Finding Our Way Back To Birth - awhonnwa.org · Myofascial release for pelvic floor Shoulders...

Finding Our Way Back To Birth Practical Skills for Maternal Movement & Fetal Positioning

Kelly Dungan, RN, BSN, RNC-OB

Confidential Customized for Lorem Ipsum LLC Version 1.0

Process

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Background

Spinning Babies® Aware Practitioner

Spinning Babies® Trainer in Training

Permission granted for use of portions of Spinning Babies® curriculum

A normal physiologic labor and birth

...is powered by the innate human capacity of the woman and fetus.

...is more likely to be safe and healthy because there is no unnecessary intervention that disrupts normal physiologic processes.

(American College of Nurse Midwives, 2012)

In the event of complications...

...medical attention may be warranted to assure safe and healthy outcomes.

...continuing to support the normal physiologic processes of labor and birth has the potential to enhance best outcomes for the mother and infant.

(American College of Nurse Midwives)

When it comes to labor progress….

...work with physiology first!

Objectives

● Discuss fetal malposition in the context of larger maternity care issues● Look at current research and its limitations● Deepen our understanding of pelvic anatomy and labor physiology● Walk away with practical, hands on skills

What is the problem?

...And what are our solutions?

Scope of the Problem

01 | Birth Complications

02 | High Cesarean Rate

03 | Negative Impact in the Postpartum Period

04 | Long Term Sequelae

Birth Complications Related to Malposition

Increase in augmentation | Use of forceps or vacuum

Use of epidural analgesia | Chorioamnionitis | Hemorrhage

More severe perineal lacerations | Meconium stained fluid

Admission to NICU | Lower 1-minute Apgar scores

(Ponkey, Cohen, Heffner, & Lieberman, 2003)

Indications for Primary Cesarean Delivery

34% | Labor Arrest

23% | Nonreassuring Fetal Heart Tracing

17% | Malpresentation

4% | Macrosomia

(ACOG, 2014)

How Can We Lower The Cesarean Rate?

● Unit culture● Management style● Individual provider practice● Model of care● Nurse role

Negative Impact in the Postpartum Period

● Breastfeeding difficulties● Separation of mother/baby● Disruption of bonding● Persistent pain● Increased rates of PPMD

Long Term Sequelae: The ACE Study

Early death

Disease, disability, & social problems

Adoption of health risk behaviors

Social, emotional, & cognitive impairment

Adverse childhood experiences

Anatomy & Physiology for Birth

Anatomy & Physiology for Birth

01 | The Bony Pelvis

02 | Ligaments, Muscles, & Fascia

03 | Hormones

04 | The Fetal Skull & Flexion

Challenging Our Cervix Centered View

Cervix Centered Question

How dilated is she?

Position Centered Question

Where is the baby?

Cervix Centered Solution

Add force to open the cervix.

Position Centered Solution

Make space for the baby.

The Bony Pelvis

01

02

Levels of the Pelvis

01

Balance

Inlet: -2, -3, -4

02

Midpelvis: -1, 0, +1

Outlet: +2 or lower

Ligaments of the Pelvis: Anterior View

01

02

Round Ligament & Uterosacral Ligament

● Round Ligament grows from 4-5 to 18 inches● Can cause spasm or a twist● Palpate halfway between umbilicus and iliac crest● Uterosacral acts as seat belt for uterus● Techniques: Inversions, RL Release

The Sacrum & Posterior Ligaments

01

02

Sacrotuberous Ligament: Lateral View

01

02

Releasing the Sacrotuberous Ligament

01

02

● When tight, can be palpated as thick band● Gentle but firm pressure for ~2 minutes● Can also use pulsing pressure● Pressing up and away from the tailbone, angling

towards the hip a little

Psoas Muscle

01

02

● Links spine to legs, indirectly affects pelvic bowl● Mind-body connection, “core” language● Fight or flight, fear, and perpetual tension● Supple and responsive? Short and constricted?● Acts as a guide wire for baby, can inhibit descent● Techniques: Forward Lunge, knees lower than hips

Muscles of the Pelvic Floor

01

The Uterus

01

02

● Fibers horizontal, vertical, and oblique● Single pacemaker vs. multiple foci● “Organizing” or dystotic pattern

The Uterus

01

02

● Fibers horizontal, vertical, and oblique● Pacemaker vs. multiple foci● Dextrorotation: tilt vs. torsion● Right obliquity: steeper on the right

and more rounded on the left● LOA = back rounded, chin tucked

Fascia

01

● “Matrix” of the body● Affected by very light compression● Doing versus being

“When one tugs at a single thing in nature, he finds it attached to the rest of the world.”

-John Muir

Hormones and the A&P of Safety

02

● Oxytocin is the “star” hormone of labor● Adrenaline is an oxytocic antagonist● Emotional safety supports labor progress

Flexion & Extension

01

02 Vertex/Well Flexed Military Brow Face

Flexion & Extension

01

02

Vertex/Well Flexed

Military

Face Brow

Tools for Assessment

Visual Scan & Patient History

Leopold’s Maneuvers

Pelvimetry & Cervical Exams

Visual Scan

01

02

Gathering Information

01

● History of injury? “Normal discomforts of pregnancy”?● Labor pattern, location/nature of labor pain● What do you notice about the soft tissues?● What do you notice about the pelvis?● What do you think baby’s position is?

Assessing Fetal Position

01

02

Leopold’s Maneuvers

01

02

Pelvimetry

01

02

● Space between ischial tuberosities● Roominess of pubic arch● Are the ischial spines protruding?

Cervical Exams

01

02

Techniques for Labor Progress

Open Chest & Open Knee Chest

01

02

Forward Leaning Inversion

01

02

Forward Leaning Inversion

01

02

● “Reset” for uterosacral and round ligaments● Untwists uterus if torsion was present● C/I with high blood pressure, glaucoma, risk of

stroke, or just ate lunch● Have a “spotter” to make sure getting in and out

of inversion is done gently● Coming back to kneeling position is important for

ligament reset

Sidelying Release

01

02

Sidelying Release

01

02

● Myofascial release for pelvic floor● Shoulders stacked, hips stacked● Bottom leg straight● Top leg up ~30°, over ~30°, and release● Support person’s hands are on hip bone● Light downward traction and gentle rocking

Rebozo Manteado

01

02

Baby at the Inlet

01

● Forward Lunge● Circles/Figure Eights on ball● Posterior Pelvic Tilt● Abdominal Lift & Tuck● Walcher’s● Froggy Walcher’s● Flying Cowgirl

Baby at the Inlet

01

Flying CowgirlPoster Pelvic Tilt

Baby at the Inlet

01

Walcher’s Froggy Walcher’s

Baby at the Midpelvis

01

● Side Lunge● Sidelying Release● Rebozo● Exaggerated Sidelying (Sim’s)● Lateral with Peanut Ball


01

Side LungeSidelying Release Rebozo


01

Lateral (With Pillows or Peanut Ball)

Exaggerated Sidelying (Exaggerated Sim’s)

Baby at the Outlet

01

● Internal Rotation of Femur● Anterior Pelvic Tilt● Squatting● Sacrotuberous Ligament Release● Cook’s Counter Pressure

Baby at the Outlet

01

Anterior Pelvic Tilt

Baby at the Outlet

01

Cook’s Counter Pressure

Sacrotuberous Release

OB Scenarios

Prodromal Labor

01 | Address emotional state with language and therapeutic touch

02 | Mind-body “reset”, moving into parasympathetic

03 | Willing to walk? Work with balancing and engagement first

04 | Going home? Teach techniques and resting positions

Persistent Posterior

01 | Balance the soft tissues: FLI with Rebozo, Sidelying Release

02 | Align the baby: Abdominal Lift & Tuck, Posterior Pelvic Tilt

03 | Peanut ball to open the level and rest during rotation

04 | Work the sacrum

05 | Pushing?: Back flat or arched, instead of curling around baby

Asynclitic

01 | Balance the soft tissues: Sidelying release, Rebozo

02 | Side lunges (head needs to swing)

03 | Hands & knees with intuitive pelvic rocking

04 | Peanut ball with internal rotation of femur

05 | Pushing?: Frequent position changes, FLI & Rebozo

“Know all the theories, master all the techniques, but as you touch a human soul be just another human soul.”

-C.G. Jung

Thank you.

Finding Our Way Back To Birth - awhonnwa.org · Myofascial release for pelvic floor Shoulders...

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