Archive for the ‘Birth Options’ Category

Choices in Childbirth- Before You Write Your Birth Plan!

Happy 2013, everyone! While my blogging is much less regular than I’d like it to be, I am still happy to come and post as I can. I hope that your holiday season was peaceful and cheerful, and that you have started the New Year with new vigor and fresh perspective.

Today, I’d like to touch on a topic that is particularly relevant to me today as I am pregnant with #2: developing a decision making process for planning your birth.

I’ve often tried to make the case for making a birth plan ahead of time, but many women may not know where to begin. How do you know what your preferences are? What factors may change your original ideas of the perfect birth? And then how will these apply to your birth plan? Let’s break the process down into five steps that you can follow prior to planning your birth.

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1) Research what is healthiest for you and your baby.

Check out some great reads on evidence-based practices in birth. (You can look at my resources page for starters, though it’s certainly not a complete list of all the great information out there.) If you have a question about a specific practice in birth, you should take some time to go on Google Scholar and search for information on it. It’s not that hard! Though you may not have access to full medical journals without paying for them, you can almost always read the abstracts from certain studies. They will give a summary of the study’s findings, and it’s usually pretty understandable. If you don’t know what something means, look it upYou can read and understand the majority of studies out there on birth practices, even if it takes a little extra research. (Make sure you double check your findings with a knowledgeable care provider- sometimes checking with two different care providers of differing perspectives can be enlightening.)

2) Figure out what your personal preferences are.

The Birth Book by Dr. Sears has a great section on developing your own birth philosophy and making some general birth choices. Here are some good questions to get you started:

  • How much do I want to be involved in the decision making process, and does my doctor support my preference?
  • Do I want to be an active participant in my labor, or would I prefer it to be managed by the hospital staff?
  • Do I prefer to go with or without pain medications? How much do I want to feel? What type of medication is right for me?
  • Who do I want present at the birth? How much control do I have over this in my planned birth setting?
  • Do I have strong preferences on any of the hot button birth controversies (e.g. episiotomy, birthing position, delayed cord clamping, etc.)? If so, is my care provider/birth place supportive of my preferences? (If you don’t know what you’d like, look up information on it to help you decide.)
  • Where and with whom am I most comfortable laboring and birthing?
  • Is there anything that I would be extremely disappointed about if it did or did not happen? If so, what can I do to maximize my chances of achieving my desired outcomes?

3) Discuss options with your care provider.

Next, take your research and your preferences to your care provider. Always double check with your provider on things before making a medical decision. Find out if you have any specific medical needs or concerns that would affect your choices for birth. Then talk about it! See if the two of you jive or not. Make sure you have a trusting, mutually respectful relationship. You should be trying to get the most from your care provider’s knowledge and experience, and he or she should be trying to accommodate your preferences as much as possible within medical possibility.

4) Do a reality check.

As your due date approaches, do a reality check. If you want a lovely natural birth with no wires or needles but are facing induction due to health concerns, you may need to step back and reevaluate your plan. Likewise, if you plan on getting an epidural at 2 cm and feeling nothing but have a history of quick, intense labors, you may need to prepare for the possibility of not having time for pain medication. You are setting yourself up for disappointment if you blindly expect that things will go a certain way when you have clear indicators to the contrary.

5) Be flexible.

As I always stress, realize that unplanned surprises can always come up. Plan a Plan B. Plan your worst case scenario birth. What would you do in that situation, and how would you feel? How could you make the best of it? Think about these things now so they don’t undermine you if they do come up later.

Now that you’ve thought through these five steps, you are well on your way to making decisions for your birth. Make these decisions before you write your birth plan to ensure that you are well informed and prepared. Then sit back and enjoy the ride!

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Delayed Cord Clamping Victory!

Just a short post to share my excitement. I was recently at a prenatal appointment with a client, and she asked her OB about the possibility of delayed cord clamping at her birth. The OB responded with this:

“So long as there aren’t any complications that prevent it, we actually have a new rule that requires us to wait at least 30 seconds to clamp the cord.”

Hurrah!  Of course, it would be great if they would wait even longer, but waiting even 30 seconds can provide great benefits to the baby.

I am excited because one of the things I’ve been pushing for has become reality. It’s not because of me, of course- it’s simply because our local hospital is incorporating more evidence into their practices. And this brings me great joy.

Want to know more about delayed cord clamping? Why is it important, and what difference does it make for your baby? Check out the Benefits of Delayed Cord Clamping.

 

The Natural Cesarean

I came across this video, entitled “The Natural Cesarean: A Woman Centered Approach.” It discusses a family-centered cesarean to promote a gentle c-section birth, early bonding and skin-to-skin, delayed clamping, and involving the mother in care decisions as much as possible. It involves the father, and includes midwifery care even in a c-section.

Moms, consider including some of these options in your birth plan in case of cesarean! If it is not an emergency, you may be surprised at how much the doctors are willing to work with you on some of these wishes.

“It’s important that with each cesarean section that you make that cesarean section special for the parents, because it’s their only cesarean section, their only child that’s being delivered. And whichever way you do it, as long as you think carefully about how to make it work for the parents, then it will be time well spent.” -Dr. Gary Stocks, Anesthetist featured in video.

Enjoy this beautiful birth!

 

Eleven Ways to Avoid the CPD Diagnoses

Cephalopelvic disproportion is commonly diagnosed, but women who have had the label slapped on have later birthed subsequent babies (sometimes larger!) vaginally without a problem. CPD has been noted as one of the most common and most controversial reasons for a c-section, and the general consensus (among birth professionals and crunchy birth bloggers alike) is that in most cases the diagnoses is incorrect. (It could just as easily be called “failure to progress”-or as I prefer to call it, “failure to be patient.”-an equally unsatisfying reason for a C-section in many cases…) If you missed it and would like to read more, check out The Problem with the CPD Diagnoses.

So, how can you avoid getting stuck with the CPD label? Try going through this checklist before determining that your pelvis is too small or that your baby is too big. Remember that some of these suggestions are pointed at the fact that the CPD diagnoses is often given to women who don’t birth quickly enough by your caregiver’s standards. (e.g., Your baby isn’t coming? He must just not be fitting through.)

1) Allow the mother as much freedom of movement as possible.

The more the mother can move about, the more room she creates for her baby to wiggle and move downward through her pelvis. Think of it like fitting a key into a tight lock- sometimes it gets jammed, but if you wiggle it this way and that, then it will fit in just fine. Many times getting up and walking around, moving your hips, or simply shifting positions can allow baby the extra room he needs to fit through.

2) Allow pain management drugs to wear off a bit.

Sometimes mothers who are on an epidural cannot feel enough to push their babies out. If they allow the medication to wear off just enough that they begin to get some sensation again, they may be able to connect to their pushing muscles to feel enough to continue on to a vaginal birth. The mother is not to blame if she cannot feel to push; rather, she should be aware of this possibility and consider asking for more time to birth vaginally, provided that she and the baby are doing fine.

3) Try alternate pushing positions.

This goes back to #1. Getting off your back and getting in the position you feel most comfortable in can help your baby to find a little more room to fit through. For example, squatting opens the pelvis up to 30% more than in other positions.  (Check out this video for a discussion on walking and squatting for labor and pushing, and this video to hear suggestions for alternate pushing positions.) Upright pushing positions can also give you the advantage of gravity, and more pushing force. Both of these can aid in getting your baby out more easily.

4) Encourage your baby to be in optimal fetal positioning.

What position is your baby in? Do you know that it can make a big difference in how easily he makes his way out? For example, a baby that is in the occiput posterior position (crown of his head facing your tailbone) has a much more difficult time fitting through the pelvis (though most will turn if given a chance). The baby’s rotation to fit through your pelvis is just as normal a part of labor as your dilation is. Check out Spinning Babies for more information on how to decipher your baby’s position and to encourage a great one for labor and birth. This can be done during pregnancy or even during labor. (Here’s a great article specifically on CPD.)

5) Consider chiropractic care in pregnancy.

“Some women report that chiropractic care throughout and between pregnancies is helpful in avoiding CPD. Look for a chiropractor who has experience working with childbearing women and utilizes in-utero constraint techniques.” –ICAN on CPD.

6) Keep your energy up during labor.

Rest. Eat. Drink. Try not to wear yourself out. The uterus is a muscle- and just like any other muscle, it can get tired and give out if worked too hard. Keeping your energy up can help your uterus (and you!) to have the strength to birth vaginally.

7) Avoid an induction if possible.

If you and the baby are both healthy, try to avoid early or routine inductions. (Remember, even ACOG states that a pregnancy isn’t considered postterm until 42 weeks.) Your risk of cesarean is significantly increased in an induced labor. What might contribute to a “CPD” cesarean caused by induction? One factor is that you are less likely to dilate as quickly or effectively in an induced labor.  Another is that you are more likely to need pain medication when induced, which in turn creates less mobility for the mother (remember #1-3?) and also tends to slow labor. (That’s not even mentioning the emergency C-sections due to increased risks to babies from inductions, but that’s off topic…)

8) Keep a calm birth environment.

If women are allowed a calm, peaceful environment where they feel comfortable and at ease, it is quite possible that they will dilate more quickly. Adrenaline suppresses oxytocin, so being nervous can quite literally slow your labor progress (& sometimes stall it out!).

9) Hire a doula.

Doulas can help suggest ways to encourage your baby to move into a better position for birth, to make pushing more effective, and to generally help speed and ease your labor. The various techniques a doula brings to your birth are invaluable for many reasons, but can also help you to avoid a “case” of CPD.

10) Listen to your body.

This might sound strange to some, but you should pay attention to how your body is feeling throughout labor. Extreme discomfort is often a signal that something needs to change. If you feel like you can hardly bear a certain position, try a different one that works for you! In the process, you may help your progress and facilitate baby’s descent.

11) Be patient.

If you and the baby are both healthy, a slow labor or long pushing phase doesn’t necessarily mean anything is wrong. It took 3.5 hours of pushing for my son to decide to turn from his posterior to anterior positioning and make his exit. Yes, it was difficult. Yes, it was exhausting. And I do admit to thinking to myself, “So what’s wrong with a c-section?” There was a period where I myself didn’t believe that he would actually come.

Most of the time labor doesn’t bring immediate results. It is long, sweaty, hard work, and all you can do is ride it out and wait for each contraction and each challenge to pass. Patience doesn’t guarantee a perfect birth, but oftentimes patience can save you from jumping the gun and trying to “fix” something that wasn’t broken in the first place. Sometimes what seems like a baby not fitting through the pelvis is actually a case of the baby simply taking longer to make his way down through the pelvis and birth canal.

Let me be perfectly clear. True CPD, though rare, does exist. If you are one of those women who actually does have it, do not blame yourself. You are not at fault. We live in a broken world, and not everything always works as it should. These suggestions are meant to be tools for you to try to help avoid the CPD diagnoses. You are doing everything you can to do the best for your baby and yourself, and in the case of a truly necessary cesarean, you are absolutely doing the best thing for your family by going through with it.

So now you have some tools to take with you to labor. Suspected big baby? Previous CPD diagnoses? Don’t be afraid. Give it a shot. You can try to birth this baby vaginally, and many of you will go on to do so.

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BRAINS

This morning, I will share a fun spin on a familiar set of questions to ask if you feel that you need to discuss a procedure. I discovered this mnemonic through a reader’s comment.

Before going through the following acronym, always ask if baby and mom are both doing okay first. Then, use your BRAINS!

B– What are the benefitsof your advice?

R– What are the risks?

 A- What are the alternatives?

  I- What’s my intuition saying?

 N-What if I say no?

 S- and lastly SMILE. Always be courteous but firm.”

A big thank you to Jean from HypnoBirthing of Lancashire and Cumbria for suggesting this great memory tool!

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I Do Not Consent: A Sequel

I wrote a post almost a year ago now entitled “I Do Not Consent,” and I noticed it was getting a lot of traffic (for my blog, anyway!) the past few days. As I reread the post, I felt as though it needed to address some additional issues in order to give a complete picture of my views. Some comments I received also confirmed this need.  I feel that further exploration of the topic of non-consent is an important pursuit.

If you haven’t read the original post, you can go ahead and read it here first so that we’re on the same page before continuing. Okay, here we go…

1) Non-consent is a serious decision.

I did say this in my original blog, However, it appeared as though some readers missed it, so I quote: “I will say… that this phrase should probably not be taken lightly. Weigh your caregiver’s experience against your own intuition. Is your baby still ok? Are you still ok?  Find out whether the caregiver is recommending a procedure out of medical necessity, or because of convenience or a hospital policy.”

I am not– I repeat- I am not recommending anyone deny a procedure that is truly medically necessary for themselves or their baby. This is utter foolishness. I am also not recommending that you go into the hospital (or at your home) throwing this phrase around at the drop of a hat. This probably will not be helpful to your cause. This leads me to my next point…

2) Communication is key!

I am not much for fighting during a birth. I am not suggesting that you argue with your care provider. Keep an open line of communication with your doctor or midwife before and during the birth. Ask for things politely. Discuss your preferences first. If you come to a disagreement, then you can can implement my suggestion from my previous post:

“You can always say, ‘Wait. I do not consent yet.’ Go on to ask these four questions:

1) Is this an emergency? (If no, move on.)

2) What are the benefits of this procedure?

3) What are the risks of this procedure?

4) What happens if we do nothing?”

If you disagree with a procedure, talk through your options with the doctor or midwife (provided that #1 is answered with a no). Goodness, you could even compromise if you’re both comfortable with it! Even non-consent to an unnecessary procedure, however, doesn’t have to be rude.

3) Consider your relationship with your care provider early on.

Please do not go into a birthing situation planning on being “up-in-arms” about everything. If you think all OBs are surgical monsters who don’t know how to let a woman labor, then why did you sign up for their care? If you think your home birth midwife is full of fluff and incompetent, why are you paying her to attend your birth?

In most cases (with some well-acknowledged exceptions), you chose your care provider. Don’t plan on not trusting them from the start. If every appointment you are thinking how much your midwife makes you mad or uncomfortable, then you should switch providers.

As one reader commented, “You should never discount your providers education, training and experience. There are times during birth when a caregiver must make life and death decisions and may not have time to offer a 30 min. consult on the pro’s/con’s of their decisions. I am not saying that there will be an emergency in every situation, however, If you do not trust your provider and their judgement to do what is best for you and your baby, you should find a different one! Yes, be well informed. Ask lots of questions PRIOR to the birthing room when there is time to go over all the nuts and buts of why things are done a certain way – but waiting to be informed until you are in the middle of your birth is…well, negligent on your part.”

Ideally, you should choose a  provider who respects your preferences as much as is possible, AND whose  expertise and training you can respect in situations that you are unsure of. However, less-than ideal situations sometimes can come up in the company of an on-call doctor, or a nurse, or with the midwife’s assistant (or what have you!), no matter how well-prepared you are.  In this case, non-consent should still be considered a reasonable option.

4) Don’t leave the hospital in the middle of a c-section.

Yes, I know I’m being silly. When I wrote in my original post that it’s never too late to switch care providers or birth sites, I guess there was an actual limit to that. Pushing and surgery are probably cutting it pretty close. However, I have heard of many women who have requested new providers, left their home birth, or traveled to a different hospital in order to find the respect, courteousness, and medical sensibility they lacked in the first place.

4) Women need to have the option of non-consent.

Women still need to have the option of non-consent. Why?

  • Because sometimes there really are flat-out medically unnecessary procedures being performed out of habit, preference, liability, or policy. I’m not saying it’s happening all the time or that this is the primary motivation for most care providers. I’m just saying it happens sometimes, and it shouldn’t.
  • Because even for the most well-prepared mom, unpleasant surprises can arise during labor. Sometimes its from an on-call staff member that she just didn’t have time to talk to before the birth.
  • Because sometimes there are situations that are just plain assault. Like the mother whose doctor cut an episiotomy “just to teach her a lesson.” Or the two doctors who ripped a mothers perineum with their hands when she asked them not to cut her. Or the midwife who emotionally abuses her patient by scolding her for not handling pain. No woman should have to feel that she should sit through something like this for the sake of being a “good patient.” If we don’t allow women the right to stand up for themselves at this point, then when will we?

I felt that expansion and clarification of “I Do Not Consent” was necessary, especially if you are not a regular reader who understands my broader views on birth and providers. I hope that my list of “qualifiers” wasn’t too long, and I hope that it was clear. Please feel free to ask questions/give input in the comment section. I’ll summarize with a reply I wrote to a commenter on my original post. Thanks for reading, as always. 🙂

“Birth should ideally be a partnership between birthing mother and caregiver. Only when the mother is being coerced or attacked for non-medical reasons should refusal be resorted to. I am sorry this didn’t come across more clearly in [my original] article… I don’t want to encourage recklessness. But I do firmly stand behind the protection of a woman’s intelligence and dignity during birth, and that means that she has to still have her rights in the birthing room.”

*Not to be taken as medical advice.

You, The Consumer.

You are a mother. You are also a patient, or a client, depending on your care provider’s terminology. But, primarily, you are a consumer.

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Most of us don’t think of maternity care in this way- deciding to pay a specific birthplace and provider, rather than just going to the place that’s cheapest or where your friends went. But primarily, you are purchasing a service, not merely sitting under nonnegotiable care.

I am not writing this to undermine trust in your provider, or to encourage being a “bad” patient who is never satisfied. However, I think that there is enough variance in opinions, management styles, and routines among qualified providers to say that it’s fair to search for one who jives the most with your ideals. Let’s look at some examples.

Hospitals & Birthing Centers- First, look at the time limitations of  your hospital or birthing center. For example, our local hospital is the only one in about a 30-45 minute radius that provides maternity care, and only has 16 OB/GYNS who practice there, delivering around 3000 babies a year (at a 36.9% c-section rate). This means that this place is, in the words of several women I know who have birthed there, “a baby factory.” There is nothing wrong with choosing to have a baby there, but the implications of doing so must be considered. When there are literally not enough beds in the mother/baby unit and new moms are being made to share rooms with elderly men in the general sick patient area, you know that the hospital might be too busy. You know you won’t be receiving care from newborn nurses. You know there’s a possibility of  exposing your newborn to strange germs. You know you will lack privacy. You know you will lack sufficient one-on-one care. Yes, this hospital has a good NICU, round-the-clock anesthesiologist and cesarean availability, and a history of generally good outcomes (by American hospital standards), but does the high number of healthy babies at the end justify the means of care in helping them arrive?

Let it be known that not all hospitals are like this. I attended one about 2 hours from me that was much less busy, had only a 21.6% c-section rate, was quiet and calm, and had enough staff that the nurses could pop in whenever mom wanted them. Which of these two hospitals would I rather pay for their services? Certainly the latter.

One must also consider monetary influences on practices. (Before I write this, you must know that I don’t think all doctors/hospitals only want more money! I really do believe that they DO care about their patient’s well being!) It is worth noting that c-section rates are notably higher at for-profit hospitals than at non-profit institutions. Check out this news story for one example of this disturbing trend.

Home Birth Midwives

Time and money are also considerations for your midwife, though not as frequently as a big organization. How much does she charge? Does this correspond to her training and experience? How many clients does she take on a month? What is her back-up plan if she has two women in labor at once? You must know the answers to these questions before you hire her for your birth.

When hiring a home birth midwife, I think the most important consideration is finding out if you are paying for a qualified provider. As much as I support home birth midwifery,you  must remember that there are different breeds of midwife (CNM, CPM, and DEM), and there is currently no standard of certification for direct entry midwives. I’m not saying you shouldn’t hire one (my own midwife was direct entry), but you should make darn well sure that she is qualified to attend your birth before doing so. Find out her training and experience. Where and with whom did she complete her apprenticeship? Does she have references? Does she have a back-up doc?What is her hospital transfer rate, and what percentage is emergencies? What is her relationship to local hospitals? What are her maternal/infant/perinatal mortality rates, and for what reasons? How would she handle a hemorrhage? What equipment does she bring to a birth? Does she practice with legal integrity? I am not trying to scare anyone out of a home birth, but the safety of a home birth has been shown to depend upon the presence of a qualified attendant. Make sure that yours is.

Birth Philosophies– Remember, you are consuming services. Would you pay for a protestant pastoral education at a local college where the professors are Buddhist? Would you go to McDonald’s to purchase an organic beef hamburger? Would you go to the chiropractor’s office for heavy painkillers? No! Of course these are silly propositions.

Yet we do this over and over again when purchasing birth services. You might want a VBAC, but your provider’s successful VBAC rate is only 15%. “Too bad,” you say. “This is where our insurance takes us. I guess we’ll just work with it.” You have to think through how important your birth preferences are to you, and then choose (and sometimes actually pay for) a provider with a similar birth philosophy as you. You, the consumer, are responsible for picking a provider and birth place that support your desires. If you do not, then it shouldn’t be a surprise when things go differently than you’d hoped. Of course there are always aspects beyond your control, but you can make every effort within your power to ensure that you have purchased like-minded maternity care.

It has been said before that most people put more research into choosing a car or a stereo system than they do in choosing a care provider or birth place. Don’t let this statement be true of you. Make every effort to be an informed consumer.