Thursday, 31 July 2014

Dynamic positions in birth

Sounds like it could be a highly personal post packed with too much information, but in fact this is a semi-formal book review...Dynamic positions in birth by Margaret Jowitt, published by Pinter & Martin.
I should say, I had a review copy from P&M but there was no obligation on me to review it positively - it just happens that I love love love it.
I've not written up A's birth story for this blog yet, and I might not (these things are so personal, but at the same time I love reading them online, so perhaps I *should* contribute) and I've also not yet written about this feeling that somehow I'm not done with birth. I feel pretty sure we'll be sticking at two children - they are such a blessing, and I feel so rich, but we're constrained by space, and money, and age, and I only have two arms, and almost I feel I would be tempting fate to risk another when my current two are such a delight. Anyway. I'm not done with birth, somehow - A's birth was so very thrilling and empowering and just perfect and I want to shout about it, and shout for the opportunity for other women to have the chance of experiencing it like this too, not as a thing of fear and pain and sadness, but as something that leaves them as giants, swelling with joy about what their bodies can do.

The book isn't so much about positions, really - it's a sort of hymn to the female body and its perfect design for labour when not impeded by unnecessary interventions. Perhaps the most thought-provoking part for me was the distinction between positioning and propulsive contractions. The idea is that latent labour, the early stage which is often seen as just being pointless "niggles", is in fact the process where a mother's body is getting her baby into a perfect position for birthing. Pain, Jowitt writes, works as a signal to the body to change something, and in those hours, days or even weeks of "non-progressing" contractions (ie those that are doing little or nothing to dilate the cervix) an empowered mother can keep shifting her position in response to these, allowing the uterus to contract in response to where the baby is, nudging him into the best position. This runs counter to the most commonly accepted current view that contractions start at the fundus (the top) and work as an ejector-type mechanism.
The part where Jowitt uses charts to show the pressure changes to support her suggestion that the pressure doesn't all come from the top are quite dense, but she also uses some fascinating analogies (the uterus compared to a balloon, and then to a trampoline). It then gets really interesting where she talks about the consequence of the top-down view for interventions - if you believe that the way to get a baby out is to apply as much ejective force from the top as possible, then it makes sense to give artificial oxytocin to make contractions very strong, which means women often want or need very strong pain relief (usually an epidural), so their birthing position doesn't really matter, because if the baby's pushed hard enough he *will* come out.
The alternative view set out here is that women can work with all of their contractions, from the beginning, by staying broadly upright (lots of cool stuff in here about the dynamic pelvis) and responding to what their body seems to be needing in terms of position. When all contractions are viewed as useful, it changes the whole mindset of both the mother and those attending her, and allows the birth to proceed at its own pace, so the baby doesn't start making his way out until he's already well positioned.
I also loved the piece about how a baby works to be born too - there's a fascinating table listing out newborn reflexes and how each one might be helpful in adopting a good birth position (eg the rooting reflex, turning the face to one side when a cheek is stroked, may help the baby to turn his face when it reaches various bony protrusions on the way out, rather than being shoved up against them and therefore requiring more pushing and more pain to get him out).
Reading this over the last week or so has given me the chance to reflect on my own birth experiences, and particularly to think about how lucky I was to give birth in water this time around. It's the ultimate freedom for changing position because it gives so much support; also because I was at home I moved around completely freely beforehand too. I've looked back and seen how much time I spent in some of the positions Jowitt recommends, without having read the book at that point - I was overtaken by instincts and these made me upright, then forward-leaning, and gave me a pretty quick labour with a four minute second stage. It also - retrospectively - makes sense of my two or three weeks of discomfort (and, let's be honest, frustration) coming up to the birth - I felt so sure that "something" was happening, then felt silly that in fact "nothing" had happened - it seems to me now that my body was working hard to put the baby exactly where he needed to be.

If I was going to criticise, it would be that some of the references are a bit woolly - I can't take a Wikipeda citation seriously, and some of the other sources are websites maintained by just one person, or personal communication. It's not a serious problem, because she's putting the whole thing forward as a theory, coherent and fairly complete, but still a theory. I wish I knew what it would take for healthcare professionals to look into this properly and consider enacting more of the principles in the final chapter, where she describes environments conducive to a good birth (mainly, ones without beds in) but I don't know, I don't know how long it takes to change practice.

For individuals, though, there's no reason not to read this, be informed by it, and put it into practice. Not as a lecture for those whose births didn't go to plan, or as admonishment for anyone planning to use pain relief, but just to make sure that decisions are based on the fullest possible understanding.
If you were looking for a suite of birth books to prepare yourself, I think you'd also need Ina May's Guide to Childbirth, Grantly Dick-Read's Childbirth without Fear, maybe something from the natal hypnotherapy stable, and then perhaps Balaskas or Kitzinger; if you're looking for more theory, particularly on how things follow through to breastfeeding, I'm just finishing up Smith's The impact of birthing practices on breastfeeding which is fascinating, technical, and scary. Oh, and you'd need some Odent, any Odent, maybe the man himself just installed in the corner of your living room.

But, this one should definitely be in there - it may look dry, but it's not, and I'm big on knowledge reducing fear.
Now, how to persuade the husband we could do it all again....

(Note - please forgive me - I'm struggling to write as clearly as I want to at the moment, combination of babybrain and doing everything two sentences at a time in between talking to bonzo...but I just wanted to get this written while I was still fresh from having read it. I'd love to be writing more on here about what I'm reading - I seem to have lots of reading time at the moment, in the cluster-feeding evenings, but time at the keyboard is sparser, so I'm doing what I can with what I have, which I suppose is really all we ever do)