by Janet Balaskas

Here is an important voice in childbirth. Janet Balaskas is speaking to those women who want to grow in self-awareness and to use their bodies actively in labor. In her childbirth classes Janet Balaskas stands for activity rather than passivity, for movement rather than immobilization, and for a woman's right to choose whatever position she finds comfortable throughout labor and delivery.

The teaching in this book is revolutionary. Yet it is age-old. All over the world and throughout recorded history women have chosen upright positions to give birth, and it is only we in the West who have had the extraordinary notion that a woman should lie on her back with her legs in the air to deliver a baby.

But to get women upright is to do much more than help them find a comfortable posture. It is to turn them from passive patients into active birth-givers. It is to challenge the whole obstetric view of birth in Western society. This is based an the assumption that childbirth is a medical event that should be conducted in an intensive-care setting. The whole pregnancy is seen as a pathological condition terminated only by delivery. The modern high-tech obstetrician actively manages labor with all the technology of ultrasound, continuous electronic monitoring, and intravenous oxytocin drip. Many obstetricians have never had the opportunity to see a truly natural birth. To turn the process of bringing new life into the world into one in which a woman becomes simply the body on the delivery table rather than an active birth-giver is a degradation of the mother's role in childbirth.

We are now beginning to discover the sometimes long-term destructive effects on the relationship between a mother and her baby, and on the family, of treating women as if they were merely containers to be relieved of their contents, and of concentrating attention on a bag of muscle and a birth canal, instead of relating to and caring for the person of whom the uterus and the vagina are a part.

Bonding is a fashionable term today. In many hospitals special time is devoted for bonding, and there must be few midwives and obstetricians who would not claim that they consider bonding important. But everything that happens after delivery is the outcome of what has gone before. Bonding is either spontaneous and easy, or made virtually impossible by the atmosphere at delivery and by the care a woman is given as a person, not merely a "para I," an elderly primigravida, a maternal pelvis, a contracting uterus, or a dilating cervix.

The way we give birth is important to all of us because it has a great deal to do with the kind of society we want to live in, the significance of the coming to birth of a new person and a new family.

When we hand over responsibility for choosing between alternatives on the basis of what we believe to be right, we hand over responsibility for the quality of the society we, and our children, must live in.

DURING THE RAPID DEVELOPMENT OF MODERN OBSTETRICS in the past three hundred years, women have lost touch with their power as birth-givers. We have almost forgotten how a natural physiological birth unfolds.

An active birth is nothing new. It is simply a convenient way of describing normal labor and birth and the way that a woman behaves when she is following her own instincts and the physiological logic of her body. It is a way of saying that she herself controls her body while giving birth, rather than being the passive recipient of a birth that is managed by her attendants.

By deciding to have an active birth you will be reclaiming your fundamental power as a birth-giver, a mother, and a woman. You will also be giving your baby the best possible start in life and a safe transition from the womb to the world. Should an unusual difficulty or complication arise, you will be free to make use of the safety net of modern obstetric care, knowing that you have done your very best and also knowing that this is your choice and that the intervention was really necessary. In this way, even the most difficult birth can be a positive experience.

Preparing for an active birth during pregnancy will lessen the likelihood of complications arising. It will also ensure that you approach the birth of your baby in optimal health, which will enhance and hasten your recovery, whatever happens. If you give birth actively you will want to move around freely during the early part, or first stage, of labor, choosing comfortable upright positions such as standing, walking, sitting, kneeling, or squatting. In between contractions you can find ways to rest in these positions, comfortably supported by pillows. As you approach the expulsive or second stage, during which your child can be born, you will continue to use the upright positions that are most comfortable or practical. At the end, for the actual birth, you can use a natural expulsive position (probably Supported) like squatting or kneeling.

An active birth is instinctive. It involves your giving birth quite naturally and spontaneously through your own will and determination, having the complete freedom to use your body as you choose and to follow its urges. Active birth is an attitude of mind. It involves acceptance and trust in the natural function and involuntary nature of the birth process, as well as an attitude or appropriate positioning of your body. It is not merely a vaginal extraction in which the attendants are in control and you are a passive patient. It is more comfortable, safer, and more efficient than a passive "confinement. " This is supported by the many scientific studies comparing women who are active in labor with those in a passive, recumbent position (see page 13).

Some women, left to themselves, will instinctively know what to do in labor, but most of us, having no example to follow, need to be made aware of the possibilities of using various upright positions in order to discover our instincts. This can easily be done by practicing during your pregnancy the birth positions and movements that are most appropriate and comfortable. The yoga-based exercises in this book will lead you towards your own instincts for labor and birth, while cultivating the right and natural body habits for a healthy pregnancy.

THE QUESTION OF BIRTH POSITIONS

A growing number of mothers, midwives, nurses, obstetricians, and childbirth educators are questioning certain modern labor and birth practices, and the passive role demanded of women in contemporary maternity care. One practice that is being criticized is the almost exclusive use of
few moments while in the position allows you to release the tightness you feel in your legs and to lengthen and relax your spine, until with practice you can make the movement with greater ease.

You will probably find, as you experiment with other movements, that a state of chronic tension exists throughout your body to some degree, affecting some areas more than others. The most effective way to become more relaxed and supple is by beginning to make the neglected movements we were designed by nature to make. It is simply a matter of spending some time each day practicing them. Gradually stiff muscles will lengthen and regain their elasticity, and joints will become more mobile as tension is released.

The program of yoga-based exercises that follows will cultivate relaxation and flexibility in a safe, unstrenuous way. Pregnancy is a unique and marvelous time to let go of habitual tensions and to allow your body to become more relaxed. If you've never exercised before, you may find some of the positions difficult at first. But gradually, with practice, you'll loosen up.

The Benefits of Yoga-based Exercise

• As your muscles become more supple and your joints more mobile, the muscular balance that supports and moves your body improves. Muscles work in teams; while one team is relaxing and lengthening, the other is contracting and shortening. When you balance the opposing teams of muscles, your joints articulate better and your posture automatically improves. This ensures that you carry your baby correctly and helps to prevent backache.
• Breathing well depends on good posture. When your pelvis and spine are in good balance and your shoulders are relaxed, your chest cavity can expand easily so that breathing is unrestricted. This ensures good oxygenation of the blood for you and your baby throughout pregnancy.
• As you become familiar with the exercises you will find movements that alleviate the minor discomforts of pregnancy, such as heartburn, pain in the hip joints or in the ribs, cramps in the legs, or headaches.
• Your circulation depends upon your muscles. They act as pumps, making the blood flow through your body and returning the blood to your heart. If a muscle is tight, then the blood vessels running through it are constricted and your blood circulation (and indeed, indirectly, the circulation to your baby in the womb) is also restricted. The exercises can help to ensure that your baby is getting everything needed to grow healthy and strong. They can also prevent or lessen problems associated with poor circulation--varicose veins, hemorrhoids (piles), and fluid retention. Finally, the exercises tend to lower the blood pressure, and can thus help to prevent problems associated with rising blood pressure (see chapter 7).
• Yoga-based exercises help to combat fatigue. If muscles are shortened and movement is restricted, the flow of energy is "blocked." After a session of exercise you will feel invigorated and refreshed, and over time this feeling will increase. Your pregnancy can be a time when you feel healthier and more energetic than ever.
• The most comfortable yoga positions in pregnancy are very similar to positions women instinctively assume in labor. So, by practicing the exercises, you will have cultivated ease and comfort in the natural positions for birth used by women through the ages, without needing to think about it very much. You will be able to move freely and instinctively; your body will know what to do. Yoga will help you to be more deeply in touch with your own center. It will be easier to surrender to the powerful forces within your body during labor.

As stiffness lessens, your body becomes free of pain.

You will gradually become familiar with the discomforts and even the pain of going beyond your usual limits. As labor and birth will demand going beyond your normal limits of pain endurance, positioning your body to go beyond your normal limits of movement during pregnancy prepares you gradually for this kind of effort. The exercises will teach you to surrender to the forces within your body. This is the best possible practice for labor; it will help you to cope with the intensity of the sensations of your contracting uterus, and will also help to reduce the pain by enabling you to relax and accept the feelings rather than tensing up against them. As one mother said--

"By exercising, I learned how to be at one physically and emotionally with the changes that would inevitably lead to the birth of my child. The teaching enabled me to 'go with' my body, even when the pain was a burden. I was physically and also mentally prepared for everything that was to happen to me, and I approached the final events with excitement and real confidence."

Active Birth at Home or in the Hospital

YOU WILL PROBABLY BE ASKED TO CHOOSE THE PLACE OF birth right at the beginning of your pregnancy, and you may be expected to stay committed to your original choice. But it is not always easy to decide at this time, as you may not know very much about the whole subject, or the options available. Certainly you will not yet know how the pregnancy is to progress, which must influence your final choice. Women, like other mammals, have a powerful "nesting instinct," which usually arises towards the end of the pregnancy. Just as a cat chooses her corner of the house before the kittens are due to arrive, you too may not know where you wish to give birth until closer to the end, though you may have some idea of the kind of setting you would prefer.

When you begin your prenatal care with your doctor, midwife, or clinic, keep open all your options for the birth. In the meantime, explore the possibilities, You may wish to change your doctor for the remainder of your pregnancy, or to choose a hospital that may not be your nearest because you like its approach. It is advisable to pay a visit to any hospital you are considering before committing yourself, to find out about the general approach in the labor ward and whether the staff encourages activity during labor and upright positions for birth. Also find out what happens after the birth, and how long you will be expected to stay before you can go home with your baby. You might prefer to explore the other options available. Remember: You are always entitled to change your mind.

Home or Hospital?

There is no way of removing every risk in childbirth. Although the vast majority of babies are born safely, the final outcome of any birth is always uncertain. Unexpected complications can arise, machines can break down; anyone can make a mistake. There is now plenty of evidence that in general it is as safe, if not safer, to have a baby at home as to have it in the hospital, and home usually provides the best conditions for a physiological birth. But different factors, such as your health, your insurance plan, your proximity to a hospital, and whether you have any problems in pregnancy, will help to determine the most appropriate place of birth. The most important thing is to discover all the possibilities, to consider what your priorities are, and then to make a choice that feels right for you. Your instinctive feelings are really important, and they will arise most strongly at the end of your pregnancy. Your choice of birth place may depend upon your choice of birth attendant, or vice versa. Most births in the United States are attended by obstetricians-surgeons who are trained to handle complications, and who are likely to resort to obstetrical interventions. You may instead choose a family practitioner, a physician who provides both obstetrical and newborn care and is trained to view birth as a normal process. Or you may choose one of the growing number of certified nurse-midwives (CNMs). Experts in the normal birth, CNMs may attend deliveries in hospitals, birthing centers, and homes. They sometimes work in group practice with physicians, and they refer women with complications to specialists. Finally, you may prefer a "direct-entry" midwife--a midwife who has entered the profession directly, usually through apprenticeship, rather than going to nursing school first. These midwives specialize in home birth. Their legal status varies from state to state, and your insurance company probably won't pay expenses for a birth attended by a midwife who is unlicensed. But sometimes, for a home birth, there is no alternative. A minority of CNMs and very few physicians attend births at home, because of pressure from hospitals, colleagues, and insurers, and sometimes because of legal restrictions.

If you, like most American women, choose to have your baby in a hospital with an obstetrician, you can still have something like the constant nurturing a midwife provides. You can have an experienced friend or relative, a trained labor support provider, a lay midwife, or a childbirth educator accompany you to the hospital to provide support throughout your labor.

Nowadays many hospitals have special, private birthing rooms that are used for both labor and delivery, and some have alternative birth centers where routines and interventions are greatly reduced. Also available in some areas are freestanding birth centers, which combine the comforts of home with proximity to emergency facilities. See "Resources" for more information on the choices available.

If you have any of the following problems, you may need to have your baby in a hospital.

Pre-eclampsia

Sometimes called toxemia, this condition can occur when blood pressure rises to dangerous levels. I do not mean the slight rise in blood pressure that is quite common at the end of pregnancy, and that needs careful observation but generally presents no problems. Blood pressure is connected with emotions, and sometimes the excitement of the approaching birth can cause a slight rise. But when the diastolic pressure (the second figure in the reading) rises by 15, you are considered to have hypertension. This can be, though it isn't necessarily, a symptom of preeclampsia. Other symptoms include edema (swelling) and protein in the urine. These can be signs of kidney and liver failure, and may result in premature labor or deprivation of oxygen and nutrients to the baby, and convulsions or coma (eclampsia) in the mother. Fortunately, eclampsia is very rare these days.

Sometimes, with bed rest and good diet, (including plenty of protein), mild preeclampsia will improve. If it doesn't, it may be safest to have the baby in the hospital. With persistent preeclampsia, doctors prefer to induce labor.

If you are confined to bed in pregnancy it will help to get up every few hours to do some relaxing yoga-based exercises for half an hour, and then return to bed. Breech Presentation

There are more risks involved in this case than in a normal presentation. (See "Unusual Presentations.")

Previous Complications

Not all complications are likely to recur. However, if there were problems with the last birth that could affect this one, you may be better off in the hospital. It is helpful to reflect on what happened last time and discuss the causes with your birth attendant. Sometimes getting a second professional opinion can help you determine whether or not the same problems are likely to recur. For example, if you had a cesarean section for pelvic disproportion, you may need one again (although this is not a certainty). But if the cause of the cesarean was fetal distress, the events are much less likely to be repeated.

Placenta Previa

Sometimes the placenta lies very low in the uterus, close to or covering the cervix. The danger is that the placenta could separate and be born before the baby, which would cause the baby to be cut off from its source of nourishment.

Although women with low-lying placentas usually end up with perfectly normal births, it may be necessary to have help close at hand in case a cesarean is required. (With a full placenta previa, in which the placenta covers the cervix, a cesarean is always necessary.)

Twins

Sometimes twins are born prematurely, so it is important to choose a hospital that has intensive care facilities for newborns. If there are no complications and both babies are a good size at full term, it is certainly possible to have an active birth; the supported standing squat (see page 140) is the best position to use.

As twins tend to be smaller than single babies, birth may in fact be easier. The positions the babies are lying in during labor can affect the outcome. Both babies may be head down; this is the best outlook for twins. However, often the second twin is in a breech position. If this is the case, an active birth is essential, with vigilance on the part of the attendants, to avoid the use of forceps or a cesarean section. Sometimes the second twin lies sideways (transverse) and the doctor can manually turn it head down from the outside before birth.

With an active birth of twins, the first is born using a supported squatting position. If there is time, the mother sits down to welcome the firstborn, whose sucking at the breast stimulates the uterus to contract to expel the second twin.

Since there are two placental sites with twins, bleeding is more than usual, and Pitocin may be needed.

Excerpt reprinted with permission from foxcontent.com