Six Tips for Gentle but Effective Hospital Negotiations

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.

10 Tips for Avoiding a First-Time Cesarean

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.

 

How to Choose a Midwife

By Jeanne Faulkner, RN, a labor nurse in Portland, Oregon

More women are choosing midwives, but lingering myths and confusion mean that many moms-to-be still have questions. We’ve got answers.

Midwives are being “rediscovered” by growing numbers of pregnant women today. According to the National Center for Health Statistics, in 2006 (the most recent figures available), they attended a record-busting 317,168 births—7.4 percent of all U.S. births; 96.7 percent of them took place in hospitals, 2 percent in birth centers and 1.3 percent in homes. To help you decide whether to go the midwife route, here are answers to some of the most common questions.

What advantages do midwives offer?

The Midwives Model of Care views pregnancy and birth as normal events; as a result, midwives suggest and perform fewer interventions than are typical with most obstetric care. “Midwives focus more on nutrition and education,” says Judi Tinkelenberg, C.N.M., R.N., clinical director of Sage Femme Midwifery Service and Birth Center in San Francisco. “We do fewer routine, often unnecessary tests—for example, we don’t automatically do ultrasounds if they’re not needed. We make decisions with patients based on informed consent.” Midwives also spend more time with patients than most OBs do, which means they often offer more personalized care.

What exactly does “midwife” mean?

All midwives provide prenatal and postpartum care, attend labors and deliver babies. Some provide additional services, such as routine gynecologic exams and contraception care. But do your homework; anyone can call herself a midwife. Here are the distinctions:

>>Certified midwives (C.M.) meet American College of Nurse-Midwives (www.midwife.org) requirements, but they do not need to be nurses.

>>Certified nurse-midwives (C.N.M.) are nurse- practitioners who are certified by the American College of Nurse-Midwives.

>>Certified professional midwives (C.P.M.) meet North American Registry of Midwives (www.narm.org) certification standards.

>>Direct entry midwives (D.E.M.) are educated through self-study, apprenticeship, midwifery school or college- or university-based programs that don’t include nursing. They include certified midwives and certified professional midwives.

>>Lay midwives are sometimes called traditional, unlicensed or “granny” midwives. These women are educated through self-study and apprenticeships, and while they may be highly experienced and skilled, they aren’t certified or licensed.

>>Licensed midwives (L.M.) can practice in a particular jurisdiction, usually a state or province.

For more information on the different types of midwives, go to www.mana.org.

What’s the best kind of midwife?

That depends on whether you want a hospital or out-of-hospital birth, a low-intervention or medicated one. The most important thing is to make sure anyone you’re considering is qualified and experienced. “Direct entry midwives and certified nurse-midwives have different educational pathways, but they’re all well-trained and competent,” says Geradine Simkins, D.E.M., C.N.M., M.S.N., president of the Midwives Alliance of North America. Most C.N.M.s deliver in hospitals, while C.P.M.s have specific training and expertise in out-of-hospital births.

The Institute of Medicine and the National Commission to Prevent Infant Mortality praise the contributions of certified nurse-midwives in reducing the incidence of low-birth-weight infants and call for their increased utilization, and the new federal Health Care Reform Act strengthens the legitimacy of certified direct entry midwives.

Is it safe to go with a midwife?

Yes, as long as you have no pregnancy complications or risk factors for birth complications. For 60 to 80 percent of low-risk pregnancies, it may be even safer to go with a C.M. or a C.N.M. than with an obstetrician. That’s because midwives use less fetal monitoring and over-diagnose fetal distress less often, which means fewer interventions, such as C-sections and forceps- or vacuum-assisted deliveries. Studies show that C.N.M.-attended births are associated with 31 percent fewer low-birth-weight babies and 33 percent less neonatal mortality.

If you have certain health risks, including obesity, diabetes or hypertension or are carrying multiples, you might still qualify for midwife care, but only if it’s coordinated with an OB. If you want to give birth at home, make sure your midwife has protocols for a quick transfer to a hospital in case of an emergency.

How do costs and care compare with those of obstetricians?

Midwifery care can cost less overall, but C.N.M.s are sometimes paid similar rates as OBs. Insurance companies currently pay for most C.N.M. services, and under the new federal health care legislation, certified D.E.M.s will also be covered.

As for whether the midwife you see for prenatal visits will deliver your baby, it’s the same as if you were seeing an OB. “Many private practice midwives make a special effort to be at their own patients’ births, even when they share call with partners,” says Karen Parker Linn, a C.N.M. in Portland, Ore. In shared practices, several midwives work together. Patients see different ones during pregnancy and deliver with whomever is on call, though midwives sometimes come in for patients with whom they’ve formed a special bond, Linn adds.

Do doctors respect midwives?

Most hospital-based midwives are well-respected by OBs. Out-of-hospital midwives? Not as much. Most out-of-hospital births are safe, but when trouble arises and patients are transferred to hospitals, doctors sometimes feel like the clean-up crew for high-risk deliveries.

“Midwives are fantastic options for low-risk women,” says Kathleen Harney, M.D., chief of obstetrics for Cambridge Health Alliance and the C.N.M-managed Cambridge Birth Center in Massachusetts. “Their philosophy and training are more focused on birth as a healthy, natural process. Doctors are trained to think something adverse may happen,” she explains. “The truth is somewhere in between. Working in concert with midwives reminds OBs not to be overly interventionalist.” .

5 questions to ask a midwife

1. What is your training, experience and certification, and do you have references?

2. Where do you deliver—at home, in a birth center and/or in the hospital?

3. What percentage of your prenatal patients do you actually deliver yourself?

4. For an out-of-hospital birth, what’s your emergency backup plan?

5. Do you take medical insurance?

Practices that Promote Healthy Birth: Avoid Common Interventions

Today, childbirth is viewed as and transpires as more of a medical procedure than a natural bodily function. Women who seek to have a natural birth often look for resources and information on how to achieve a more natural experience instead of one that is over-medicalized.

Truthfully, if you want to avoid all common hospital interventions, the best place to give birth (for low-risk women) is either at home or in a birth center. In my own experience, confronting hospital staff to avoid simple things like an IV line can bring added stress that just isn’t part of an enjoyable birth experience. That being said, birth should take place where you feel most comfortable, and if that is in a hospital, the best thing to do is educate yourself about the choices and risks and related to common medical interventions.

 

Common Medical Birth Interventions

  • IV for fluids
  • Epidural anesthesia
  • Continous electronic fetal monitoring
  • Pitocin
  • Artificially breaking the bag of water
  • Episiotomy

Most of these interventions are medically unnecessary, but are used in many hospitals today in the United States. An IV, for example, is used to administer fluids and medication, if necessary. However, when women are allowed to eat and drink during labor, an IV for fluids is not necessary. Recent studies show that there is no need to prevent a woman from eating and drinking while she is in labor

Continuous electronic fetal monitoring is also over-used in low-risk women. In recent years, The American Congress of Obstetricians and Gynecologists (ACOG) has shown that in the 40 years that electronic fetal monitoring has been the norm, there have been no improved outcomes in mothers or babies. Of course, like anything, there are some situations when it is necessary, but mostly in high-risk cases. 

Epidurals for those who choose to use them for labor can be the right fit, but they are not risk free. Epidurals can slow labor and pose other risks to mothers and babies. There are other, more natural and effective ways to help relieve the pain of labor

Pitocin can cause contractions, but it can also cause contractions that are too strong and result in fetal distress and bring on a cascade of interventions

Episiotomy has been shown in recent years to be medically unnecessary in the majority of cases. 

Skipping Common Interventions

There are several ways to avoid routine hospital interventions.

  • Hire a birth doula to help be your advocate and employ natural pain relieving strategies
  • Write a birth plan and provide copies to your provider and hospital staff on call during your stay
  • Talk to your provider about your expectations and practices and procedures you are concerned about
  • Take a tour of your hospital
  • Research your chosen hospital’s cesarean and intervention statistics prior to giving birth

These simple steps can help you avoid common medical interventions and increase your chance of having a safe and healthy birth experience.

Practices that Promote Healthy Birth: Continuous Labor Support

There was a drastic difference in the labor experiences I had for both of my children. Besides labor induction in one case and not the other, I had a labor doula who provided continuous support for me while I was making the journey to have my second son. Looking back and reflecting on the number of benefits I had through Karen (my doula) I wish I had opted for one with my first child also. The differences in my labors and experiences are partially contributed to my doula. This brings me to third practice that promotes healthy birth: Continuous Labor Support!

Support from my incredible doula Karen Kilson, who passed away last October.

Not everyone must have a doula to experience continuous labor support; a partner, husband, friend, or other support person can make up an effective labor support team.

Continuous labor support means :

  • Physical support – Help moving into more comfortable positions, massage, back rubs, feet rubs, and helping the mother in whatever needs, from laboring in the shower to getting in and out of the bath tub.
  • Informational Support – Someone to help provide mom with unbiased support regarding decisions she would have to make in labor, from interventions to critical surgical choices. Also, the support person can assist in relaying a mother’s birth plan or discuss any issues she is having to staff members.
  • Emotional Support – This can come in many forms. From the showering of love and encouragement, to helping her to relieve stress. High levels of stress in a laboring mother can cause problems and increase her pain levels.

While continuous support can come from anyone, hiring a doula for labor can help alleviate the worry from your partner, who may at times feel stressed or helpless during labor and birth. According to DONA International, a well-respected Doula certifying association, a birth doula:

  • Recognizes birth as a key experience the mother will remember all her life
  • Understands the physiology of birth and the emotional needs of a woman in labor
  • Assists the woman in preparing for and carrying out her plans for birth
  • Stays with the woman throughout labor
  • Provides emotional support, physical comfort measures, and an objective viewpoint, as well as helping the woman get the information she needs to make informed decisions
  • Facilitates communication between the laboring woman, her partner, and her clinical care providers
  • Perceives her role as nurturing and protecting the woman’s memory of the birth experience
  • Allows the woman’s partner to participate at his/her comfort level

So who should be part of this team supporting you through your labor?

  • Choose people who you know will be helpful, instead of those who you think may distract you from being focused during labor.
  • Choose people who you are familiar with, or who are willing to learn about the birth process and what you would like to achieve in your experience in labor and birth.
  • Pick people you know will learn your birth preferences and who will be an advocate for you.
  • Ask your support person(s) to attend your birthing classes with you.
  • Before labor, practice relaxation techniques and other techniques you want to try during labor.

To understand more about continuous labor support, view the Mother’s Advocate & Lamaze video for Better Birth on labor support:

Numerous clinical studies have found that a doula’s presence at birth:

  • Tends to result in shorter labors with fewer complications
  • Reduces negative feelings about the mother’s childbirth experience
  • Reduces the need for pitocin, forceps or vacuum extraction and cesareans
  • Reduces the mother’s request for pain medication and/or epidurals

Research shows that parents who receive support:

  • Feel more secure and cared for
  • Are more successful in adapting to new family dynamics
  • Experience greater success with breastfeeding
  • Have greater self-confidence
  • Are less likely to have postpartum depression

Support during labor, whether it is from a doula, another form of hired labor support, or a friend or family member, is your key to having a healthy and positive birth experience.

 

Natural Birth at a Hospital: Making it Work for You

Last weekend, when discussing childbirth among women at my husband’s firehouse, mostly girlfriends and wives, I was shocked when most of the women discussed wanting a natural birth. It was a pleasant change—one that I have been working so hard toward!

I started doing some research after my discussion and came across a quote on natural childbirth in The Official Lamaze Guide that really struck a chord:

“In spite of evidence, U.S. maternity care continues to sabotage normal birth rather than support it. In 2002, the Listening to Mothers survey learned that among nearly 1,600 new mothers across the U.S., 44% had labor induced, 71% did not move freely during labor, 93% had electronic fetal monitoring, 86% had intravenous lines, 74% gave birth on their backs, and almost 50% of their babies spent the first hours after birth with hospital staff. Only 1% of the women experienced all six care practices that promote normal birth, and none of these women gave birth in a hospital.”

Lots of alarming statistics in there. This first-ever national survey of U.S. women’s childbearing experiences gives us a look into the way women are giving birth today in spite of evidence showing that these practices are outdated, unfounded, or harmful rather than helpful. Let’s take a closer look into each of the statistics listed and learn ways you can try to avoid becoming “one of the statistics” when birthing in a hospital:

44% of women had their labor induced. (!!)
That is a huge number for labor induction, especially since labor should only be induced for necessary medical reasons. Letting labor begin on its own is key for a healthy birth experience for women. It is also the way our bodies are meant to work in the natural stages of pregnancy. Labor induction is not a procedure that is risk free—it can increase the risk of premature birth, cesarean section, abnormal fetal heart rate, fetal distress, shoulder dystocia, and increase the risk of your baby needing to be admitted to the NICU. 

To reduce the incidence of unnecessary induction, find a provider with a low labor induction rate, and research the policies of the facility where you plan to give birth. This may be tricky, as many hospitals do not publicly advertise their rate of induction, cesarean surgery or other interventions. You might be lucky enough to find it on your hospital’s Web site. Or perhaps your hospital’s rating and feedback is listed on The Birth Survey. If not, take a hospital tour and be sure to ask LOTS of questions. Knowing information ahead of time gives you the opportunity to change your place of birth if you’re uncomfortable with their practices.

71% of women did not move freely during labor.
Being confined to a bed while laboring is not ideal by any means. Not only does it decrease the size of your pelvis, but it also can cause lowered blood pressure and fetal distress.  Better positions to give birth in and labor in include:

  • Standing
  • Hands and Knees
  • Side Lying
  • Knees to Chest
  • Squatting
  • The Sitting Position

93% had continuous electronic fetal monitoring.
This is a high number despite the fact that several studies have shown no improved outcome to mothers and babies with continuous electronic fetal monitoring. Also, recently, there has been a number of controversial articles about fetal monitoring and how medical professionals are reading the fetal heart tones.  Many think that the over-analyzing of small decelerations in fetal heart tones is leading to a higher rate of unnecessary cesarean births.  There are situations where monitoring may be a beneficial procedure, but in most birth situations, intermittent monitoring is safe. 

86% had IV Lines.
 Having an IV line in place in a laboring mother means that hospital staff has easier access to administering fluid and medications if needed. However, being attached to an IV line also restricts a laboring mother’s movement, interfering with her ability to change positions. Something that may help is requesting a “hep lock” in place of an IV line. A hep lock is a device that is inserted into a mother’s hand or arm so it is ready in case an IV line needs to be hooked up. Also, drinking and eating during labor will help to eliminate the risk of needing any kind of IV fluids during labor.

74% gave birth on their backs.
Laboring and giving birth on your back is pretty much the worst position. I recently wrote about this in two posts, Positions You Should Be Giving Birth In Part 1 and Part 2. Decreased pelvis size, blood pressure complications, lack of gravity to help with the birth itself are all huge factors in the supine (back-lying) position.

50% of babies spent the first hours of life with hospital staff. (!!)
Many mothers are not familiar with the benefits of skin-to-skin contact with your baby after they are born.  The first few hours are critical for mother-infant bonding. Unless your baby is experiencing complications or needs NICU care, babies should be kept with their mother in the first few hours — baths, weighing and measuring, etc. can all wait. Babies who have skin-to-skin contact after birth:

  • Cry less
  • Have more stable temperatures
  • Have more stable blood sugars (with the lack of skin-to-skin contact with my second son, because of my cesarean, made a change in his blood sugar which resulted in a 30-hour NICU stay)
  • Breastfeed sooner, longer, and more easily
  • Are exposed to normal bacteria on the mother, which can protect them from getting sick from unhealthy, or other types of bacteria, especially if birthing in a hospital
  • Have lower levels of stress hormones

Only 1% of these women experiences all 6 Lamaze Healthy Birth Practices.
Having a birth plan, and being an advocate for yourself and what you want for your birth experience in a hospital is key here. Communicate with your care provider and create a written birth plan to share with your care provider as well as the hospital staff when you arrive for baby’s birth. Make sure your partner knows about your birth preferences so he/she is comfortable talking with and reiterating to your provider and hospital staff on the big day.

When it comes to birthing in a hospital, being an empowered patient is critical to having a healthy and happy birth experience. Read, do research, take a Lamaze class, interview care providers and hospital settings — learn all that you can to be informed and make the best choices for you and your baby.

Photo from Inexplicable Ways

Squats: Not Just for a Cute Butt

Both men and women in less-industrialized nations used to, and in some places still do, squat on a daily basis in their jobs, to use the bathroom and as a means of waiting, eating or resting. We Westerners do not squat. Unless we’re trying to shape up for swimsuit season, and even then, the practice is usually short-lived.

Why is this important, you ask? Katy Bowman, MS, a biomechanical scientist and author of the blog Katy Says, describes how repeated squatting changes the physical structure of our body to prepare it for birth:

“The squatting action, preferably done since birth, creates a wide pelvic outlet (the space where the baby passes out).  Starting from childhood, squatting to bathroom aids in the ideal ossification (bone shaping) of both the pelvic bones and the sacrum.  The wider the outlet, the safer and easier the baby passes through.  Squatting also lengthens the muscles of the glutes, hamstrings, quadriceps, calves, and psoas.  When these muscles are tight, they can actually reduce the movement of the pelvic bones and increase stress and pressure on the baby (and mama) during delivery.  Back then and today still, the populations of people who move a lot (and I don’t mean exercise an hour per day) have better, easier births.”

 Of course, there’s no way to dial back to childhood and change our ability to squat. You’re either born into a culture that squats or not. There are ways, however, to incorporate squats into your pregnancy fitness routine (What? You don’t have a fitness routine? Well, now is the time to get started!) to reap the benefits during birth. Katy advises:

“The squatting action, preferably done since birth, creates a wide pelvic outlet (the space where the baby passes out).  Starting from childhood, squatting to bathroom aids in the ideal ossification (bone shaping) of both the pelvic bones and the sacrum.  The wider the outlet, the safer and easier the baby passes through.  Squatting also lengthens the muscles of the glutes, hamstrings, quadriceps, calves, and psoas.  When these muscles are tight, they can actually reduce the movement of the pelvic bones and increase stress and pressure on the baby (and mama) during delivery.  Back then and today still, the populations of people who move a lot (and I don’t mean exercise an hour per day) have better, easier births.

Delivery Preparation

1.  If you aren’t walking at all, begin with one mile, increasing your distance by 1/2 a mile every two to four weeks, until you hit 5-6 miles per day.  Doing all your mileage at once will help you with endurance, but if you are feeling tired or sore, break your distance up over the course of a day.

2.  Start your squatting program NOW.  Hamstring and calf tension (both muscle groups down the back of the legs) tuck the tailbone and pelvis under, instantly impacting the size of your delivery space.  FUNNY STORY:  I made the mistake of trying to teach my pregnant sister this exercise while she while she was giving birth.  I’m not going to write down what she said here. :) ”

Check out the rest of Katy’s blog post for more background information on squatting and crucial tips on how to squat correctly – yes, there is a wrong way to do it. Want to know another awesome thing about squats? They protect your pelvic floor… but that’s a discussion for another day!

 Photo by Katy Says.

Your Questions Answered: What Is a Doula?

Q

I’ve heard a lot about doulas, but I don’t really know what they do and how they can help me during birth — can you provide more information?

A

A doula is a care provider who understands and trusts the normal process of birth. She provides care from the prenatal period through to postpartum. She provides emotional support, such as encouragement, reassurance, and continuous presence for a mom and her partner. She also offers physical support during labor and birth, such as comfort and relaxation measures, and suggesting different positions to facilitate labor. A doula is also a great resource for helping mom and her partner to understand medical tasks, so mom and her partner can make informed decisions.

A doula can be very helpful for you and your partner during your birth experience. The power of labor may surprise you and your partner, so it is helpful to have a knowledgeable person like a doula to reassure you that what is happening is normal. A doula’s presence can relieve anxiety for you and your partner so you can stay home longer and transition easier to your birth place. A doula also can sense when a laboring you need to change positions or when you need a comforting touch. She may also sense when it is beneficial for you to take a walk or a relaxing shower. When you are comfortable and feels well supported by your birth team, your labor may progress more quickly and feel easier.

Doulas stay with you through the whole process of labor and birth and through early postpartum. She also helps guide you through your first breastfeeding. Doulas do not perform any medical tasks, but she will help you understand and be able to explain any medical interventions that may arise. Doulas are there for your continuous emotional and physical support.

Studies have found that with continuous support, like that offered by a doula, laboring women are less likely to have:

  • Cesarean surgery
  • Assisted delivery with vacuum or forceps
  • Epidural or need for other pain medication
  • Dissatisfaction or negative feelings about their childbirth experience

For more information or how to find a Doula for your birth, visit www.dona.org or www.childbirth.org.

Preparing for Natural Childbirth — First or Second Time

I looked at my second pregnancy as a “do over for the surgical birth of my first. I truly wanted an unmedicated, natural Vaginal Birth after Cesarean, also known as VBAC. I didn’t realized how much research I would put into my second pregnancy. Looking back on all the information I put together, learned, and came across, it would be foolish not to share with others. I think a lot of the efforts and education I put into my second child’s pregnancy and birth has been very helpful in my journey to becoming a childbirth educator.


I worked my own experience into small steps all pregnant women, or women considering trying to conceive, should read before birth.

  1. Interview Providers – Most women I have come across usually choose the OB their sister used, or even a simple referral from their insurance provider. With my first pregnancy, that is exactly what I did. By the end of my pregnancy, and after my birth, I knew the provider choice was a mistake. Providers can make or break your experience. Choose wisely.
  2. Find a Chiropractor – Most women think, “What the heck do I need a Chiropractor for?” without knowing the ins and outs of how your pelvis works!  Not only can Chiropractic Care help with pain, and discomfort, but it can help prepare your pelvis for a successful vaginal birth!
  3. Take a Childbirth Education Class - New studies show women who take a childbirth education course not only are better prepared for class, but they are less likely to be subjected to routine or unnecessary interventions in the hospital. Skip the classes hospitals offer in one day, most teach you how to be a good patient in their facility, rather than anything about childbirth. Lamaze is a great course that is not too long, and provides great education, and positive thinking surrounding birth.
  4. Hire a Doula! – Several North American studies have shown many benefits to having a birth doula. From lowering your chance from a cesarean, to shorter labor times.  There was an amazing difference in my two birth experiences, one including a doula, and one without.
  5. Check Out Your Local Hospital Statistics – Some states such as New York and Massachusetts publish the maternity care statistics by hospital, which is also required by law in these states. Unfortunately for women in other areas of the country, these numbers may not be as easily accessible, but local health departments and The Birth Survey can help you with this.
  6. Do Your Reading! – There are so many great childbirth books that can help you to focus on your journey to a natural childbirth experience.  Some of my favorites, and the most popular books include :        
    • The Thinking Woman’s Guide to a Better Birth – Henci Goer
    • Birthing From Within – Pam England
    • Gentle Birth Choices – Barbara Harper
    • Creating Your Birth Plan – Marsden Wagner
    • Ina May’s Guide to Childbirth – Ina May Gaskin
    • The Official Lamaze Guide – Judith Lothian & Charlotte DeVries
    • The Birth Partner – Penny Simkin
    • Birth The Surprising History of How We are Born – Tina Cassidy
    • Check out the ICAN Recommended Reading List also!

    What are your favorite pregnancy and birth books? Leave a comment to let other moms know about your favorite reading resources.

  7. Go internet shopping!  I get that term from the lovely Feminist Breeder, the term was something her provider hit her with when she discussed her own research she had done regarding VBAC.  Go online, and do your reading, there is so much amazing information on the internet that can help you in the right direction for starting a journey to natural childbirth. Some of my favorite online resources include :

    What are your favorite websites for natural childbirth, or preparing for birth?

These are simple steps that can’t all be done overnight, but they are basic steps in the right direction, many of which you can even start before getting pregnant.  The biggest key in having a successful and positive birth experience starts with education!

A Birth Story: Amy & Baby June

Enjoy a beautiful birth story from the perspective of Amy Bauer, a labor & delivery nurse in a hospital, as she prepared for and birthed her own child in a birth center with a midwife.

When my husband and I got pregnant earlier in the year, we set right to work to prepare for our child’s birth. Long before getting pregnant, I knew what kind of birth experience I wanted to have. We researched birth centers in our area, identified childbirth education and lactation classes, and talked at length about what it means to have a natural, normal birth. Throughout my pregnancy, I worked the night shift as a new labor and delivery nurse at a hospital that specializes in high-risk pregnancy and birth. At this hospital, natural, normal birth is a rare event. Physicians routinely meddle with the labor process at every turn. Artificial rupture of membranes (AROM) and Pitocin are routinely used to hurry labor along, sometimes without medical indication. On top of that, nearly 95% of our patients opt for epidural anesthesia and approximately 41% of births are by cesarean section. New to nursing and now preparing for my own labor, I felt uncertain how, as a new L&D nurse, I could best support women in labor and birth in this environment. I also began to wonder if my body would know what to do in labor. As my due date neared, I shared these concerns with Katie, my midwife, who gave me a great piece of advice: while working in labor & delivery, I was to a) visualize my own labor and birth every day; b) surround myself with positive stories about natural labor and birth; and, c) keep my “nursing brain” out of my own labor and birth when labor began. I did just that – I confided in fellow nurses who were strong advocates of natural, normal birth and poured over written birth stories that illustrated the beauty and power of natural birth. At the risk of feeling a bit silly, I also recited positive affirmations each day to remind myself that my baby would find her way and that I could in fact trust my body when labor began.

In the early morning hours of June 27, my labor began with mild irregular contractions. It was a beautiful, yet uneventful labor, lasting nearly 19 hours from start to finish. In the beginning, distraction helped. I remember sneaking out of bed at 4:00 in the morning to write thank-you notes for a recent baby shower in between contractions. Rhythm also proved to be helpful. Later that morning, when labor became more intense, I relied heavily on my husband to literally rock me back and forth through each contraction. The contractions were hard and consistent throughout the day, but by no means unbearable. Following the advice of my midwife, I remained mentally present in my labor, keeping my “nursing brain” out of it, never stopping to wonder how far dilated I might be or when it would be time to push. I simply breathed, rocked, and swayed my way through each contraction, focusing solely on the rhythm of my movements and the power of my laboring body.

By late afternoon, after nearly 15 hours of regular contractions, I sensed that my labor had changed. We had spent the early afternoon walking around an indoor mall, during which my contractions increased in frequency from about eight minutes apart to three to six minutes apart. We came home and I immediately made my way to the bathroom, overwhelmed by two or three very long, strong contractions. Looking for relief, I crawled into a hot shower while instructing my husband to call the midwife. I could feel my labor intensify with transition. After a brief phone call with the midwife, Jason and I decided to head over to the birth center. With help from my husband, I used short quick breaths to help me stay relaxed through the most intense contractions. Twenty-five minutes later, Katie, our midwife, greeted us at the door of the birth center as I toddled my way into the center. Between contractions, I felt calm and focused, even conversational.

On the four-post bed of the labor room, which looked nothing like the hospital labor rooms I was accustomed to, Katie confirmed by digital exam what I already knew: I was completely dilated with just an anterior lip. We continued to labor at the center. An hour and a half later, it was time to push. With my first push, my water broke, bringing the baby’s head far down into my pelvis. Even then, with the baby at plus 1 station, I didn’t feel a tremendous urge to push. We pushed anyway, and in many different positions: on the toilet, on my side, on hands and knees, in a squatting position. Finally, in hope of getting the baby’s head to slip under my pubic bone, I asked to push in a semi-sitting position, which did the trick. At 9:01pm, June Dahlia Bauer was born. The midwife placed her on my chest, and I immediately wiped her dry and placed her on my chest to greet this little life in my arms. In that moment, our lives changed for ever.

Just eight short weeks after June’s birth, I returned to work full-time: three night shifts a week. Initially, I was afraid that I would judge those who chose to use epidural anesthesia, given that I had labored on my own without medication easily enough. I was also apprehensive about returning to a birth culture that embraced active management of the labor process. Instead, my personal experience with labor and birth transformed me on the unit floor. As I gain strength in my clinical skills, I continue to draw from my own experience to better advocate for my laboring patients. For example, I steer my patients’ focus away from the pain of contractions using imagery and rhythm. I encourage movement in labor, even for those who are confined to a bed following epidural anesthesia. When it comes time to push, I dim the lights in the room and ask the residents and medical staff to use soft voices to maintain a calm and centered ambiance. Most importantly, I have learned that patient education is central to my role as an advocate for normal birth. I put more energy and time into reminding my patients to question medical interventions that seem unnecessary or routine. By doing this, I believe I am better serving my patients and helping women find their own way through labor and birth in the hospital setting.