for any country. The U.S. cesarean rate is 33%, meaning that more than half of the cesareans performed are unnecessary.

This is a good cause for all of our concern.

The overuse of technology is the real cause for increasing cesarean rates

The real problem for rising cesarean rates is not a shrinking pelvis, its the overuse of modern technology

While we are indebted to modern medicine for saving lives from time to time, it’s overuse is driving up cearean birth rates.  In time this may indeed cause selection pressure against normal vaginal birth!

Giving birth in the hospital with all its practices and technology directly increases the liklihood of delivering by cesarean.

Interventions such as labor induction with cytotec and pitocin, Friedmans curve, continuous fetal monitors and anesthesia increase the cesarean rates when over used.  Impatience of the providers, driven by production demands, also drives cesarean birth rates.

In order to decrease the cesarean rates, modern medicine needs to be used judiciously and only for delvieries that become high risk.

Planned homebirths have low cesarean rates

Planning a homebirth is the best way to avoid an unnecessary cesarean delivery.  The likelihood of requiriing a cesarean delivery for a homebirth mother is under 10%, well within the World Heatlh Organizations recommendation.

A woman planning a homebirth can trust that even if she ultimately delivers by cesarean, it is necessary and life saving.  It won’t result from the overuse of technology.  She should also believe that her pelvis is adequate and has not shrunk through evolution.Stages in human evolution

World Health Organization reommendation for cesarean rates

Cesarean births affecting human evolution

NICE recommendation for low risk mothers

Birth in the Caul

It is rare and special for a baby to be born in the caul.  It’s also known as ‘born in the veil’ because the membrane covers the baby’s face like a veil at birth.

Caul- the amniotic membrane enclosing a fetus.
Caul- The amniotic membrane enclosing a fetus.

Benefits of strong water bag

To be born in the caul is the result of a strong amniotic membrane that doesn’t break.  There are many physical benefits to an intact water bag including decreased infection, protection of the umbilical cord, and more freedom of movement for the baby.

How to have a strong water bag

The best known method for an expectant mother to grow a strong waterbag is to eat a diet high in Vit C, amino acids lysine and proline and phytonutrients.

Spiritual benefits of birth in the caul

Beyond the physical benefits, there are long standing beliefs about the spiritual gifts of caul births.  Supposedly these people inherit the gift of clairvoyance and healing abilities.

Legend tells us the “caul carriers” can never drown and are able to divine sources of underground water.  Best of all, birth in the caul bestows overall good fortune to these chosen ones. Parents and midwives used to save the membrane and keep it for the child for good luck and protection.  It’s possible to put the membrane a locket or wear it as an amulet.

Superstition and persecution

It’s not all good news though.  During the medieval inquisition, the inquisitors accused “caul bearers” of heresy,  along with midwives and healers, for suspicion of witchcraft and supernatural powers.  The penalties for heresy at that time were various tortures and punishments, including burning at the stake. In spite of persecution and torture, caul births have survived.

Modern birth in the caul

Even in modern times, we continue to recognize the rarity of caul births and respect them as such.  The majority of babies are born in hospitals nowadays, and attended by obstetricians. Only 9% of births are attended by midwives in the U.S.  Since doctors are more likely to artificially rupture the membranes to hurry along the birth, caul births are more and more rare.

We midwives still have the good luck to attend caul births because we do not routinely break the water bag.  It’s not our practice to rush the birth and we respect the benefits of the intact water bag. Allowing the membrane to remain intact increases the likelihood for a baby to birth in the caul.

How to deliver a baby in the caul

If the baby births in the caul, we simply wipe or peel the membrane from the face so the baby can draw his or her first breath.
Influenced by our predecessors, we modern people continue to unconsciously believe birthing in the caul bestows certain good qualities.
If we check, a lot of us believe caul babies and waterbabies, their waterbirth siblings, are lucky and have an affinity for water.  We might even believe they will grow to be talented swimmers, surfers and water people.

Caul birth and water birth

Nowadays many birthing women instinctively choose to birth in the water.  Water births and caul births are virtually the same because both result in the baby born in water.

Surfer
Surfer

Women can’t give precise reasons for their interest in water birth but I suspect their  unconscious attraction to it grew out of our ancestors  folklore about birth in the caul.

Would you like your baby to be born in the caul or in the water?

NY Times Midwife Article