A Powerful Position

In our world – the world of pregnancy and babies – Penny Simkin is a rock star.


The childbirth educator, doula and author of many books (most recently When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on the Childbearing Woman but probably most famously for The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia) recently spoke at the Cedars-Sinai second annual Birth Community Day in Los Angeles. The day was sparked a couple of years ago by a conversation between a Cedars-Sinai Labor and Delivery nurse and a doula (imagine!), with the goal of sharing valuable knowledge and experience about the best ways to ensure a safe, comfortable and memorable birthing experience. In attendance: nurses, midwives, doulas, MDs and press. Bini Birth of Sherman Oaks, CA co-hosted.

Of course, the event drew additional interest because Cedars-Sinai has a reputation for a high C-section rate (currently their website clocks the C-section rate at 22%; in 2008 it was 37.1% — the national average for 2011 was 32.8%). This community, however, is committed to their mission, which includes, as OB/GYN Sarah Fitzpatrick says, making sure that women know about all their options for managing pain and increasing comfort during childbirth: "As new research leads to new best practices, we must continue to transform our models of care." I loved her statement that followed: "Too many interventions are bad; what's most important is safety. We work together, communicate when we're worried, and it makes us better doctors and nurses. Is the C-section rate high? Maybe, but we'd like to get it lower, but safely, which means customized care, education, and touch. Lots of touch."

Some of the options already in place at Cedars, or in the works, include walking epidurals (for real!), aromatherapy (for both vaginal and Cesarean birth), doulas for natural, epidural-assisted and even surgical births, immediate skin-to-skin contact. A new program called "Rock and Roll" encourages laboring women to change position every 20 minutes, and even try some labor positions (such as on a birthing ball or squatting), even if they have had an epidural. The aim – to reduce the C-section rate (Cedars reports an 8% decrease) and the length of time in labor, which spokespeople say has gone down by 20%.

Penny Simkin has herself long been committed to reducing C-sections in this country. Simkin has been in practice more than 50 years, and has prepared nearly 11,000 women and families for labor and delivery. She says the #1 reason for C-section is dystocia, or failure to progress, "and many other terms," Simkin says, "that all mean the baby just isn't coming out." The problem with a C-section is that it almost always leads to another, second, or third, and so on. She believes that there are small early steps that can be taken to prevent dystocia and the very first Cesarean.

"There are physical reasons for dystocia, including scarring, intense contractions (often brought on by induction and Pitocin), doctor-caused and man other physical causes," but the most powerful types, she says, are emotional: fear, stress, suffering as opposed to pain — all can reduce blood flow to the cervix and interfere with dilation.

Part of the problem, Simkin says, "is allowing the clock to be our guide." Many providers will give up and resort to induction when a woman's cervix has not dilated more than 6 cm in a certain amount of time; Simkin calls for more patience. "Let's stop blaming the mother" for what might be going wrong, instead, "know that she is the key to the solution."

Steps can be taken early, according to Simkin, that can improve the birth outcomes, including waiting full term (37 – 42 weeks), early movement when labor starts, acknowledgement that normal labor is strenuous physical work, sleep (even if induced with drugs). "Also, don't tell women that because they have a big baby they will probably be induced, that scares them!"

Eating, drinking, distraction (Simkin suggests kneading bread), acupuncture. And support during the contractions that goes beyond the pain scale (1 – 10) and instead observes the level of suffering a woman is experiencing during her contractions. "Ask her, 'What was going through your mind during that last contraction?' Pain does not mean the inability to cope; suffering does."

"When a woman is in pain, but not suffering," explains Simpkin, "she can still practice her three Rs – She has the ability for relaxation, rhythm and ritual. If she's suffering, she won't be able to sway, rock, breathe in a pattern or even moan rhythmically. If she can't stop crying even in between her contractions, if she says 'I can't do this,' she is suffering, and she should probably have the epidural."

Birthing positions are powerful and empowering tools: "It's important to use gravity," Simkin says, "not stay in a victim position lying flat in bed." She showed slide of an all-fours, open-knee position; a squat with support; lap squatting, even an ingenious sling that allowed the woman to dangle, lengthening her trunk and allowing nothing to impinge her pelvis.

Penny Simkin continues to be optimistic, and feels we are moving forward to educate women about their options, and even more, attracting them to those options. And she believes much starts in medical school. "It's so important that residents and students get exposed to midwives, that they get a chance to work with them and see that being with a women in labor is a privilege. Then, they grow up and become chiefs of staff, and will open doors to midwives and doulas."