United Brachial Plexus Network

¿Qué imagen se le viene a la mente cuando piensa en una mujer en labor de parto en el hospital?

La mayoria de las personas pensarían inmediatamente en una mujer acostada boca arriba, las piernas levantadas, con las rodillas al pecho. Ese es el modelo técnico de un nacimiento común grabado en nuestras mentes.

En esta posicion se puede observar de forma obvia que es al descansar sobre la espalda o de manera semi reclinada que la mujer reduce hasta 30% el espacio en el canal de salida o de nacimiento hasta en un. Al adoptar esta posición que se ve tradicionalmente en hospitales y preferida por porfesionales del campo médico, reducimos y hacemos mas dificil el nacimiento de cualquier bebe de manera inadvertida.

No existe ninguna razón médica que exija esta posición. Por el contrario, existen muchas razones por las cuales las mujeres deberían dar parto en una posición menos peligrosa que corresponda a la anatomía y fisiología femenina.

Abiri el canal vaginal para asegurar una salida menos riesgosa para el bebe no es complicado y esto reduce las probabilidades de un lesión al cuerpo de la madre. Simplemente con darse la vuelta sobre el costado de un lado al otro, lo cual se puede hacer facilmente incluso bajo el efecto de anestesia epidural, le permite al hueso sacro moverse hacia atrás en el momento que el bebé desciende por el canal de nacimiento.

¡Lo más importante es recordarle a la madre que no permnezca acostada de espaldas!

Simplenete con cambiar la posicion en la primera y segunda etapa durante la labor de parto se puede reducir la frecuencia con que ocurre la distocia del hombre, y sus consecuencias.

Riesgo del posicionameinto tradicional Las posiciones que cierran el canal de nacimiento, tal como es la posición tradicioanl de parto acostada boca arriba , pueden incrementar el riesgo de:

• Uso de forcep o succión
• Fractura de clavícula
• Presencia excesiva de hematomas
• Presión en las vertebras del cuello del bebé
• Deformidad de la cabeza
• Compresión del cordón úmbilical
• Estrés del bebé
• Mal posicionamiento del feto con relación al ángulo de aproximación a la pelvis.
• Fractura del húmero
• Interrupción del suministro de oxigeno Y también existen mayores riesgos para la madre, tales como
• Contracciones menos efectivas
• Demora y falta de progreso de la labor de parto
• Mayor probabilidad de hipotensión e hipertensión inducida por el embarazo
• Poca efectividad al pujar
• Ilusión de desproporcion cefalo pelvica debido al diámetro reducido de la pelvis como consecuencia del posicionamiento
• Mayor riesgo de necesitar cesarea
• Desgarramiento de tejidos en la madre
• Episiotomía
• Dolores de espalda
• Fractura del coxis

Janet Balaskas, la conocida pionera en partos naturales y autora de "Active Brith" segun su titulo en inglés, reitera el peligro de dar a luz en posición supina:

"En la posición semisentada el peso de la madre descansa sobre su coxis y la capacidad de la pelvis se reduce. En la posición semireclinada el hueso sacro no tiene mobilidad alguna y el canal pélvico se cierra. La estructura de tu coxis permite moverte y darle paso al feto a medida que la cabeza desciende por el canal. Si te sientas sobre tu coxis impides la salida a traves de la pelvis y tambien puede resultar en la dislocación del mismo, lo que puede ser extremadamente doloroso por meses aún después del nacimiento."

La union entre el hueso sacro y el coxis se ablanda durante el embarazo, lo que le permite al coxis poder moverse hacia atrás para ensanchar el canal de nacimiento a medida que el feto emerge.

Beneficios de posicionamiento correcto

Al utilizar posiciones de parto apropiadas a la anatomía femenina que amplian el canal de nacimiento se reducen las posibilidades de trauma para el bebé y el cuerpo de la madre. Con un poco de movimiento durante la labor de parto y con la utilización de posiciones de parto tales como recostada sobre el lado izquierdo del cuerpo, o sobre las manos y rodillas, de pie, agachada, etc, ofrecen varios beneficios:

• Mayor comodidad
• Menos dolor
• Mayor control y participación en el parto
• Contracciones más efectivas
• Mejor progreso en la labor de parto
• Mayores porbabilidades para que el feto descienda en una posicion óptima
• Se evita trabajar en contra de la fuerza de gravedad
• Mejor suministro de oxígeno y sangre al bebé

Aparte de estas ventajas tambin existen otros efectos que ofrecen beneficio en la´labor de parto. El cambio de posicion durante la labor de parto puede cambiar la forma y el espacio en la pelvis, lo cual puede ayudar a que la cabeza del feto encuentre la posición óptima en la primera etapa del parto, fascilitando de esta manera su rotación y descenso en la segunda etapa.

Las actividades que provéen al cuerpo con algún tipo de movimiento como mecerse de un lado a otro, caminar, subir escaleras, caminar con pasos agigantados agachandose con una pierna al frente, pueden ayudar también.

Movimientos y posiciones erguidas pueden ayudar con la frecuencia, duración y eficiencia de las contracciones. El efecto de la fuerza de gravedad puede ayudar al feto a descender con mayor rapidez. El cambio de posición asegura un suministro de oxigeno continuo al feto.

"Existe evidencia que demuestra que cuando la madre va a dar a luz y está acostada sobre su espalda, esto produce presión sobre la vena caval, lo que resulta en hipotensión, lo cual puede ocasionar tambien una falta de oxigenación al feto y escacés de nutrientes suministrados por la placenta. La eficiencia de las contracciones del utero también pueden desmejorar".( Humprey et al. 1974, Kurz et al.1982)

El cambio de posición tanbién puede reducir la duración de la labor de parto. Mendez- Bauer y Newton afirman que la duración de la labor de parto en relación a la dilatación de 3 cm a 10 cm se acorto en 50% en pacientes que alternaron las posiciones de pie y supina, asi como también sentada y de pie.

Otros resultados positivos como consecuencia del posicionamiento es la disminución de episotomias y desgarros de cuarto grado. Esto se debe a que con la disminución de distocias los doctores no tienen necesidad de cortar el perinéo para crear espacio para la manipulación del bebé. Esta técnica se ha utilizado por mucho tiempo mas por razones legales que anatómicas.

La posición ideal incluye

• Abrir la salida pélvica tanto como sea posible
• Provéer una posición fetal adecuada de modo que la salida del bebé por el canal de nacimiento sea óptima.
• Ultilizar la fuerza de gravedad como ayuda
• Asegurarle a la madre que no corre riesgos y que ella esta en control del proceso.
• Disminuir el riesgo de lesiones al bebé y la madre

What image comes to mind when you picture a birth in a hospital?

Most people see a picture of a woman on her back, with her legs raised or perhaps in stirrups. That is the perception that the technological model of birthing has transfixed into our mind's eye.

The obvious problem is that by lying on one's back or by sitting semi-reclined on one's tailbone, the space of the pelvic outlet (birth canal) may be reduced by up to 30%. By adopting a traditional hospital position that is convenient for birthing professionals, one unknowingly reduces the space the baby has to enter this world.

There is no medically sound reason to give birth on one's back, and there is every reason to give birth in a safer position that works with female anatomy and physiology, in a way that women’s bodies were designed.

It is so easy to open up the birthing canal to help ensure a safer passage for the baby, and to reduce the risk of injury to the mother's body as well.

By simply rolling over to one's side, which can be easily accomplished, even with an epidural, allows the sacrum the freedom to move back as the baby is passing through.

What is most important to remember is to get the mother off her back!

Changing positioning during the first and second stages of labor can dramatically reduce the incidence of shoulder dystocia, and thus eliminate the resulting complications
Risks of Traditional Positioning

With positions that close the birthing canal, such as lying down, there may be increased risk to the baby of:

* increased need for forcep or vacuum delivery
* broken clavicle/collarbone
* excessive bruising
* pressure on baby’s neck vertebras
* excessive head molding
* compression of umbilical cord
* stress on baby
* poor position/angle of the fetus in relation to the pelvis
* brachial plexus injury
* broken humerus
* disruption of the baby’s oxygen supply

and increased risk for the mother of:

* less effective contractions
* labor slowing and not progressing
* possible increased hypotension & pregnancy-induced hypertension
* ineffective pushing
* may lead to illusion of cephalo-pelvic disproportioin due to reduced pelvic diameters from poor positioning
* increased risk of need for Cesarean section
* strain and tearing to the mother's tissues
* episiotomy
* back pain
* fractured coccyx/tailbone

Janet Balaskas, the recognized pioneer of natural childbirth and author of “Active Birth” reiterates the danger of being in a supine position:

“In the semisitting position the mother’s weight rests on her coccyx and the pelvic capacity is reduced.” “In the semireclining position the sacrum is immobile and the pelvic outlet narrows.” “Your coccyx is designed to move out of the way as your baby’s head descends. Sitting on your coccyx during birth restricts the pelvic outlet and can also lead to dislocation of the coccyx, which can be extremely painful for months after the birth.”

The sacrococcygeal joint, the joint between the sacrum and the coccyx or tailbone, also softens in pregnancy; it is designed to swivel backwards to widen the outlet of the pelvis as the baby emerges. Of course, this is impossible if the mother is sitting on her coccyx.
Benefits of Proper Positioning

Opening the birth canal by using positions that support a woman’s anatomy, will decrease the risk of possible trauma to the baby and mother’s body. .Moving around during labor and using birthing positions such as left side-lying, hands and knees, upright, squatting, etc. offer several benefits:

* increased comfort
* reduced pain
* an enhanced sense of control and involvement in the birth
* more effective contractions
* better progression of labor
* baby more likely to descend in an optimal position
* work with gravity instead of against it
* better blood and oxygen supply to the baby

Beyond these advantages, there are equally important effects on the baby and on the progress of labor. Changing positions during labor can change the shape and size of the pelvis, which can help the baby's head move to the optimal position during first stage labor, and helps the baby with rotation and descent during the second stage.

Swaying motions such as walking, climbing stairs, lunging, and swaying back and forth are especially helpful with this.

Movement and upright positions can help with the frequency, length, and efficiency of contractions. The effects of gravity can help the baby move down more quickly. Changing positions helps to ensure a continuous oxygen supply to the fetus.

“There is evidence to suggest that if the mother lies flat on her back then vena caval compression is increased, resulting in hypotension. This can lead to reduced placental perfusion and diminished fetal oxygenation. The efficiency of uterine contractions may also be reduced”. (Humphrey et al. 1974, Kurz et al. 1982)

Changing position can also reduce the length of labor. Mendez-Bauer and Newton (1986) state that duration of labor from 3 to 10 cm cervical dilation was about 50% shorter in patients who alternated supine and standing with standing and sitting positions.

Another positive outcome from positioning is the reduction of the use of episiotomies and fourth degree tears. Since there will be less dystocias, doctors will not feel inclined to cut the perineum, to give more manipulation room. These have been done for many years without anatomical reason, but more so for legal record.

An ideal position would include:

* opening the pelvic outlet as widely as possible
* providing a better fetal position with a smooth path for the baby to descend through the birth canal
* using the advantages of gravity to help the baby move down
* giving the mother a sense of being safe and in control of the process
* and most importantly, decreasing the risk of injury to the baby and to the mother

Recommended Books

Ina May’s Guide to Childbirth by Ina May Gaskin, Bantam Dell, 2003.

Immaculate Deception II: Myth, Magic and Birth

Active Birth : The New Approach to Giving Birth Naturally, Revised Edition.

The Thinking Woman’s Guide to a Better Birth by Henci Goer, Perigee Books, 1999.

Gentle Birth Choices

Essential Exercises for the Childbearing Year: A Guide to Health and Comfort Before and After Your Baby Is Born

Birth Reborn

Sit Up and Take Notice! Positioning Yourself for a Better Birth. by Scott, Pauline - Great Scott Publications, 2003.

The Birth Book: Everything You Need to Know to Have a Safe and Satisfying Birth (Sears Parenting Library)

The Birth Partner: Everything You Need to Know to Help a Woman Through Childbirth, Second Edition

The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia

Recommended Videos

A Breech Birth and Shoulder Dystocia. The video shows two separate 10-minute segments of different births. The first birth shows a frank breech delivery, and during the second birth, the unexpected complication of shoulder dystocia occurs, while the mother is pushing lying on her back, semi-reclined. With the correct and effective intervention of rolling mom over to hands and knees, the 10lb. 8oz. baby is quickly dislodged and delivers. Mom had no episiotomy or tear. Video Farm, Summertown, Tennessee.

Birth in the Squatting Position. Women birthing upright in privacy, with powerful images. We are left wondering, "How have we strayed so far away from what birth once was?" 10 minutes. Purchasable through Birth Works®, Inc. @ (888) 862-4784

Gentle Birth Choices This documentary demonstrates the ability of women in childbirth, dispels commonly held beliefs, and speaks to the importance of women taking charge and making choices regarding their birth. VisionQuest Video, Venice, CA. (310)577-8581.

The Timeless Way: A History of Birth from Ancient to Modern Times. Vintage film footage and recent video combined depicting the history of birth from ancient to modern times, with emphasis on the history of upright birthing positions. This video promotes introspection and inspiration for mothers considering birthing choices available today. 20 minutes. 1998. InJoy Videos, Boulder, CO. 1-800-326-2082.

 (series of 5 episodes)

Newborn Birth Injuries: The Untold Story is a life-changing documentary on the cause and prevention of brachial plexus birth injuries that aired on PBS stations nationally, and was viewed by millions of people. PBS used the 5-minute Spotlight On short as filler in between programming times. While currently no longer airing on PBS, you can view it by clicking here.

UBPN was also fortunate to be able to produce a more detailed 25-minute version of the documentary, to help generate greater awareness and educate the general public with actionable specifics regarding the cause and prevention of brachial plexus birth injuries.

WATCH AND SHARE! Help us spread the word, share this video, and save future babies and their families from unnecessary suffering! 

 You can also purchase the DVD of the full 25-minute documentary by clicking here, and will help continue UBPN's efforts towards awareness and prevention of this injury.

There are many sites that will go into detail of how a baby sustains a brachial plexus injury (BPI). There is much controversy in the obstetrical field regarding causation. Simply put, the overwhelming evidence is that the delivering practitioner applies too much traction on the baby's head and/or uses contraindicated procedures while trying to dislodge the baby’s shoulders (shoulder dystocia) from behind the pelvic rim or from the bony sacral promontory (tail bone) while the woman is usually lying on her back and/or sitting on her tail bone.

In doing so, the nerves that innervate the shoulder, arm, wrist and/or hand can be severely damaged, resulting in partial to complete paralysis. Sometimes the force is so great that the nerves are actually pulled completely out of the spinal cord-reducing most possibilities of any useful function of the arm, and necessitating numerous surgical interventions in an attempt to gain even the slightest function.

Also, the nerve to the eye may be damaged, resulting in Horner’s Syndrome. In severe cases the nerve to the diaphragm (phrenic nerve) may also be injured.

Shoulder dystocia is described as an obstetric emergency involving the lack of rapid, spontaneous delivery of the anterior shoulder of the fetus. The accepted proposal is that the shoulder gets lodged against the mother's pelvis symphysis (Inlet), although there is evidence to suggest that it can be a pelvic outlet phenomenon -a proposal that could support either shoulder being impacted. If it is a pelvic outlet issue, then either shoulder could be damaged from the traction, whether it be upward or downward traction that is applied. Rotational toruque on the babies head must be avoided during any manual manipualtions to free the shoulders.
Risk Factors:
Prepregnancy:

* Maternal birth weight
* Prior shoulder dystocia
* Prior macrosomia (large baby)
* Pre-existing diabetes
* Obesity
* Multiparity (a woman birthing her second child or who has had two or more children)
* Prior gestational diabetes
* Advanced maternal age

Antepartum (while pregnant):

* Excessive maternal weight gain
* Macrosomia
* Short stature
* Postdatism

Intrapartum(during birth):

* Prolonged second stage
* Protracted descent
* Failure of descent of head
* Abnormal first stage
* Need for mid-pelvic or assisted delivery

Weight and weight gain during pregnancy are critical factors during pregnancy. Mothers that weigh more than 81kg (~180 lbs) pre-pregnancy, experience 30% of all shoulder dystocias. In addition, more than a 20kg (44 lbs) pregnancy weight gain shows an increase in shoulder dystocia from 1.4% to 15.2%. This is an area that must be stressed by the OB/GYN during pre-pregnancy discussions and throughout the pregnancy. Screening for maternal diabetes must be the standard protocol, not an elected option.

For infants of non-diabetic mothers, the risk of shoulder dystocia is approximately 10 percent for infants weighing 4,000 to 4,499 grams (8.8-9.9 lbs)and 23 percent for infants >4,500 grams (9.9 lbs) . For infants of diabetic mothers the risk is 31 percent for infants >4,000 grams (8.8 lbs). Unfortunately, these statistics are only retrospective, since there is no adequate method for determining the accurate fetal weight.

Maternal weight gain, and the development of a macrosomic fetus are not the only predisposing factors.

The use of epidurals has been implicated to cause an increase in the incidence of cesarean sections for shoulder dystocias (10% vs. 3.8 % without epidurals). In addition, Stoddart et al., in a well-controlled randomized prospective study, showed that epidural anesthesia affects rotation of the shoulders because it relaxes the pelvic floor. Being in a recumbent position (lying down) has also been implicated in slowing down the baby's descent, prolonging the labor process, and potentially closing the birthing canal by up to 30%.
Positioning

Using the proper positioning during labor will help reduce the incidence of shoulder dystocia, by allowing the sacrum to move back freely and by allowing the birth canal to fully open. Thus, using the recumbent position (lying down) or semi-reclined position exacerbates the shoulder dystocia.

Borell and Fernstroms' (1957a) x-ray studies showed that the sacroiliac joint (part of the tailbone) moved during labor in relation to the descent of the fetus, and that these movements were not brought about by a change of maternal position at the particular time, but by the freedom of the joints to spread and open more.

In other words, the sacroiliac joints were free to move back as the baby passed through the birthing canal, because the women were not lying on their sacrum’s thus restricting such movement. They found that as the fetal head passes the pelvic inlet, i.e. at engagement, a movement of rotation occurs within the sacroiliac joint that increases the sagittal diameter of the pelvic inlet.

At the time the fetus passes the pelvic outlet, this movement of rotation is reversed, increasing the sagittal diameter of the pelvic outlet.

Basically, by keeping off her back (tailbone) the woman is giving her baby the widest possible opening for passage thus reducing the risks of trauma.

If a woman is sitting on her sacrum and sacroiliac joints during delivery, then there is an increased chance of precipitating a shoulder dystocia, and an increased likelihood of a brachial plexus injury.

Significantly closing the birth canal in the lying down or semi-reclined position, also increases the likelihood of a forceps or vacuum delivery, which in turn increases the risk of a brachial plexus injury and other birth trauma as well.

In an article from the Perinatal Institute, shoulder dystocia is discussed:

“Shoulder dystocia needs to be distinguished from a mere difficulty with delivery of the shoulder. The latter occurs because of the prevailing delivery practice, with the mother in a semi-recumbent position on the delivery bed. There may be insufficient room for appropriate lateral, i.e., downward flexion for delivering the anterior shoulder. In addition, the weight of the mother is in part taken on the sacrum that is therefore pushed upwards, thus decreasing the diameter of the pelvic outlet. Many of these cases require only a positional change, into left side lying, or kneeling, which frees the sacrum and allows lateral flexion”.
Prevention

The BPIPP’s main goal is to provide information for the Prevention of shoulder dystocia and hence brachial plexus injuries.

There are many publications that describe medical interventions to try and resolve a shoulder dystocia, such as McRoberts Maneuver (which is used to reopen the pelvis after it has been previously closed by lying on the tail bone).

We hope to convey that by taking a birthing position that allows for maximum pelvic opening, that shoulder dystocia and brachial plexus injuries will drastically be reduced.

“Prevention” is always a much more sensible and successful approach than attempted “interventions” after the fact.