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The Wonder of Mothers: Spontaneous Pushing During Birth

May 9, 2012 By Cara Terreri 3 Comments

May 13 is Mother’s Day and to celebrate, Giving Birth with Confidence will post throughout the month of May on “The Wonder of Mothers,” a series dedicated to sharing some of the many ways mothers’ bodies are beautifully designed to grow, birth, and nourish her baby. We’re also giving away a Lamaze stroller and infant car seat, so be sure to enter to win!

 

The Wonder of Mothers: Spontaneous Pushing During Birth

As a writer for Lamaze for nearly eight years now, I’ve read time and again about the point in birth when a woman’s body “just takes over” and she feels the uncontrollable urge to push out her baby. But it wasn’t until last year, during my third birth, that I truly experienced the phenomenon known as “spontaneous pushing.” After birthing two children, this was my first birth without any medicinal pain relief. When it came time for me to push (a mere 10 minutes after being admitted to my room), there was no denying the intense urge. My brain was no longer in control — my body “just took over.” At the time, I remember feeling overwhelmed by the intensity and seeming lack of control. And when you think about it, it can feel scary to lose control. What I realized after the fact, however, is that I did have control, my body was controlling and leading the way to birthing my baby. The wonder — and power — of a mother’s body is awesome.

The following is excerpted from the Lamaze Healthy Birth Practice #5 and talks about the benefits of spontaneous pushing.

Types of Pushing 
When you push in response to the natural urge to push, it is called “spontaneous pushing,” meaning you are doing what your body tells you to do. This natural urge comes and goes several times during each contraction. Each of these bearing-down efforts or urges usually lasts from five to seven seconds. However, when you are directed by your caregiver and those around you to hold your breath and push to a count of 10 seconds, repeating this two to three times during a contraction, you are using directed pushing.

Responding to the urge to push with short periods of holding your breath in a calm, unrushed environment has many advantages. Your baby will get more oxygen through the placenta, you will be less likely to become physically exhausted, and there is less chance of damage to the perineum and the muscles of the pelvic floor in the vagina (Albers, Sedler, Bedrick, Teaf, & Peralta, 2006; Roberts & Hanson, 2007). If you are having a very difficult time pushing the baby out, directed pushing might help. However, pushing spontaneously will usually be easiest and safest for both you and your baby.

What Research Tells Us 
According to the Cochrane Pregnancy and Childbirth Group, a respected international organization that defines best practices based on research, the use of any upright or side-lying position compared with lying on your back with your legs in stirrups is associated with the following results:

  • shorter second (pushing) stage of labor;
  • a small decrease in the use of vacuum or forceps;
  • fewer episiotomies;
  • less chance of experiencing severe pain;
  • fewer abnormal fetal heart tracings;
  • a small increase in second-degree tears (in the upright group only); and
  • an increase in estimated blood loss, although there was no evidence of serious or long-term problems from the extra blood loss (Gupta, Hofmeyr, & Smyth, 2004).

Were you able to spontaneously push during your labor? Share in the comments about your experience!

Filed Under Birth, Featured Story, Healthy Birth Practice, Hospital Birth Tagged With pushing, spontaneous pushing

All About Pushing During Labor

February 22, 2012 By Cara Terreri 1 Comment

Despite what the media likes to depict, pushing while lying flat on your back during labor may not the most comfortable, helpful or efficient way to birth a baby. According to the Lamaze Healthy Birth Practices, “Upright positions—such as standing, kneeling, or squatting—take advantage of gravity to help your baby move down into the pelvis. Squatting increases the size of the pelvis, providing more room for the baby to move down (N. Johnson, V. Johnson, & Gupta, 1991; Simkin & Ancheta, 2005).”

Additionally, the outdated holding-your-breath-and-count-to-10-and-PUSH! method of pushing is not ideal. Also known as “purple pushing” (because your face turns purple when you hold you breath!), this style of pushing is often used in many hospital labor rooms, but it can deprive your body of oxygen, add undue stress to you and your baby, and increase your risk for perineal tears and further weaken your pelvic floor muscles after birth. A healthier way to push is to follow your body’s instincts and cues to push, taking breaks when needed and bearing down when you feel the urge.

Want to learn more by seeing examples? Watch this helpful video, created by Lamaze, which shows women birthing in hospitals– with and without epidurals — using different positions for pushing.

 

Filed Under Birth, Featured Story, Healthy Birth Practice, Labor Tagged With pushing

What Does Lamaze Say About Epidurals?

January 30, 2012 By Cara Terreri 4 Comments

With all the talk recently about epidurals, we would like to share with you where Lamaze childbirth educators stand — and what they teach — when it comes to epidural usage in labor.

 

What is Lamaze’s position on epidural use?

  • Expectant mothers need balanced and accurate information about the risks and benefits of epidurals to determine the best choice for her and her baby.
  • Mothers don’t need judgment – they need information.  Women are not always told all of the risks associated with an epidural.
  • Lamaze Certified Childbirth Educators provide the information moms need to make an educated decision.

 

What risks do epidurals pose to mothers and babies?

  • Epidurals are associated with a number of risks, including:
    • Prolonging labor
    • Higher risk of fever and postpartum separation to rule out infection
    • Increased risk of instrument delivery
    • Increased perineal trauma
    • Maternal hypotension, which can lead to worrying fetal heart rate changes
    • Increased difficulty with breastfeeding
    • If the mother opts to have an epidural, the timing is important.  The early use of an epidural is associated with increased cesarean rates.
    • Having an epidural inhibits the mother’s ability to move freely during labor – an important part of keeping labor moving smoothly.

 

When is an epidural medically necessary?

  • Expectant mothers may need an epidural in certain situations:
    • Labor is prolonged and difficult.
    • The mother undergoes a cesarean.
    • The mother has very high blood pressure.

 

What alternatives are there for coping with pain?

  • Lamaze teaches coping techniques to help women cope with labor pain, including bathing and changing position.
  • Continuous support from a partner, relative, friend or doula also can help women through contractions.
  • It is important to remember labor pain is not a pathological pain, like the pain of a broken arm or illness.  It is a natural part of the labor process and signals that the mother’s body is working as it should.
    • Pain can actually help keep the birth process moving, triggering a cascade of hormones needed to keep labor active.  It can also signal important things to the mother, such as the need to move and change positions to allow the baby to descend.

 

For additional information on epidural usage, check out the following links:

 

Filed Under Birth, Featured Story, Healthy Birth Practice, Hospital Birth Tagged With epidural, interventions

Historical Perspectives: Lamaze Healthy Birth Practice 2 and 4

November 7, 2011 By Shannon Valenzuela Leave a Comment

“Walk, Move Around and Change Positions throughout Labor” and “Avoid Interventions that Are not Medically Necessary”


This month in our Historical Perspectives series, we’re focusing on Healthy Birth Practices 2 and 4.  Encouraging mothers to use movement throughout labor (#2) goes hand in hand with avoiding routine medical interventions (#4) that interfere with the mother’s ability to get out of bed, so we’ll consider them together.

Why is movement so important for labor?  Labor is movement – the baby is descending and rotating her way through the birth canal, the uterus is contracting, the cervix is dilating.  When mothers add their own movement to the baby’s, they can effectively work together to help labor progress.  As Lamaze Healthy Birth Practice 2 notes, movement and upright positioning “is the best way for you to use gravity to help your baby come down and to increase the size and shape of your pelvis.  It allows you to respond to pain in an active way, and it may speed up the labor process.”[1]

Movement is a natural response to physical discomfort.  If you’re carrying something and it hurts your arms, you shift its position.  We don’t just “take it” – we move!  So why, so often, are women prevented from having freedom of movement during labor?

Healthy Birth Practice 4 gives us part of the answer.  Many times, routine interventions like IVs, continuous External Fetal Monitoring (EFM), and continuous blood pressure monitoring make it difficult for mothers to labor out of bed.  Some nurses are more accepting than others of a mother laboring on a ball or in a rocking chair while continuous monitoring is taking place, but walking any distance would be impossible.

The other part of the answer can be found by taking a look at our birth culture.  When did these kinds of interventions become “routine?”  And when did labor move into the “labor bed?”  Let’s take a look back and see what we find.

Where We’ve Been

If you didn’t watch the video presentation of the history of birth last month, I highly recommend visiting the Mothers’ Advocate channel on YouTube and watching the video clips “Images of European Childbirth from the 1500s” and “Changes in Birth Practices”.[2]  Even before the 20th century, the differences between midwife-attended births and physician-attended births are clear.  While midwife-attended births happen with the mother upright and out of bed, those with physicians feature the mother lying in bed.

Once birth moved to the hospital at the turn of the 20th century and “twilight sleep” for labor and birth became the all the rage, there was no other labor position for mothers than strapped (literally, in most cases) to their labor beds.

The use of “twilight sleep” was eventually phased out, but the medical management of birth continued, and new interventions in the birth process became common.  In 1958, Dr. Edward Hon reported the first uses of external fetal monitoring, and medical colleagues from around the world soon began using the technology to detect fetal distress in high-risk pregnancies.  However, “[b]y 1978, it was estimated that fetal monitoring was in routine use in over half of labors.“[3]  Once EFM became the norm, the mother’s ability to move was restricted.

Problematically, EFM became routine without being proven to be helpful or safe.[4]  In fact, the technology rapidly became used more and more for low-risk mothers: the percentage of low-risk mothers monitored in 1988 was 76.3%, compared to just 62.2% of high-risk mothers.[5]  According to the Listening to Mothers II Survey, completed in 2006, 76% of mothers were montitored continuously during labor and 80% reported having an IV.[6]  So, interventions originally intended for high-risk women only are now routine, without any benefit to mothers or babies.

When considering freedom of movement during labor, it’s important also to mention the development of the epidural.  Dr. John Bonica, who worked with pain management for wounded soldiers, developed the epidural block technique in the 1940s.  His wife Emma, who nearly died from complications from ether anesthesia during the birth of their first child, was the first to receive an epidural during their second child’s birth.[7]  The popularity of the epidural has surged in recent years, and it is now the most frequently used form of pharmacological pain relief.

Women using epidurals can’t put weight on their feet, and because epidurals require continuous EFM, an IV, a urinary catheter, and maternal blood pressure and heart rate monitoring, their freedom of movement is severely restricted.  In order to preserve the position changes that help labor for the mother using an epidural, Penny Simkin developed a series of rotations called “the Rollover”.[8]  So, epidural use, while it does restrict freedom of movement, shouldn’t mean that the mother doesn’t move at all.

Where Do We Go from Here?

In 2009, ACOG revised its guidelines on continuous EFM.  George A. Macones, MD, who headed the revision, points out that

[a]lthough EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.[9]

Lamaze’s Healthy Birth Practice 4 is aimed at reducing the number of women who undergo unnecessary interventions in the birth process, which often lead to complications that require further intervention.

According to the Listening to Mothers II Survey, epidurals are used by 76% of mothers (or higher, depending on the hospital).[10]  As women continue to use pharmacological pain relief options (like the epidural), they need to know what techniques they can use to help their labor progress.  Lamaze’s Healthy Birth Practice 2 encourages women to understand how freedom of movement helps the progress of birth, which can then be applied to their unique birth experiences.

 

[1] Healthy Birth Practice #2.  Reference to P. Simkin & R. Ancheta, The Labor Progress Handbook (2nd ed.). Malden,MA: Blackwell Science, 2005.

[2] Mother’s Advocate YouTube Channel: http://www.youtube.com/user/MothersAdvocate.

[3] Freeman, Roger K., Thomas J. Garite, Michael P. Nageotte.  Fetal Heart Rate Monitoring.  3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2003.  Available on Google Books.

[4] Ibid.

[5] Ward, Joyce.  “The Evolution of External Fetal Monitoring from Use in High-Risk Women to Routine Practice: A Critical Historical Perspective.”  1999.  Available at http://www.instituteofmidwifery.org/MSFinalProj.nsf/a9ee58d7a82396768525684f0056be8d/1e5626880167e04

0852569fc00610cf3?OpenDocument

[6] Listening to Mothers II Survey.  Available at www.childbirthconnection.com.

[7] http://painresearch.utah.edu/crc/CRCpage/Bonica.html

[8] Simkin, Penny.  The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions.  3rd Edition.  Harvard: The Harvard Common Press, 2008.  284.

[9] http://www.acog.org/from_home/publications/press_releases/nr06-22-09-2.cfm

[10] Available at www.childbirthconnection.com.

Filed Under Birth, Featured Story, Healthy Birth Practice Tagged With Healthy Birth Practices, History of Birth

Historical Perspectives: Lamaze Healthy Birth Practice #1

October 17, 2011 By admin Leave a Comment

 “Let Labor Begin on Its Own”

By Shannon Valenzuela, PhD, LCCE

The purpose of this series is to explore the historical context behind each of the Lamaze Six Healthy Birth Practices in order to understand where we’ve been, where we are, and where we need to go from here.

This week, we’re focusing on Healthy Birth Practice #1: Let Labor Begin on Its Own, which recommends that labor induction should be avoided unless there is a medical indication.  According to ACOG’s 2005 guidelines, there are six medical reasons for labor induction:

  • your water has broken and labor has not begun
  • your pregnancy is postterm (more than 42 weeks)
  • you have high blood pressure caused by your pregnancy
  • you have health problems, such as diabetes, that could affect your baby
  • you have an infection in the uterus; your baby is growing too slowly[1]

In its 2009 revision of the Induction Practice Bulletin, ACOG indicated that there are possible nonmedical indicators which might make induction prudent, though not necessary.[2]  According to both ACOG and the Milbank Report, the national average induction rate is 22%, a figure that leads ACOG to advocate for a reduction in unnecessary elective inductions.[3]

So this is where we are now: needing to reduce the overuse of the practice of labor induction in order to improve outcomes for both mother and baby.  But how did we get to this point, and where do we go from here?

 

Where We’ve Been

The knowledge of certain practices (such as rupture of membranes or nipple stimulation) or substances (herbs like blue cohosh) that could induce a woman to go into labor have been known for centuries.  In fact, descriptions of ways to “mechanically” open the cervix can be found in both ancient and medieval medical writings.[4]  The idea of getting labor to start before it begins on its own is nothing new, but it was not until after birth moved to the hospital at the beginning of the 20th century that the practice of labor induction became more common.

The use of Twilight Sleep (a combination of the drugs scopolamine and morphine) in the early 20th century necessitated that women be hospitalized and tied down because they were either conscious but unaware of their surroundings or completely unconscious.  This in turn required that doctors find ways to intervene and manage the processes of labor and birth.[5]  For an amazing video presentation of this period in the history of birth, see the video clip “Changes in Birth Practices,” on the Mothers’ Advocate channel on YouTube.[6]

In 1906, Henry Hallet Dale discovered that pituitary extract could induce contractions, and in 1909 this extract was first used to induce labor.  By 1913, it was rapidly gaining acceptance by the obstetrical community.[7]  Because the outcomes were unpredictable and, in many cases, highly dangerous for mothers and babies, pituitary extract fell out of favor after a few years.  When the structure of oxytocin was finally mapped in 1953, it made the production of a synthetic version possible, and this has been in common use since 1955.[8]

It was during the heyday of the rise of this new birth culture – with its new technologies for the medical management of childbirth and the unconscious or barely conscious birthing mother – that Grantly Dick-Read released Childbirth without Fear (1944) and Ferdinand Lamaze released Painless Childbirth (1946).  These books and organizations like Lamaze® International (formerly ASPO/Lamaze, founded in 1960), emphasized the need to educate women about their bodies and the process of birth.  And, as birth technology evolves, the need for education grows.

Even with the advent of synthetic oxytocin (Pitocin), the rates of labor induction were still fairly low, until recently.  In 1990, for example, the induction rate was only 10% — by 2006, it was 22%.  This jump correlates with the similar rise in the rate of cesarean birth, which is now over 30%.[9]  Looking at these statistics, we have to wonder why there has been such a significant jump over the last two decades.  What’s happening in our birth culture?

 

Where Do We Go from Here?

As we look back over the history of birth, we can see a definite ebb and flow in the use of technology.  For example, after the discovery of x-rays in 1895, practitioners used them to monitor fetal well-being.  The dangers of radiation exposure weren’t discovered until the 1950s, at which point practitioners reduced their use.  When ultrasound was discovered in 1958, it replaced x-rays as the diagnostic tool of choice.[10]  So, the enthusiastic adoption of technological advances often seems to lead to their overuse, only to be scaled back as research shows where those technologies are most beneficial.

The problem, in short, isn’t necessarily the technology – the problem is the application of the technology to situations where it isn’t warranted.  With ACOG’s recent revision of its induction guidelines, the buzz in the media on the dangers of late preterm birth, and the growing number of studies revealing that inducing for non-medical reasons doesn’t contribute to best outcomes, perhaps we’re witnessing the beginning of the ebb in elective labor induction.[11]

Lamaze’s Healthy Birth Practice #1 is part of this movement toward equilibrium, boosting awareness and encouraging mothers to demand the best care for themselves and their babies.

 

[1] Lamaze Healthy Birth Practice #1.  http://www.lamaze.org/Portals/0/carepractices/CarePractice1.pdf

[2] ACOG Press Release.  http://www.acog.org/from_home/publications/press_releases/nr07-21-09.cfm

[3] Milbank Report.  http://childbirthconnection.org/pdfs/State-Level-Maternity-Care-Statistics.pdf.

[4] Sanchez-Ramos, L. and A. Kaunitz. “Induction of Labor”.  http://www.glowm.com/index.html?p=glowm.cml/section_view&articleid=130.

[5] “Obstetrics and Midwifery.” Encyclopedia of Children and Childhood.  www.faqs.org/childhood/Me-Pa/obstetrics-and-midwifery.html.  Also see “Conception and Birth.” Encyclopedia of Children and Childhood.  http://www.faqs.org/childhood/Ch-Co/Conception-and-Birth.html.

[6] Mother’s Advocate YouTube Channel: http://www.youtube.com/user/MothersAdvocate.

[7] Sanchez-Ramos and Kaunitz.

[8] Ibid.

[9] O’Callaghan, Tiffany. “Too Many C-Sections: Docs Rethink Induced Labor.” TIME Health Online.  August 2, 2010.  http://www.time.com/time/health/article/0,8599,2007754,00.html.

[10] “Conception and Birth.”

[11] For an example of media coverage, see “Hospital Bans Elective C-Sections and Labor Inductions.” Parenting.com. July 12, 2011. http://www.parenting.com/blogs/show-and-tell/melanie-parentingcom/hospital-bans-elective-c-sections-and-labor-inductions.  For more information on the studies on labor induction, see Childbirth Connection (www.childbirthconnection.org).  For information on the campaign against late preterm birth, see the March of Dimes (www.marchofdimes.com).

Shannon Valenzuela is a certified as a Lamaze Certified Childbirth Educator and has also trained with DONA International as a birth doula. She is the mother of four boys and a baby girl, who provide her with energy and inspiration. Prior to becoming a childbirth educator, Shannon taught English Literature at the college and high school level. She graduated in 2000 Summa Cum Laude with a B.A. from the University of Dallas, and received her M.A. (2004) and Ph.D. (2007) in English Literature from the University of Notre Dame.  

Filed Under Birth, Featured Story, Healthy Birth Practice Tagged With Healthy Birth Practices, History of Birth

What to Do When You’re Overdue

August 22, 2011 By Cara Terreri 6 Comments

40 weeks have come... and gone

As I write this, I am five days past my due date with my third baby. I’m no stranger to being “overdue.” With my last pregnancy, I gave birth five days after my estimated due date. I was lucky enough with my first to go into labor three days before being due. Despite the fact that a perfectly healthy pregnancy can last between 38 – 42 weeks,  we are so ingrained to hinge on the almighty 40 weeks “deadline.”

Here’s the reality: 40 weeks is an average time for pregnancy that is based on a date (last menstrual period or conception) that can be uncertain or inaccurate. The result is an estimate – not a deadline, expiration or delivery date. Your baby is not a FedEx package. And yet, women who go beyond the magical 40 weeks due date are made to feel like a pressure cooker. Well-meaning family and friends call, text and email to check in, asking questions like, “Are you still pregnant?!”; some care providers put women who are postdates on a time clock, often stripping membranes to jumpstart labor, performing a barrage of tests to check on baby and scheduling an induction date; and then there is the general discomfort and exhaustion that comes along with the end of a pregnancy that makes a woman feel like she is “so done” with pregnancy. With all of this pressure, even the most patient and informed woman becomes irritated, on edge and prone to doing whatever it takes to birth her baby.

Have you ever heard anyone say that children develop and hit milestones at different rates? The same is true for developing babies. Some may be ready for birth at 39 and-a-half weeks while others need an extra two weeks or more. Allowing baby to initiate birth helps ensure that he or she receives enough time to develop and mature. Contrary to what many believe, the last few weeks of pregnancy are not just for fattening baby up. Important organs, like the brain, lungs and liver, are still developing, as well as functions like sucking and swallowing. Interrupting these processes by scheduling an induction — unless there is true medical reason — can deprive baby of the time he or she needs to grow, and poses risks associated with induction.

So, what do you do when you’re overdue? Having been in this situation twice now, my best advice is to stop waiting around. Sitting around, jumping at every little twinge, ache or contraction, waiting for labor to begin will do nothing but drive you absolutely crazy! If you’re physically able, schedule something to do every day for three days straight. Make dinner plans, get a pedicure, see a movie, visit a friend, make freezer meals — you get the idea. If you come to the end of those three days and baby is still cooking, schedule the next three days. Having something to look forward to besides the birth of your baby will help pass the time and keep your mind occupied. And when you encounter the questions, comments and suggestions from others about your overdue-ness, smile and say something like, “Just like a cake, baking times may vary.”

Filed Under All Recent Articles, Birth, Healthy Birth Practice, Induction Tagged With early induction, labor induction, overdue, postdates

Six Tips for Gentle but Effective Hospital Negotiations

August 15, 2011 By admin 9 Comments

By Jessica English, CD(DONA), LCCE

Is the hospital you’ve chosen totally supportive of the six Lamaze Healthy Birth Practices?  Once you educate yourself on the elements of a healthy birth, there may be times you need to advocate for yourself and your baby. Hopefully you’re able to choose a birthplace that largely supports your goals for birth, but if that’s not possible, here are some suggestions that might make negotiating easier.

1. Talk it out beforehand, and get it in writing. If something is particularly important to you, talk it over with your midwife or doctor at an office visit. For example, if you know it’s standard for women to get a routine IV in labor, explain your concerns to your provider ahead of time. If you can agree that you will not have a routine IV for a healthy, normal birth, ask your provider to write that in your chart and either put it in writing on a prescription pad, or sign your birth plan. That way, if your doctor or midwife isn’t in the building when you arrive in labor, you’ll have that piece of paper to back you up. Individual midwives or doctors usually have the power to override routine policies for their own patients.

2. You’ll catch more flies with honey than vinegar. It’s great when moms and dads are passionate about healthy birth. Unfortunately, sometimes that passion can leave them feeling confrontational. You don’t need to start off with guns blazing. I suggest to my students that they are firm but very polite when working with the staff. Is continuous monitoring the policy at this hospital? You might say to the nurse, “Our midwife OK’d intermittent monitoring. We’d be so grateful if you could help us with that.” And if her answer is no, try again. “This is so important to us. I know it’s not the standard, but we really appreciate your understanding. We did OK it ahead of time.” Nurses, midwives and doctors are just people. A gentle approach is usually received much better than angry demands, and you’re more likely to get what you want. Be likeable.

3. Brainstorm. If you can get your nurse or provider working with you, they may start to take ownership of your ideas. Try asking for their help to brainstorm a problem. For example, a dad or other support person might say to the nurse between contractions, “We really want the baby to stay skin-to-skin after birth. Can you help us think about how that might work? Can some of the routine things be done while the baby is on her chest? What if we waited to weigh and measure him?” Or maybe continuous electronic monitoring is required because of a medical complication, and you’ve been asked to stay lying down in bed. Ask your nurse or provider to help you think through other options, such as laboring with continuous monitoring on the birth ball, on hands and knees or sitting upright. If they respond with reasons why something won’t work, you can always throw out a phrase like, “Let’s try together.” When people are part of the process they generally respond better than if you simply list your demands.

4. Bring a doula. An experienced doula has usually seen other families successfully negotiate in the hospital environment. She probably knows what’s possible and may have some techniques for helping you “get to yes.”  For example, hospitals in our area require 30-40 minutes of continuous monitoring when a woman first arrives, with intermittent monitoring as an option after that time. The mom is usually asked to lay on her side in the bed for this monitoring, which is hard for most women to do when they are in active labor. Sometimes the nurse will stay and hold the monitor device on her belly, so that she can still move with her contractions without losing the baby’s heart tones on the monitor. Once one of my doula clients had a nurse who was not willing or maybe not able to stay. The nurse kept insisting that the mom lay on her side, and the mom kept insisting that she couldn’t do that because it would make the contractions too intense. I asked if it might be possible for the dad to hold the device on her belly. The nurse happily agreed. She was able to leave and still get the monitoring she needed, the mom was able to continue standing and leaning with her contractions, and the dad was happy to help.

5. Don’t stop at the first “no.” If you’re asking for something outside routine hospital policy, the first answer you receive will probably be no. Expect that first no, and be pleasantly persistent, using all the techniques mentioned above. I know one woman whose nurse kept telling her there was no way she could have the special requests she’d made for her planned cesarean, such as having both her husband and her doula in the operating room and having her baby skin-to-skin on her chest while the doctor finished the surgery. The mother just kept nodding and smiling and saying, “I understand, but this is what I want. How can we make it happen?” Her negotiations were successful, and her doula and husband were both at her side when that beautiful baby was laid on her chest almost immediately after his cesarean birth. Had she accepted that first no, her birth experience would have been much different.

6. Remember, it’s your body, your birth and your baby. If it comes down to the line, remember that no one can force you to do anything or accept any intervention that you do not want. Shared decision making requires your consent. I remember my client who was pushing on hands and knees with a nurse, only to have a midwife come in at the last minute and tell her to turn over on her back. She asked why, and the midwife replied, “I don’t deliver babies this way.” Between strong pushes, the mom simply said, “No.” The midwife told her again to turn over, and again the woman said, “No.” The midwife successfully caught the baby while she stayed on her hands and knees. It was a beautiful birth! It can be intimidating to have professionals in scrubs and white coats telling you to do something, but if there is no clear safety reason for the request, it is always your right to say simply and clearly, “No.” After all, it is your body, your birth and your baby.

Jessica English, CD(DONA), LCCE, is the owner of Birth Kalamazoo, which offers birth and postpartum doula services, natural childbirth and breastfeeding classes, and in-home lactation consults. A DONA-certified birth doula and Lamaze-certified childbirth educator, she teaches an 8-week series of classes called “The Best of Natural Birth.” She is the editor of DONA International’s eDoula newsletter. A longtime writer and business woman, she also works as a consultant for organizations and birth professionals.

Filed Under All Recent Articles, Birth, Birth plans, Dads, Healthy Birth Practice, Hospital Birth, Working with a doula Tagged With birth plan, doula, Healthy Birth Practices, hospital birth, natural birth

10 Tips for Avoiding a First-Time Cesarean

July 27, 2011 By admin 3 Comments

By Jessica English, CD(DONA), LCCE

More and more women in the United States (and around the world) are having cesarean births. A recent study from the Yale University of Medicine showed two main reasons for the rise: more c-sections in first-time moms and lower rates of VBAC (vaginal birth after cesarean).

For your first baby, what can you do to reduce your chances of an unnecessary cesarean birth? We’ve identified 10 areas where you can be proactive and stack the deck in your favor.

1) Hire your provider wisely. This point is number one for a reason – it’s critical. In most practices, you could have any one of several doctors or midwives. You get whoever is on call when you go into labor. It’s helpful to know your practice’s cesarean rates. The labels “obstetrician,” “family doctor” and “midwife” don’t necessarily tell you what you need to know about your provider’s philosophy. Some doctors practice more like midwives, and some midwives practice more like a stereotypical doctor. Will they have a toolbox of natural techniques or only medical tool to help you if your labor is complex? If you’re not sure which doctor or midwife to choose, ask a doula. Doulas see all kinds of births with many different practices, and they will be happy to make a recommendation of a provider with a low cesarean rate and good bedside manner.  If you find out that your provider is not supportive, it is never too late to switch, even if you are just a few weeks or even days before your due date.

2) Hire a doula. Simply put, doulas make birth better, and there’s research to prove it. A meta-analysis of studies shows that women who use a doula are 26 percent less likely to have a cesarean birth, among other dramatic benefits. Having continuous support from a friend of family member can be helpful too, but the best results come when women hire an outside doula, according to a recent Cochrane Review. What exactly is the doula magic? The research hasn’t pinpointed the magic, but I think the unique combination of physical, emotional and informational support, plus gentle advocacy makes a huge difference. Doulas help women feel safe and comfortable so the hormones of labor can work at optimal levels, positioning ideas and tricks can help babies work their way out, and evidence-based information and help communicating with the medical staff can help women have their best chance inside a system that doesn’t really promote natural birth.

3) Take an independent natural childbirth class. It’s not so much that you need to know a lot about giving birth, but many women (and men) need to undo what society has taught us about birth. Independent classes are usually longer and more in-depth, with more interaction and less lecture. A good instructor can help increase your confidence in your body and help you trust in the normal birth process. An independent Lamaze-certified instructor will base her class on the six Lamaze Healthy Birth Practices, a wonderful resource that lays the groundwork for the best possible birth. Another benefit of an independent class is that your teacher works for you. She can teach you how to advocate for yourself within the system, without having to worry about what doctors, administrators or anyone else might think.

4) Avoid induction unless there’s a serious medical problem. As a first-time mom, some studies show that simply walking in the door for an induction of labor doubles your risk of a cesarean. Doubles it. That’s huge! Avoiding induction is never more important than with a first baby. But if you must be induced for a medical reason, call on your natural childbirth instructor and your doula (remember them?) to help you with tips to keep it as normal and natural an experience as possible, even with the unexpected circumstances. If mom and baby are not in immediate danger, low-and-slow inductions can result in a better chance of a vaginal birth, but you’ll need great support on the journey.

5) If having your baby in the hospital, stay home at least until strong, active labor. Your independent childbirth instructor will teach you how to recognize active labor. If you follow the common hospital recommendation to “come in when contractions are five minutes apart, at least a minute long, for at least an hour,” most women having their first baby will be very early in labor. The intensity of contractions is a much better guide than the timing. The more hours you are at the hospital before your baby is born, the higher your risk of intervention (including a cesarean). In her book “Pushed: The Painful Truth About Childbirth and Modern Maternity Care,” Jennifer Block tells the story of a hospital in Florida that lost power after a major hurricane. A generator kept the essentials running, but there was not enough power for air conditioning. They wanted to save resources and keep laboring women cool, so for a full week they turned away any woman who was not in full-blown, active labor. Their emergency cesarean rates during that week dropped dramatically.

6) Avoid an epidural, at least in early labor. Research is a bit mixed, and not all studies have been high quality. But still, the best evidence available does seem to show that epidurals, especially when women get them early in labor, do increase the cesarean rate in first-time mothers. Childbirth Connection is a great resource for information on the benefits and risks of epidurals. There are rare times, of course, when getting an epidural can actually help a woman have a vaginal birth, if she simply doesn’t have the strength to go on. Every labor is different. But an epidural also makes it harder for a baby in a bad position to move into a better one, it limits your ability to move, and it requires a lot of other interventions (IV, continuous monitoring, bladder catheter, etc.). Your doula and your independent childbirth class may give you enough natural tools so that you won’t even need the drugs. Most women don’t.

7) Read only the best childbirth books. Get these books, and read them cover-to-cover. Seriously, throw away “What to Expect When You’re Expecting,” and dive into these wonderful books instead.

• “The Official Lamaze Guide: Giving Birth with Confidence,” by Judith Lothian and Charlotte Devries (the book that inspired this blog!)

• “Ina May’s Guide to Childbirth,” by Ina May Gaskin

• “The Thinking Woman’s Guide to a Better Birth,” by Henci Goer (Written in 1999, this book is due for a revision, but it’s still excellent information and routine procedures and hospital technology have not changed much since that time. Henci also runs a helpful Q&A forum on the Lamaze International web site, so you can ask the expert yourself.)

• “Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience,” by Ricki Lake and Abby Epstein (they also offer a great web site and community)

And while you’re at it, buy the DVDs “The Business of Being Born” and “Orgasmic Birth” – they’re even on Netflix. That’s right, I’m recommending “Orgasmic Birth.” Stretch yourself a little!

8) Get your partner on board. It’s hard to do this alone, you need support! Even with the best doula, your partner is still an integral part of your birth journey. Penny Simkin’s book “The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas and All Other Labor Companions” is a great place to start. Be sure your partner attends that independent childbirth class with you – sometimes partners benefit even more than moms from that information and support.

9) Consider an out-of-hospital birth. It’s possible, with the right support, to have a great first birth in the hospital – even a vaginal birth without pain medication. As a doula I see them fairly often, and you should definitely choose the hospital if that’s where you feel safest and most comfortable. But the best research is pretty clear that your odds of a vaginal birth are better outside of the hospital: at home or in a birth center. In 2005 the British Medical Journal published a large study that looked at home births in the United States attended by Certified Professional Midwives. The women who gave birth at home had similar outcomes to low-risk women who had hospital births in terms of safety for moms and babies. But just 3.7 percent of the women who had their babies at home transferred to the hospital for a cesarean, while 19 percent of the low-risk women who had their babies in the hospital ended up with c-sections. The current cesarean rate in the United States is 32.9 percent, according to the Centers for Disease Control. Many studies have shown similar results, which makes out-of-hospital birth at least worth considering.

10) Believe in your body! The cesarean rate for women who birth at The Farm in Tennessee is less than 2 percent. Many industrialized countries around the world have cesarean rates of 15 percent or less. Women have been doing this for millions of years! Your body works. Birth works, in all its complex and wonderful variations. Surround yourself with knowledgeable support, of course, in case you encounter any rare and unexpected complications. But truly… trust your body. Trust birth.

 

Jessica English, CD(DONA), LCCE, is the owner of Birth Kalamazoo, which offers birth and postpartum doula services, natural childbirth and breastfeeding classes, and in-home lactation consults. A DONA-certified birth doula and Lamaze-certified childbirth educator, she teaches an 8-week series of classes called “The Best of Natural Birth.” She is the editor of DONA International’s eDoula newsletter. A longtime writer and business woman, she also works as a consultant for organizations and birth professionals.

 

Filed Under All Recent Articles, Birth, Birth plans, Choosing a care provider, Healthy Birth Practice, Homebirth, Induction, Pregnancy, Working with a doula Tagged With cesarean, childbirth class, doula, home birth, hospital birth, labor induction, Lamaze Certified Childbirth Educator, natural birth

One Woman’s Birth Plan

July 25, 2011 By Cara Terreri 6 Comments

As I mentioned in Friday’s post on birth plans, I have written a birth plan for the birth of my third child (due sometime in the next 3-4 weeks, give or take!). Although this will be my third baby, it’s my first official birth plan. For my first two, I thought endlessly about my birth and had birth plans/preferences in my head, but never followed through with writing and submitting an actual birth plan. And in hindsight, I really wish I would have — not necessarily for my care provider (she and I discussed at length my preferences for birth), but rather for the labor and delivery nurses, with whom I did not meet in advance and discuss my birth and preferences for newborn care.

In sharing my birth plan below, my intent is not to show you the “perfect birth plan,” but rather to show one that demonstrates the tips and formatting that I mentioned in my last post as well as to point out my thought process and reasoning behind why I included (or didn’t include) certain items. The text in black represents my birth plan and the red text is my commentary.

__________________________________________________________________________________________

Birth Preferences – Cara Terreri

DOB: XXXXXX [Included as an identifier in addition to my name.]

Thank you for taking the time in advance to read our birth preferences. We realize that unexpected circumstances do arise and do not intend this as a “script” for our birth. We hope you will be able to keep us informed and aware of our options. Thank you!

LABOR

Please do not offer an epidural or narcotics for pain relief.

If mom does not require antibiotics for GBS, she does not want a routine IV.

[I've been told by my doula that this is frowned upon at the hospital where I plan to birth. At a minimum, nurses want to insert a Hep lock to provide access to an IV if needed. However, I also know that it is within my right to refuse an IV. Because I have had an uncomplicated pregnancy, do not want an epidural, want the freedom to move around and plan to eat and drink as needed, the likelihood for me needing an IV is very low.]

Please use fetal monitoring intermittently so that mom can be mobile as much as possible.

[Most hospitals, per guidelines developed by the American Congress of Obstetrics and Gynecology, require that fetal monitoring be performed every 30 minutes while in labor. I agree and will gladly comply with this request, but do not want to be monitored continuously. Fetal heart rate monitors work most effectively when mom is on her back -- the worst and most uncomfortable position for a laboring mom! Continuous monitoring would severely restrict my ability to move around in labor.]

Please allow mom to push as she feels urges; do not count or coach for pushing.

[I've never pushed without nurses counting and coaching me to hold my breath, bear down and push for 10 seconds. It seems to be the hospital standard. Because I plan to birth for the first time without an epidural blocking my sensations to push, I would like to follow that urge and push on my own.]

Please allow mom to push in a position that is most comfortable for her.

[This shouldn't be an issue, as I'm told that the providers in my practice have helped moms birth babies in other positions than the standard "dead cockroach" position. Who knows -- I may be comfortable pushing while on my back. But if I'm not, I want the option to do otherwise.]

[**What I did NOT include in this section: I plan to wear my own clothes for labor and birth. I am well within my right to do so and therefore, this should be a non-issue. I plan to eat and drink as I wish. This is technically against hospital policy, but I also know that my provider tends to turn her head and allow it. Routinely restricting food and drink during labor is outdated advice and is not an evidence-based practice.]

BIRTH (vaginal)

Please allow dad to announce baby’s gender.

Please allow baby’s cord to stop pulsing before cutting. Dad would like to cut cord.

Please provide immediate, uninterrupted skin-to-skin contact after baby is born.

[This was the most frustrating issue I experienced with the birth of my last child. He was born healthy and crying and yet, the nurses took him from me very shortly after birth to perform routine procedures. I barely had the chance to see his face and touch his body before he was whisked away. None of these procedures was urgent or life-saving. This time, the staff will need to be patient and wait for us to meet, bond and breastfeed. Only then will I allow anyone to take my baby!]

Please perform all necessary tests while baby is with mom – please delay other routine procedures after the baby has breastfed for the first time.

[Contrary to what is typically done, apgar scores can be taken while baby is with mom. Weighing and measuring the baby is not something that needs to be done immediately after baby is born.]

IF CESAREAN IS REQUIRED

[While moms expecting and planning a vaginal birth don't want to consider an unplanned cesarean, it can and does happen. It's important to prepare mentally for this possibility. Including preferences in your birth plan for an unexpected cesarean is part of that process.]

Please allow dad to be present at all times.

Please allow doula, Tracy Cuneo, also to be present.

[I've been told that this is against my hospital's policy, but it doesn't hurt to ask.]

Please allow dad to announce baby’s gender.

Please allow baby’s cord to stop pulsing before cutting. Dad would like to cut cord.

Please allow mom to have skin-to-skin contact with the baby in the OR.

[Skin-to-skin in the operating room after a cesarean surgery is not standard, though it is starting to happen in a few locations across the United States. When mom is not under general anesthesia for a cesarean, this should be a reasonable request and will help with the initial mother-baby bonding that might have otherwise been missed.]

NEWBORN

Routine newborn procedures:

  • NO eye ointment
  • NO Hep B shot (we will do this later)
  • YES vitamin K shot

[These are the three basic, routine administrations given to baby after birth. If you have strong feelings about any of these procedures, make your wishes known in advance. If not, when you give birth in a hospital, they will be performed routinely.]

Baby will be exclusively breastfed; please NO pacifiers, bottles, water, formula or otherwise.

Dad will be going with the baby to attend or give the first bath.

[Many hospitals will invite dads to attend or give baby's first bath, but this is not always the case. I want to be sure that my husband goes with our child to his or her first bath for a few reasons: because he wants to be there; because I don't want our little one to be without a parent when he or she leaves the room; and because we plan to bring our own natural soap to wash the baby.]

__________________________________________________________________________________________

Feedback? Questions? Comments? Let’s hear it! How did your birth plan differ from mine?

 

Filed Under All Recent Articles, Birth, Birth plans, Healthy Birth Practice

Healthy Babies Are Worth the Wait

June 10, 2011 By Cara Terreri 4 Comments

Source: PRNewswire-USNewswire

Every week of pregnancy is crucial to a newborn’s health, and today, the March of Dimes unveiled a new public education campaign to raise awareness about the important development that occurs during those last few weeks.

The campaign, called “Healthy Babies Are Worth the Wait,” encourages women to allow labor to begin on its own if their pregnancy is healthy. It aims to dispel the myth that it’s safe to schedule a delivery before 39 weeks of pregnancy without a medical need.  

Babies born after 37 weeks of pregnancy are full-term. However, new research has shown that a baby’s brain nearly doubles in weight in the last few weeks of pregnancy. Also, important lung and other organ development occur at this time. And, although the overall risk of death is small, it is double for infants born at 37 weeks of pregnancy, when compared to babies born at 40 weeks, for all races and ethnicities.

“Some women mistakenly think that the only thing a baby does during the last weeks of pregnancy is gain weight, making labor and delivery more difficult,” said Judith Nolte, a member of the March of Dimes national Board of Trustees and former editor-in-chief of American Baby Magazine Group, who worked with the March of Dimes to develop the new awareness campaign. “When the moms in our focus groups learned about the important brain and organ development that occurs, they were more than willing to put up with their own discomfort so their baby could get a healthy start in life.”

Only 25 percent of women know a full-term pregnancy should last at least 39 weeks, according to research published in the December 2009 issue of Obstetrics and Gynecology.

“Women may feel worried, anxious, or simply uncomfortable near the end of their pregnancy.  But unless there are medical complications, the healthiest and safest place for that developing infant is in the womb,” said Eve M. Lackritz, M.D., chief of the Maternal and Infant Health Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, who outlined the health consequences of an early birth. “Term labor and delivery are not just normal and natural – they’re the healthiest alternative for both the mother and the infant.”

Information about the new Healthy Babies Are Worth the Wait educational campaign can be found at marchofdimes.com/39weeks.

The March of Dimes is the leading nonprofit organization for pregnancy and baby health.  With chapters nationwide, the March of Dimes works to improve the health of babies by preventing birth defects, premature birth and infant mortality.  For the latest resources and information, visit marchofdimes.com or nacersano.org. For free access to national, state, county and city-level maternal and infant health data, visit PeriStats, at marchofdimes.com/PeriStats.

Filed Under All Recent Articles, Birth, Healthy Birth Practice, Induction, Pregnancy Tagged With early induction, labor induction, March of Dimes
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