Penny Simkin at BINI Birth

Advice from Penny: "Plant a seed that will grow"

I recently had the privilege of attending a workshop by the legendary Penny Simkin on normal birth, traumatic birth, 3rd and 4th stages of labor, rebozo techniques, and advanced comfort measures. If you’re not already overcome with envy, you must not know who Penny is. In short, she is a physical therapist, childbirth educator, doula, one of the founders of DONA, has written some of the best birth books out there (The Birth Partner and Pregnancy, Childbirth and The Newborn are my favorites), and it is because of her that we have squat bars and birth balls in hospitals (she invented them). The woman has a seriously impressive resume. If it wasn’t for Penny Simkin, doulas as we know them may never exist, and they certainly wouldn’t be as common as they are now. She is the mother doula and is by far one of the best. Its incredible to see her in action supporting a woman and I am so grateful that we have the ability to observe great doulas doing what they do best. Her motto is “How will she remember it?”. She, being the mother, is at the center of a doula’s work and Penny promotes and executes this model of care flawlessly. She is equal parts sweet, motherly, warm, intuitive, insightful, funny, honest and feisty. It is such a gem to see a nearly 70 year old woman (although you wouldn’t guess it by the joy and cheer spilling out of her) who has spent the last 44 years in the face of animosity to facilitate better experiences for women, still has such a fire burning within her after all this time and hard work.

The workshop was hosted at BINI Birth (my doula home!) by my trainer Ana Paula Markel. I love when we have big names come to BINI because the energy buzzing is electrifying and SO contagious. We are like fan girls eagerly awaiting (insert legendary birth professional’s name here) arrival, we constantly check in on Facebook and Twitter to see if they have landed at the airport yet, what amazing dish Ana Paula made them for dinner, funny things they’ve said, if they’re almost at BINI,… its like expecting The Beatles to arrive.

Just like with Ina May Gaskin and Phyllis Klaus, the morning of March 31st had the same wild  buzzing energy. If you thought any of the 60+ doulas, RN’s, and midwives who attended were able to sleep a wink the night before, you would probably be wrong. My wake up time couldn’t come soon enough and I, like the others, spent the day both in awe and furiously scribbling down every inspirational word that came out of Penny’s mouth (that’s just about every word, by the way). She granted me permission to share her wisdom, which I think is so important because while she has touched thousands upon thousands of people with her findings and insights, there can always be more minds opened and lives touched.
Here are some of Penny’s insights and knowledge:

ON NORMAL BIRTH

Before we can talk about what normal birth looks like, we must answer the question of normal vs. natural. Is normal birth and natural birth the same thing?

Definition of Natural: existing or derived from nature, not made, caused by, processed by, or derived from man.
Definition of Normal: Conforming to a standard; usual, average, typical or expected.

• Normal Birth never changes physiologically, however statistical norms change constantly and are influenced by trends and values. It also varies geographically.

• The WHO defines normal birth as being low risk from start to finish with spontaneous onset at 37-42 weeks. UK Midwife Debby Gould adds to this definition that normal labor and birth involves strenuous physical work by mother, includes movement seeking comfort and progress, and movement by fetus through birth canal.

• The outcome of a normal birth is a healthy motherbaby who are ready to adjust to their new roles, with the woman feeling empowered, with a sense of achievement for productive work she has done.

The doulas role in preserving normal birth is to:
-Simply being present with her
-Model confidence in process with no sense of urgency or need to control it
-Watch before acting
-Have patience and confidence “babies come out’
-Help her accept labor pattern “labor unfolds at its own pace”

Doulas Motto: “If it ain’t broke, don’t fix it”

Physiologic norm is the standard against which all care should be measured: How and how much is normal process altered? What are the outcomes?

ON INTERVENTIONS AND OUTCOMES

What are the 2 main approaches to labor today?

Psycho-physiologic (mind/body) management:
-designed to maintain and enhance the mother’s resources for giving birth
-woman’s state of mind influences labor
-active role of woman improves outcome

Industrialized:
-designed to replace or alter the body’s own resources
-more control over process
-based on beliefs that normal process is unsafe/unreliable and outcomes are improved with intervention
-requires less skill for difficult birth (example: quick c-section for breech baby instead of turning )
-inductions/cesareans are no worse for motherbaby and may be better than normal birth
-original intention was to improve outcomes with interventions that have now become routine
-we are paying the price in prematurity and perinatal mortality/morbidity

How does place of birth affect labor?

A “safe” undisturbed environment support spontaneous behavior and facilitates secretion of Oxytocin (by not feeling disturbed, watched, connected).
Strange environments (unfamiliar, noisy, bright, and intrusive) interfere with Oxytocin production and create an adverse fetal response.

How does the way labor begins affect labor?

Spontaneous labor ensures fetal readiness since it is the baby who starts labor when he is ready for extra-uterine life.

Induced labor increases late term prematurity and incidences of postpartum hemorrhage, fetal distress, c-sections, instrumental deliveries, NICU admissions, separation and increases labor time. 80% of inductions are done for non-medical reasons.

How does IV Hydration affect labor?

• Creates discomfort and inconvenience (wires and restriction of movement)
• Causes fluid overload at an average of 7 gallons/12 hours. This leads to swelling of feet and hands (more discomfort) and Hyponatremia (loss of sodium in blood)
• Mother feels deprived of basic comfort. Drinking her liquid of choice enhances sense of normalcy and in most cases will provide her with adequate hydration
• Body prepares for labor by increasing fluids by 40% and women tend to need less fluids in labor than they usually do.
• Too much oral fluid can lead to prolonged labor (Note to doulas: do not force fluids, only offer)

How does external fetal monitoring (EFM) affect labor?

• Restricts mother’s activity
• More c-sections for non-reassuring fetal heart rate tracings
• Differing interpretations of heart rate tracings by experts
• No improvement in fetal outcomes
• Inability of caregiver to auscultate (hearing with ears, stethoscope, fetoscope, or pinard horn). Auscultation is less disturbing to mother and has outcomes as good as EFM.
• Impact of doulas have been studied more than EFM

How does amniotic sac care affect labor?

Artificial Rupture of Membranes (AROM)

• may speed labor by 40 minutes
• May cause pre-existing fetal malposition to become persistent (fluid provides baby with space and medium in which to move and reposition)
• increases risk of infection

Spontaneous Rupture of Membranes (SROM)

• usually occurs late in 1^st stage or in 2^nd stage
• 75% of women’s waters break during transition, 66% break during pushing, if not before labor
• 1 in 7 break before onset of labor

 How does pain medication affect labor?

• Narcotics are uneffective and unpleasant for mother but great for caregiver.
• Woman is relaxed and sleepy, not active, and her movement is restricted. This can slow and even halt labor.
• She only feels hard peak of contractions perceived as sudden unexpected pain which is quickly over. There is no chance for her to become used to the sensation as she cannot feel them build.
• Invasive and unsafe without precautions and interventions
• 7 to 8 other tubes/lines to keep epidural safe
• There is a difference between pain and suffering. If mother is coping with pain, no big deal. Mother can suffer without pain and with epidural. Suffering may increase likelihood of trauma and PTSD.

How do positions and movement affect labor?

Standard (Supine/Lithotomy) position –

• Restricts movement
• Increases risk of Dystocia and malposition
• Increases pain and discomfort
• Higher risk of maternal and fetal distress

Freedom of Movement/Choice of Position –

• Increases comfort
• Enhances maternal satisfaction
• Shorter labors in some studies

Supine/Lithotomy

• Narrows birth canal up to 30%
• Working against gravity
• Increases assisted deliveries (forceps, vacuum, cesarean)
• Increases pelvic floor damage (tearing and episiotomy)
• Prolongs 2^nd stage (pushing)

Non-Supine and Mother’s Choice

• Increases chance for spontaneous birth
• Reduces pelvic floor damage
• Increases mothers satisfaction
• More on labor positions can be read here and here

ON 3RD AND 4TH STAGE  (Placenta delivery/cord cutting and first hours after birth)

Holistic definition of 3rd Stage:

• Enormous transition of fetus-to-newborn
• Baby is dried and placed skin-to-skin and all senses are involved. How does mom feel (skin and breath), sound (voice and heartbeat), smell (breath, breast), taste (sweat and colostrum), look (breast and face)?
• In a normal 3^rd stage, family should be together skin-to-skin

Hormonal influences of 3rd Stage (all promote bonding):

• Prolactin (‘the altruistic hormone’) levels rise related to baby’s suckling (intensity, duration, and frequency)
• Oxytocin (‘the love hormone’) levels increase in motherbaby in first hours and remain for days, smells augment the mother and baby’s release of Oxytocin-
• Beta-endorphins (anti-pain hormone) – induces feelings of pleasure, euphoria, mutual dependency, released in response to pain, peaks at birth for motherbaby
• Catecholamines (‘the stress hormones’) are high during 2^nd stage (pushing) and drops steeply after baby is born, baby produces catecholamines during birth which promotes adaptation to extra-uterine life (absorption of lung liquid, inflation of lungs, alertness, wide eyes, temperature regulation, placental blood transfusion to baby, metabolism of brown fat for warmth.
• Epidurals block Oxytocin release, Michel Odent says everything gets wiped out by epidural (hormonally), endocrine system is “pretty well blocked” by epidurals and cesareans

In human life, there is no greater transformation than what happens within the first 5 minutes after birth:
Baby absorbs/spits up lung fluid > lungs expand for air > baby takes first breaths > within 2-3 breaths circulation of entire body is re-routed to lungs > ~20 mins later saliva is produced and digestive juices begin to flow > baby searches for breast and suckles

What are the effects of suctioning?

• Bulb and deep suctioning can cause gagging, abrasions of mucus membranes and oral aversions
• Does not reduce respiratory problems or meconium aspiration in vigorous babies
• Deep suctioning can cause cardiac arrhythmia
• Vigorous newborn is able to expel fluids, mucus, and handle meconium. Self-clearing of secretions may improve early breastfeeding

Penny spoke quite a bit about the harmful effects of immediate cord clamping (routine practice in hospitals) and the benefits of delayed cord clamping. I didn’t take many notes during this time since this is a topic I am also very passionate about and wanted to really absorb everything she was saying. In lieu of notes, here is Penny’s wonderful video on the subject:

4^th stage A.K.A. Family Integration Period

Mutual regulation occurs as Mother helps baby to:

• improve adaptation to life outside of the womb
• regulate temperature
• conserve energy
• adjust respiration, reduce crying
• adjust noisy behaviors

Baby also helps mother with:

• involution (uterus contracting down to pre-pregnancy size
• caring for baby with touch, nursing, and hormone production

The first hours are a sensitive period for parent-infant bonding.

Preserving these moments by holding space and not interfering is so vital in the beginning of a baby’s life and the bond she will share with her parents. The stronger the bond, the better, and usually all it takes is to step back, leave the room, and let the new family be (unless medical intervention is absolutely necessary). Penny talked quite a bit about traumatic birth as it is unfortunately more common than we may believe (1 in 3 to 1 in 4 women report their births as being traumatic and may of those births were considered clinically normal). There is much information to be shared on the subject and for that I will let Penny take over. Her website is a wonderful resource that includes many of her powerpoint presentations and articles she has written which you can see here.

Thank you to Penny Simkin for everything you have done for families, for sharing your wisdom so enthusiastically, and for giving me permission to share your words and findings as well. It was truly a blessed day at BINI and we hope you come back soon!

The Amazing Placenta A.K.A. The Tree of Life

The Placenta - Notice how the arteries look just like the branches of a tree?

The placenta is a fascinating organ with many healing properties. For myself and other birthies, it is a highly revered organ and something that should be cherished and appreciated, instead of a source of cringes and gags. That being said, if you are easily grossed-out or are just plain close-minded, you may want to proceed with caution.

What is a placenta? A placenta is a temporary organ that your body grows just for your baby. Cambodians call it “the globe of the origin of the soul”. It is composed of 50% of your cells and 50% of your baby’s cells. It provides a filter for toxins while your baby’s liver is still developing and provides your little one with oxygen and nutrients via the umbilical cord. The umbilical cord is attached to the center of the placenta (in some cases it is attached to the side, known as a Battledore insertion). The placenta is attached to the uterine wall and is one of the first things to develop upon conception. In a way, its is your baby’s first home! Inside it you will find the amniotic sac (also known as the caul, waters, or membranes) and inside the sac you will find your baby. It’s like womb inception!

Wombception - image via Babycenter.com

Isn’t it just human waste? A bio-hazard? Not at all! The placenta (commonly referred to as afterbirth) is a very misunderstood organ and since we rarely see it and learn virtually nothing about it, of course we think its gross! I admit even I was a little irked by them at first, but as I learned more and got to know it better I can look at them endlessly and don’t mind handling them either (more on this later). Hospitals generally view it as waste and incinerate them, however midwives know how special they are and will show it to you, explain its features, point out any abnormalities (such as areas of calcification), explains its benefits postpartum, cultural practices, and what you can do with it after (other than tossing it). This is especially cool for older siblings!

So what can be done with it? There are many ways to show your appreciation for the very thing that helped your baby to grow. Most of these have ancient cultural origins, ranging from spiritual to nutritional to biological.

Placenta Prints

We are all so unique!

Before burying or consuming their placenta, many women choose to immortalize their unique and beautiful Tree of Life by painting (paint, blood, or even fruit juice can be used) and imprinting it on paper or canvas.

Encapsulated Placenta A.K.A. Happy Pills!

Consumption

This is the part where you may cringe if you haven’t already, but if you can, get over it and fast. Here’s why: The placenta is LOADED with nutrients and hormones that are lost after birth! It is widely-accepted that new mothers will experience depression, low energy, anemia, and other not-so-fun postpartum symptoms. What if I told you taking a pill that is 100% safe and organic could decrease, prevent, or even entirely eliminate all of those things and more? You would totally take it right? Sure, it’s made out of your placenta, but once its in pill form, it looks just like a vitamin. Don’t just take my word for it! A small but growing number of women are using their placentas to better heal from pregnancy and birth and there is more and more research being done on this practice. Guess what? They all have the same conclusions about its effectiveness and many news stations have recently reported on its benefits and the increasing number of mothers who swear by it.

Most mammals consume their placenta after birth, and while many believe this is to limit the scent detectable to predators, this simply isn’t true. Mothers shed lochia, newborns are covered in fluid and vernix, etc. It is thought that mammals (including humans) instinctively consume their placenta in order to balance their bodies back to its pre-pregnancy state and also to satisfy mammals (even herbivores) near instant carnivorous state postpartum.
More on the biological reasons for placenta consumption can be read here.

Among other things, placentas contain many beneficial hormones including oxytocin (promotes bonding), prolactin (increases milk supply and makes milk come in sooner), iron (decreases anemia and increases energy),  Vitamin B6 (fights postpartum depression and baby blues), and progesterone (balances pituitary and ovarian hormones), among other minerals and nutrients. It can also be life-saving: in the event of a postpartum hemorrhage, many cultures, such as the Amish, place a piece of the placenta between the gum and cheek. Within minutes, the hemorrhaging will subside. Cool huh?

January Jones, who went back to working grueling hours as Betty Draper on the set of Mad Men just six weeks postpartum, is one of the few celebrity moms who has been open about her "happy pills", which she suggest for all moms and has been taking every day since the birth of son Xander Dane.

There are many ways in which placentas can be consumed: raw (some women prefer to “hide” it in a smoothie), cooked (it tastes and smells almost identical to liver), tincture, or encapsulated (dehydrated and ground into a powder which is then put into pill form). Powder from the encapsulation process can also be put into a smoothie or juice. I think one of the coolest things about placenta pills is that, when stored properly, they will last a literal lifetime and have been found to be helpful during menstruation, menopause, and even when your child is having hormonal issues during puberty. Remember: 50% your cells, 50% their cells.

NOTE: In the event of a cesarean, you can still consume your placenta. It is standard procedure for them to take it to pathology where it is often treated with Formalin of Formaldehyde. It will no longer be healthy for consumption after this treatment. If they insist, ask them to cut a piece off for testing instead of using the whole placenta. Women who have had surgical or highly interventive births can especially benefit from placenta consumption.
You can learn more about the benefits and encapsulation process (the Traditional Chinese Medicine way) with many pictures here.
If you’re up for it, there are is a link at the end of the article to a detailed retelling of author Emma Kwasnica’s home birth which completely opened up my eyes and changed a lot of my beliefs about birth. A fantastic read with lots of pictures!

Lotus Birth

Image via lavendilly.wordpress.com

Lotus Birth, or Umbilical Non-Severance, is the practice of leaving the baby’s umbilical cord attached (to him/herself and the placenta) until the cord detaches naturally. This often happens in a much shorter period than the time it takes for a clamped and cut umbilical stump to fall off and is viewed as being a more organic, natural, safer, spiritually and emotionally-conscious practice.
If this sounds unnatural, remember earlier when I said most mammals consume their placentas? Chimpanzees, the species we regard as having the highest intelligence in the animal kingdom, practices lotus birth as observed by Jane Goodall.
Evidence of lotus births can be found in ancient Eastern texts, including those of Tibetan and Zen Buddhism, Balinese, and some Aboriginal cultures as well. Placentas are wrapped in a soft cloth, bowl or bag which are often made specifically for the purpose of housing the postpartum placenta , and treated daily with herbs and salts to decrease smells and promote drying. If lotus birth is something that interests you, but you are also intent on consuming your placenta, it is still possible. Read a very well-written how to here by the fabulous Gloria Lemay.
You can read all about lotus birth here (seriously, there is a TON of information out there about it!). I also suggest learning about the benefits of delayed cord-clamping and the harm our current practices are causing.

Burial

Girl next to the apple tree nourished with her placenta. Upon viewing the burial of her siblings placenta, her mother says 'When I said "goodbye, placenta,' Mia said, 'It’s not goodbye! It’s HELLO! It is going to grow forever and ever.' So there you go. Wise words from the mouth of a child." Image via tikkitavi.wordpress.com

Placenta Burial Ceremonies are another ancient practice, one which has been performed on nearly every continent. This is a deeply spiritual and often emotional practice. I think Wikipedia sums it up best: “The Maori of New Zealand traditionally bury the placenta from a newborn child to emphasize the relationship between humans and the earth. Likewise, the Navajo bury the placenta and umbilical cord at a specially chosen site, particularly if the baby dies during birth. In Cambodia and Costa Rica, burial of the placenta is believed to protect and ensure the health of the baby and the mother. Several cultures believe the placenta to be or have been alive, often a relative of the baby. Nepalese think of the placenta as a friend of the baby; Malaysian Orang Asli regard it as the baby’s older sibling. The Ibo of Nigeria consider the placenta the deceased twin of the baby, and conduct full funeral rites for it. Native Hawaiians believe that the placenta is a part of the baby, and traditionally plant it with a tree that can then grow alongside the child. Various cultures in Indonesia, such as Javanese, believe that the placenta has a spirit and needs to be buried outside the family house.” I think this is such a sweet, natural, connected, and beautiful practice.

Matthew McConaughey told CNN he planned to bury his son Levi’s placenta after being inspired by his travels, “When I was in Australia, they had a placenta tree that was on the river…and all the placentas of all that tribe, all that clan, whatever aboriginal tribe that was, all the placentas went under that one tree and it was this huge behemoth of just health and strength. This tree was just growing taller and stronger above the rest of Mother Nature around it. It was gorgeous.”

As for the location of Levi's placenta, Matthew says, "It’s going to be in the orchards, and it’s going to bear some wonderful fruit".

End note: Taking your placenta home from the hospital can be a hassle, but since it is YOUR organ and belongs to YOU, you have every right to take it home. Here is a placenta release form to prevent staff from giving you a hard time. Be prepared with a Ziploc bag or container to store it in. Best practice is to write your name and basic info on it and refrigerate or freeze it immediately. Hospitals have a tendency to “lose” placentas when storing them for you, so it is best to have a friend or your doula run it home for you.

More information about placenta’s benefits and cultural practices can be viewed at the following links:
All About Placenta Encapsulation ~ via Mommy Feel Good
Placenta Encapsulation FAQ ~ via Placenta Mom
Cultural Reverence of the Placenta ~ via Tides of Life
Cultural Placenta Traditions ~ via Birth To Earth