Healthy Mother and Johnson & Jonson (India) Monthly Workshop Series

In the past month we kicked off a monthly meeting / workshop titled “Transition to New Motherhood and Infant Care“. The workshop series is a collaboration between Healthy Mother and the global healthcare company Johnson & Johnson (India). The idea behind the workshop series is that many new mothers (dads), especially from nuclear families find it difficult to make a smooth transition from being just a couple to new parenthood. They have lots of questions on bathing their child, massage, sleep patterns, breastfeeding etc, and are hardpressed to find credible answers which are evidence-based.

The June workshop saw a team of pediatrician, gynaecologist, and yours truly talk about myths and good practices in infant care, how to care for yourself when you become a new mother, and had a interactive session on infant massage.

The workshop was a big hit among the parents and we feel encouraged that we are able to help many new parents in this crucial time of adjustment and transition. Watch out for the announcement for the July workshop.

Here is the link to some pictures from the event.

Dr. Vijaya

Lamaze Teacher Training Update – Hyderabad and Mumbai

An important announcement!

In view of the concerns surrounding the Swine Flu virus, we have decided to postpone the Lamaze Childbirth Educator Workshop in Hyderabad to July 30, 31 and August 1, 2009. We have take this step in consultation with our partner Douglas College and Kathleen Lindstrom, with the belief that the WHO would lower the risk of travel by that date.

We believe the postponement would be good news for aspiring Lamaze Teachers in Mumbai as we will now be conducting the same workshop in Mumbai on August 6, 7, and 8, 2009. So all you Mumbai folks, sharpen your pencils!!

Both the workshops will be followed by free Doula Training conducted by Kathleen Lindstrom.

Here is the final schedule by location:

Hyderabad – Lamaze Educator Training: July 30, 31 and August 1

Doula Training: August 4, 2009

Mumbai – Lamaze Educator Training: August 6, 7, 8, 2009.

Doula Training: August 9, 2009

Please contact us at hm@healthy-mother.com in case you have any questions. You can also call us at 94907 95950.

Dr. Vijaya

Lamaze Childbirth Educator Training Comes To India

Some very good news….

Over the past many months I have had many queries from aspiring Lamaze Childbirth Educators from all over India asking if we conduct any training program for Lamaze teachers. In fact some of my new mothers who have graduated from our Lamaze classes have been quite fascinated by the Lamaze Philosophy and their birth experience that they now want to become Lamaze teachers and help other expectant mothers.

Good news for all of you!! We at Healthy Mother have partnered with Douglas College, one of the foremost institutions for Lamaze Educator Training and are bringing their program to India. We will be hosting a Lamaze Teaching Skills Workshop on May 14, 15, and 16, 2009 in Hyderabad for those who want to become Officially Certified Lamaze Childbirth Educators. The workshop will be conducted by Kathleen Lindstrom, CD, CDT (DONA), LCCE, FACCE (Lamaze International) and co-taught by me. Attending such a Workshop is one of the eligibility requirements for sitting for the official Lamaze Certification examination from Lamaze International.

Kathleen is the Perinatal Program Manager, in the Faculty of Health Sciences, Douglas College, Canada and has 25 years experience in teaching prenatal classes, developing Lamaze Training Curriculum and presenting workshops. She is currently on the Board of Directors of Lamaze International. In addition, Kathleen is a DONA certified Doula and Trainer and has 28 years experience in training nursing staff about breastfeeding techniques, and working with breastfeeding families.

We will also be offering a FREE Doula Training Workshop on May 19th and 20th. I encourage everyone who is interested to register for the workshop as soon as possible as slots are very limited.

You can contact me for details about costs, and other details.

Dr. Vijaya Krishnan

Listening to mothers (its relevance in normal birth)

When I counsel mothers during their pregnancy, or when they attend one of our Healthy Mother Lamaze Programs, one of the first things I assure them is that I believe in their bodies’ ability to give birth naturally. I also tell them that I will spend as much time as they need to overcome their concerns, fears, and anxieties – not how much time I am able to spare for them on a given day.

I think that giving mothers the confidence in their bodies’ ability to give birth naturally starts with good prenatal care and counseling. The paramount factor in a normal birth and in obtaining a fulfilling outcome for mother and her baby is the ability of care providers to ensure continuity of care. As the relationship between the health care provider and mother develops during the course of prenatal care, a mutual trust between them brings a sense of safety, security and openness. When it comes to the time of birth, rarely do we have to deal with psychological issues which may stall or impede labor, since many fears and concerns have already been dealt with during the prenatal period. This is great comfort to a mother who is going to give birth for the first time and who has so many questions. Through the consultations and the prenatal sessions, we have not only taken care of most of their immediate needs, but we have also taught the mother what to expect during labor. In addition, we have given them the tools and techniques to overcome the challenges of labor. So, even when the going gets tougher, the mother – who by now knows that we will give her the best possible support – is free to focus on the task at hand – giving birth! Often, I have sat with a first-time, would-be mother in labor, when I can feel a particularly difficult wave of contraction coursing through her body, when I know she is in slight panic, and I know she is wondering if she will be able to complete the task that she started, I look straight into her eyes and say to her, “You have just a little further to go.” She grasps my hand a little harder, nods, breathes and blows through her contraction and replies, “OK”. Then, we manage the next contraction together. In fact, many a time, after giving birth my new mother will say “I don’t remember the pain – I just remember you saying “you are almost there” and this gave the strength to finish what I so strongly desired.”

The amount of time spent by us during prenatal visits, using our powers of observation is the second most important factor impacting a normal outcome. Most of today’s prenatal visits are assembly line in nature, and may be worse than no visit at all. This is particularly true when a woman has a condition that requires more frequent visits. Today’s routine prenatal exams in which the blood pressure is taken, fetal heart tones quickly found, a quick check done on the ultrasound monitor, and various tests ordered, may have little relevance in determining the normalcy of a woman’s pregnancy. Of course, it is important to do all of these as standard care practices. However, in my consultations and in my Lamaze classes, I am much more interested in how a mother carries herself. Does her back hurt? Can I teach her better ways to improve her posture, and teach her husband / family members some massages to help relieve her discomfort? Should she be adjusting the way she works at her workplace? Can I teach her ways to avoid pulling some of the muscles and ligaments that are lax during pregnancy? How’s her energy level? Perhaps she is anemic or depressed. How’s her self-esteem? Perhaps she is constantly being reminded that she has put on too much or too little weight. Is she anxious about something that she has perhaps been unable to voice? How is her appetite? Is she able to sleep well at night? Can I show her some comfort positions to use during sleep, or some relaxation and breathing exercises she can do before she goes to bed?

Then, when I examine her and feel her belly, it is wonderful to have a baby who responds to my touch – the personality of the tiny being is probably mirrored in the tenor of her prenatal movements! If the baby is found to be in the breech position (head up and buttocks down within the womb), I take time to teach the mother exercises and positions to try and invert the breech. More often than not, the baby does turn to the head down position within a week to ten days! All in all, it takes time to “tune in” with the mother’s pregnancy—to talk about nutrition, her groin strain, the things that she has heard from her cousin about cesareans, what her friend has told her about “how wonderful it was to have a “painless” epidural birth”, and many, many other things that are not a part of usual hospital case sheets and charts.

This does not mean that labor is not hard work for both the mother and for those of us who provide continuous labor support. However, in order to help each of my mothers and their families achieve the best possible labor and childbirth outcomes I try to spend the bulk of my energy during the prenatal period.

A final important factor in assuring that birth will proceed normally is the birthing environment. Where does the mother feel safe? With whom does she feel confident? A couple of years back, I was talking with my cousin’s daughter who had just finished her 3^rd year physiotherapy exams. She was feeling very exhausted and yet was not satisfied with her performance. She had studied very hard and felt that she had a good grasp of the subject matter, yet when she went to take her practical exams in Electrotherapy, she had been overcome by feelings of fear and anxiety. Although she did well in all the other exams, she felt she should have done better in her “practical”, and that the marks that she got did not reflect her knowledge of the subject fairly. I asked her why she had suddenly developed feelings of fear, and she told me that the testing site was a room she had not been in before, and full of equipment with which she was not familiar. There were about thirty others being tested whom she did not know, and the invigilator was a stranger. To top it all, the room was very hot! As she was talking, I felt like she could be describing the conditions that are present when most women walk into a typical hospital for delivery! No wonder so many women have “failure to progress” when exposed to an unfamiliar environment. Recently, I read a wonderful article about the functioning of sphincters and privacy – it is commonsense – we all know that our bowel and bladder sphincters do not open up and release in public; they need privacy. Why would the “cervical sphincter” be any different? The article reinforced my belief about calm, quiet and privacy and familiarity that are needed to “progress” labor and to give birth.

It has been my experience that when the mother is able to labor in an environment of her choice, with people surrounding her who make her feel respected, loved and safe, she feels empowered to give birth to her baby, rather than be delivered. I have read some wonderful birth stories written by midwives in Europe and US, of short, almost painless labors that they were a part of. Although I used to be somewhat skeptical of these birth stories, I am starting to believe that they are probably true. Belief, faith and spirituality are in equal measures important for the wonderful transformation of a woman into a mother. I am left wondering how much of an effect does my belief in the mother have in her final birthing outcome? The more I believe that “mothers birth their babies”, the more I am able to facilitate mothers to have a better birthing experience.

My musings for today….. feel free to write in your thoughts and experiences…

Dr. Vijaya

How Lamaze Helps Women Give Birth with Confidence?

As the new batch of would-be mothers and dads join our Healthy Mother childbirth education classes, more than a few mothers have come up to me or have called me with a myriad of questions. One such call was from a first time mother-to-be, who wanted to find out how our program could help ease her fears regarding childbirth; more importantly she also said to me: “Why are you against the use of epidural if it can relieve the pain?” and “I have heard that Lamaze really doesn’t help (during labor)”. I called her in to meet with me and explained to her the Lamaze philosophy. I told her that Lamaze is not just a “breathing technique”, but a source of knowledge and information that she could use to empower herself in order to make informed choices about her pregnancy and childbirth. By the end of her discussion, she was convinced and is looking forward to start her classes.

As I finished this discussion, I thought I would write about how Lamaze “really” helps women give birth with confidence. The Lamaze philosophy and the Six Care Practices that Promote Natural Childbirth are fundamental to the organization’s efforts to prepare women and their families physically and emotionally to give birth normally. “Breathing” which was once the hallmark of Lamaze (which was what the expectant mother who was questioning Lamaze’s efficacy was referring to), is now simply one of the many different techniques that women learn and have in their “labor tool-bag” to help them in the exciting journey of giving birth.

In a position paper titled “Lamaze for the 21^st Century”, Lamaze International has presented a wonderful reorganization of thoughts that ultimately helps parents in understanding how and why Lamaze is so effective in promoting, supporting and protecting natural childbirth. Hand-in-hand with its six care practices, Lamaze talks about:

Reframing Pain: Pain is protective – By responding to labor pains with physical movements and position changes, the mother actively helps her baby descend down her pelvis. This process, by which as she moves a little her baby moves a little, also helps to protect mom’s body. As the pain increases, women also find that they have energy and strength to cope with the stronger contractions because of help from nature’s narcotics – endorphins, which are released during this stage.

Rethinking Relaxation and Breathing: These two techniques are wonderful tools to decrease the perception of pain and are fairly simple to learn. Women in Lamaze classes are shown a variety of breathing patterns; however, they are encouraged to find a pattern that is comfortable to them. As each woman has her own way of dealing with pains/discomforts, many women prefer breathing and relaxation techniques a part of the larger gamut of rituals that they can use to decrease their pain perception in labor and to actively release tension when they can.

Retiring the Coach: The person who supports the mother during labor, be it the doula or her husband, is just that – her continuous source of encouragement and support. They are not present to take charge and run things for the laboring mother. Although there might be times when they need to “coach” her through a particularly difficult contraction, more often than not, they are her best source of calm and gentle support that she knows she can fully depend on. They also become her advocates during labor, so that they can help her with any decisions that she may need to make in the course of her labor.

Reshaping the Birth Environment: Lamaze classes provide information and encourage expectant parents to find a birth environment where staff shows empathy, one that provides the mother confidence, space and continuous support and where medical interventions are as minimal as possible. Environments where birthing balls, rocking chairs, showers etc, promote comfort for the laboring mom. Where ultimately, with a truly supportive environment, the mother is able to achieve a fulfilling birthing experience as well as outcome.

Respecting the Mother-Baby Connection: Lamaze classes encourage the mother to keep the baby close from the moment of birth, to breastfed within the first hour of birth and also sensitize them to the amazing capabilities of their newborn. Finding hospitals that respect this mother-baby connection and those which actively promote this bond, is extremely important in the first few hours of the newborn’s life, as well as influences early parenting.

Reclaiming Normal Birth: The goal of Lamaze classes is that every woman is entitled to give birth confidently, supported by her family and health care professionals. Lamaze classes (such as those conducted by Healthy Mother) reinforce the fact that a laboring mom has great inherent strength, the wisdom and the ability to give birth naturally, and assists her (as per her needs) to achieve her goal of normal birth.

Finally, I think that the position paper’s conclusion really emphasizes how Lamaze classes and Lamaze Certified Childbirth Educator help the mother to give birth with confidence: “Birth does not change, but over time the environment in which birth takes place has changed. Our understanding of both the simplicity and the complexity of birth deepens. As a result, Lamaze preparation for birth has evolved and will continue to evolve. The Lamaze Certified Childbirth Educator promotes, protects and supports every woman’s right to give birth confident in her own ability, free to find comfort in a variety of ways, and supported by her family and all members of the healthcare team.”

Please find the link to the entire paper here

As always, please do write in your comments and questions.

Dr. Vijaya

Rethinking the atmosphere in which you give birth….

Recently, I was talking to one of our Healthy Mother Labor and Childbirth program participants who had gone to her parents’ house in Kerala to spend the rest of her pregnancy. During a routine check up at the local hospital four weeks before her due date, her baby’s heart rate was seen to be fluctuant, accompanied by significant decelerations. Her OB suspected that there may be cord entanglement, and immediately admitted her to the hospital. With severe decelerations of the baby’s heart rate continuing, her doctors  decided to immediately take her for an emergency C-Section. Soon after her delivery, the doctors found that her baby had significant difficulty with breathing, and the pediatrician counseled the parents to admit him to the Neonatal Intensive Care Unit (NICU).

However, neither the hospital in which the baby was born, nor any other hospital in the vicinity, had NICU facilities. Thus began a ten day emotional and physical rollercoaster ride for mom and dad. The baby was shifted to the nearest hospital with NICU facilities, which was about 6 hours away. Mom could not be discharged from where she was for the next 3-4 days, and baby was 6 hours away in NICU. Dad shuttled between the 2 places daily, until mom was finally discharged and was able to see her baby. In adition, the hospital practices where the NICU was located were not mother-friendly, so mom was not allowed to touch or hold her baby for several days. She could only see her baby from outside the glass walls of the intensive care unit.

Finally the baby was discharged from the NICU in good health, and as I write this mom and baby have been at their home for several days, and both are doing well. Since the mother had continued to pump breastmilk while her baby was in the NICU, she is now nursing her baby without much difficulty. Way to go, mom!

As I was speaking to this couple, I thought I would re-emphasize the importance of choosing the right hospital for your baby’s birth. Not only is it important to choose a hospital that provides you with the best possible support and care that can promote a natural childbirth, but it is also important to check whether they have good emergency backup and post-delivery care infrastructure such as NICU facilities, should your baby need it. If not, at least you should check to see whether there are hospitals in the vicinity which offer NICU facilities, so that mother-baby separation can be kept to a minimum. Over and above this, there are several questions that you need to ask of your doctor and/or hospital, so that you can ensure the best possible birthing experience for you and your baby.

The Coalition for Improving Maternity Services (CIMS) is doing a remarkable job of advocating mother-baby friendly practices in US hospitals and medical facilities . I have adapted some of their recommendations in a document after making them relevant to the current Indian conditions. You can download the document here (Points to consider about your hospital).

In my next post, I will write about how Lamaze is helping women and their families in rethinking the different aspects of labor and childbirth.

Dr. Vijaya Krishnan

A Simple Birth – the way it should be….

Dec 20, 2008: Our Mom started having pains on the night of the 18th. Pains were crampy, coming off and on with no particular rhythm. Since there was not much progress in either the duration or the intensity, we decided to wait and watch, since it could be false pains. By the next morning, the contractions had all but disappeared. However, on the night of December 19th, mom again started with cramps, but this time they were regular – 30 seconds duration about 10-15 minutes apart. As per our birth plan, mom labored at home with dad’s support. By about 4 pm, the contractions were 5 minutes apart, and they headed over to the hospital. An internal exam showed about 3 finger-widths dilation and 70% effacement. Mom continued to walk the hallways, and used many of the exercises and positions that she learnt in the Healthy Mother Lamaze classes (www.healthy-mother.com), to help her labor progress. She had a light meal at around 7 pm, and progressed into more active labor by about 8:30 pm. Still out of bed, she was managing her transition pains in the chair-straddling position, and whenever she started to panic, dad would make himself her point of focus, and breathe with her.

Finally, at just past midnight, on Dec 21st, a healthy baby boy weighing 2.8 kgs was born with mom having to push for just about 3-4 times. Mom and baby were together immediately, and she was able to nurse her baby within half an hour of giving birth. Recovery was remarkably easy, and the family was able to go home 48 hours after their baby’s birth.

Lessons learnt: Labor can be simple, when it is allowed to be. Here mom and dad were well-prepared for what to expect. They labored at home until labor was in a more active stage, and this helped labor to progress comfortably, minus any interventions. Labor in the hospital also happened in the quietness of their room, and the hospital provided support only for intermittent monitoring and for the final delivery. In writing the experiences of these 7 very different labors and deliveries, I hope to have given my expectant moms and dads a better understanding of how labor progresses if it is allowed to, and how moms feel good about their birth experiences if they are well-informed and a part of the decision-making every step of the way.

I invite moms and dads who are reading this to let me know of their birth experiences with their babies. It is my belief that sharing such experiences will benefit countless of women and their families to go through pregnancy in a more informed manner and trust their own bodies to give birth in a more confident manner, all of which helps in facilitating a natural birth outcome.

Dr. Vijaya Krishnan, DPT, PT, MS, LCCE

Significance of waiting and giving mothers a say in childbirth – a case in point

December 19^th, 2008: I had known this mom since her 4^th month of pregnancy. She had joined one of our antenatal programs early, since she knew she would be traveling to her hometown of Assam, in northeastern India within the next couple of months and would remain there for her delivery. However, the very next week she was discovered to have placenta previa and was put on complete bed-rest. After a month and a half , she was allowed to be up and about, as her placenta started to pull itself up. Mom and dad finished the rest of their sessions and headed for Assam. After the 7^th month, mom started practicing her birth fitness exercises – by this time placenta previa was no longer an issue. She continued to remain in touch with me after every OB check up, and was waiting for labor to start on her due date of Dec 14^th.

Dec 14^th and went, and there were no signs of labor. On December 18^th, mom was admitted to the hospital and was started with gel priming and induction protocol. Since her cervix was not ready to begin with, even after several hours of induced labor, it could finally open up to only 1-2 cm when her baby’s heart rate started to show decelerations. Finally, on December 19^th a healthy baby boy weighing 3.5 kg was delivered via C-Section.

Lessons learnt: In this case, mom’s delivery was done by a family member who is an OB. Mom felt that she did not have much say in the process. In my opinion, waiting for labor to start on its own would have been the ideal plan of care, especially considering that mom and baby were both doing fine. Since natural hormones had not yet started to cause the cervix to ripen and be ready for birth, induction failed, leading to a C-Section that could have potentially been avoided.

Another natural birth in Hyderabad

December, 18^th 2008: Just around the time that our mom in Bangalore was starting to be induced, one more of our mothers went into labor here in Hyderabad. Mom and dad had attended our Healthy Mother antenatal sessions to re-prepare themselves for this birth: they already have a 7 year old boy. Since her first delivery was normal, she wanted to ensure that she was able to birth naturally again. Mom was also concerned about starting her pregnancy being slightly overweight, and she wanted to ensure that she did not gain too much weight during the pregnancy. We worked on her nutrition needs, and she diligently followed her exercise programs and walking on a daily basis. She remained very active till the time her labor started.

All through labor, mom remained out of bed, and as active as possible, moving and changing positions, drinking plenty of fluids and practicing her pelvic tilts in various positions. Pains were very manageable with breathing until about 7 pm, and by 10 pm her bag of waters broke. She started to progress into active labor immediately after, and preferred to lie down on her side for a little while. Again, dad was a good source of support and encouragement in managing this intense phase. At one point, she was not very comfortable with trying any other position, so I suggested that we try labor with the head of the bed up in a semi-sitting position. This seemed to help her quite a bit, and she labored through her transition in this position. Finally, at around 4:30 am the next morning, mom felt the urge to push. After pushing in C-position for around 30 minutes, a healthy baby girl weighing 3.5 kgs was born at 5 am on December 19^th.

Lessons learnt: Mom and dad were very involved in the whole process of making this pregnancy and childbirth as healthy as possible. Even though they had a previous birth experience, they did not leave anything to chance for this delivery as well, and prepared themselves well for it. Congrats to mom, dad and big brother!

A Healthy Mother natural birth in Bangalore

Dec 18^th, 2008:: This particular mom had attended my Prenatal Lamaze program in Hyderabad, but went to Bangalore for her delivery – Bangalore being where her mother lives. At the start of the antenatal program, she expressed to me that she was so afraid of labor pains, that she had instructed her sister (who is a doctor) to help her go ahead with an elective C-Section. By the end of the program, this same mom had become a staunch believer in the power of natural birth, but most importantly, in her own ability to handle pains and birth naturally. We worked on a customized birth plan to suit her particular needs, and when she went to Bangalore, she met with her OB and hospital staff several times, to ensure that everybody in the team respected and appreciated her desire to give birth as naturally as possible.

We kept in touch over the next several weeks, and as the due date neared, there was still no sign of labor. Dec 15^th was her due date, and it came and went without any signs of labor. However, at the previous OB visit, she was found to be 4 cms dilated, so as per her plan, it was decided that everyone would wait and monitor over the next week for labor to begin on its own. Mom followed her exercise program eagerly, as well as tried some of the pressure points that she had learnt in our classes, to try and help labor to begin. Meanwhile, her husband had to go out of the country on a business trip on the 19^th, so mom decided to go in for an induction on Jan 18^th, so dad could be present for their baby’s birth. She was induced with oral prostaglandins at about 10 am in the morning, with a repeat dose being given at around 3 pm. Labor started soon afterwards, and by 7 pm, she was in intensely active labor. At some point during this phase, she asked for an epidural, but her husband, sister, OB and her support staff, all reminded of her birth plan, and amply supported her during this phase. Finally, she went onto the pushing phase at around 9 pm, and pushed with her urge and lots of support for around one and one-half hours. Even though her OB knew from her previous visit and scan that the baby’s birth weight would be high, all involved were committed to the cause of natural childbirth, and finally at 10:45 pm, mom gave birth to a healthy 4.2 kgs baby girl without any episiotomy. There were perineal tears that mom sustained during pushing, but in the end mom was able to give birth the way she wanted. Way to go mom!

Lessons learnt: This mother was in charge of her birthing experience, and that is always good. Her OB and labor support were very good and encouraged her every step of the way. Yes, the labor was induced – and yes, it would have been ideal to wait for labor to start on its own; however, given her personal circumstances and the fact that she was already past her due date made her decide to go in for induction. However, her induction probably had better chances of working, since she was already effaced and dilated to 4 cm. If this had not been the case, then the induction might have failed, and potential for a C-Section could have arisen if labor failed to progress adequately. In the end, mom’s knowledge of what to expect, her due diligence in choosing a good OB and hospital, and her preparation for labor through the antenatal sessions, as well as excellent labor support helped her to make her daughter’s birth experience exceptional for her.