My Long Hiatus

It has been 9 months since my last post. What have I been doing for the past nine months? Not growing a baby, but helping so many others grown one! :-)

There have been 43 babies born to my Bradley Method students or doula clients in the past nine months. 43 healthy, happy, delightful babies in just 9 months! I am so amazed at how many parents feel the strong desire to learn all that they can about birth and to do their best to make the birth of their child the safest and also the most joyful occasion they can make it. These dedicated parents faced struggles, unexpected circumstances and surprises, but they worked together to make the best choices and in the process build stronger family bonds. I am SO PROUD of all of them!

What is a Doula?

The role of a Birth Doula

More and more women are opting to hire professional labor support for thier births... a Birth Doula. A Doula is an independent professional who works for the laboring couple and provides support prenatally and throughout the entire labor process. Her role is to help the couple maintain a comfortable environment and mindset as labor progresses.

Some of the services that a Doula may offer are:

• Educate the couple about birth (though she is not a substitution for a childbirth preparation course)


• Help the couple create a birth plan


• Help the couple understand what is happening during the birth and provide emotional support


• Offer suggestions for positions that may help the mother during the labor and birth


• Use massage, aromatherapy, hydrotherapy, counter pressure or other techniques to provide comfort to the mother.


• Remind the couple of the benefits and risks of procedures, medication and technology that may be used during the birth


• Help with the first breastfeeding


• Take photos of the labor, birth and postpartum period

What a Doula does not do:

• Any medical tests or procedures


• Vaginal exams


• Make decisions for the laboring woman


• Intervene in medical decisions

How to find a Doula

Ask your friends, neighbors and co-workers if they used a Doula or could recommend someone. Search the Internet for local Doula groups. Often Doulas will host "Meet the Doulas" night to give parents a chance to meet several Doula and ask questions. Ask your care provider if they have any Doulas they recommend. Ask for recommendations from local message boards.

Once you have some potential names, make appointments for a free informational interview (which should be standard). Use the DONA pdf "Questions to ask a Doula" for a guide during your interview.

The Doula you hire should be someone who both you and your partner are comfortable being around. She should answer your questions clearly and honestly. She should be available for two weeks before and two weeks after your due date.

When you have decided to hire someone, it is a good idea to have a signed contract with her. The contract should specify the total fee and the timing of payments. She will usually require a deposit in advance with the balance due near the due date or after the birth. Make sure that you agree with all of the provisions in the contract. If there is anything that you want to alter, request to make these changes before signing the contract.

Make sure you know when and how to contact your Doula if you think you are in labor. Have her phone numbers, your care providers phone numbers and the birth center/hospital phone numbers saved in your phone, listed on the refrigerator and/or in your wallet. This way you and your partner will always be able to get in touch with someone quickly.

Don't hesitate to ask your Doula for recommendations and referrals for other pregnancy,birth and postpartum services. She should have a wealth of information that could help you in many ways. There are also Antenatal/Antepartum and Postpartum Doulas. Antepartum Doulas assist women going through a high-risk or difficult pregnancy. Postpartum Doulas assist new families in the days and weeks after birth. More to come on these topics!

Positions for labor

Movement and Gravity

One reason many women choose natural childbirth is the idea of being tethered to a bed for many hours is frightening. Epidurals come with a whole lot of wires and tubes and make the mother immobile. Movement in labor helps your body to open and assists the baby in rotating to fit through the mother's pelvis. If you lie in bed for hours then your labor progress may be much slower than if you were changing positions, moving and using gravity to help the baby descend.

There are multiple positions that women can assume in labor. The best and most effective positions are the ones that use gravity and movement to help the baby descent. Gravity and movement are helpful in many ways; they help shift the baby into the proper position for birth, can apply more direct pressure on the cervix increasing dilation, and they can help open the pelvis allowing more room for the baby to come through.

Positions in which a woman is upright or forward leaning are going to have the biggest impact from gravity. Many upright positions also allow for plenty of movement during or between the contractions. Women can rock, sway, or do hip circles easily from these positions.

Using a birth ball/exercise ball can also be very helpful for birth. Birth balls allow for lots of movement and are quite comfortable for a laboring woman to sit on or lean over.

A woman and her partner should practice these positions in advance to get a feel for how to best relax and how the partner can best support her in each position. Women will try a variety of positions over the course of the labor. Partners should encourage moms to change positions every 30 minutes to encourage the baby's descent.

The Mayo Clinic has a nice slide show of some of the positions for labor.

Here is a link to a pdf from Injoy with photos and tips for labor positions.

Happy birthing!

Improve your health and fitness during pregnancy

How do you influence your birth experience?

Step three: Your health and fitness during pregnancy can impact your birth!

It is never too late to make a change. Even small things... like one egg a day, can improve your health and the health of your unborn baby.

Eating better:

• You may lessen your chance of preterm labor by eating the proper amount of Omega 3/DHA. "...when pregnant women who were at risk for preterm birth were given eggs enriched with an Omega-3 (DHA), the length of their pregnancies increased by an average of six days (Smuts et al., 2003)."

• Avoiding some food additives may lessen your risk of birth defects, diseases in your newborn or even cancer. Here is a helpful article on the additives to avoid during pregnancy. Start eating more fresh, homemade and/or organic food and save yourself the trouble of researching a bunch of chemical ingredients!

• Eating a balanced diet during pregnancy, which includes 80-100 grams of protein a day may reduce your risk of pre-eclampsia? Detailed information on the Brewer Diet can be found here.

Fitness:

• Practicing yoga during pregnancy may reduce your risk of preterm labor and pregnancy induced hypertension (PIH) and may reduce your risk of having a low birth weight baby.

• Practicing yoga during pregnancy may shorten your labor and you may have higher levels of comfort during your labor!!! Hurray!

• Women who engage in moderate physical exercise (30 minutes per day) may have less depression during and after their pregnancy.

Other:

• Women who are under stress are at greater risk of preterm labor, of having a low birth weight baby or stillbirth.

• Stress (either prolonged or acute) may increase your risk of having children with neurological (autism, ADHD) or physical complications (asthma, allergies)

• Smoking or exposure to second-hand smoke can increase your risk of stillbirth, low birth weight babies, preterm labor, SIDS, birth defects, placental abruption, placenta previa, etc.

• Thoroughly research and ask your care provider the risks/benefits of prescription medication while pregnant. (Very little research has been conducted on the safety of their use during pregnancy.)

• Thoroughly research and ask your care provider the risks/benefits of herbs, dietary supplements and over the counter medication while pregnant. (Very little research has been conducted on the safety of their use during pregnancy.)

• I hope it goes without saying that you should avoid alcohol and all illegal substances or drugs while pregnant.

A little change now can make a big difference!

Choice of birth location

How do you influence your birth experience?

Step two: Your choice of birth location (Sometimes your choice of location comes before your choice of your care provider)


There are three main locations that women choose to give birth in:
Home
Birth Center
Hospital

Each has positive and negative qualities, but ultimately the choice is yours. Let's briefly discuss each option.


Home birth
Pros:

• For low risk women, there are the same or better outcomes for mother and baby at home with a certified professional midwives as in hospital births (Johnson K, Daviss B. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ: British Medical Journal [serial online]. June 18, 2005;330(7505):1416-1419.)

• Less chance of an episiotomy

• Less chance of developing a hospital acquired infection

• No unnecessary medical interventions (such as routine I.V's, continuous fetal monitoring, strict time lines for delivery, etc.)

• Comfortable and familiar environment for labor

• Freedom to labor as the mother sees fit

• No access to pain medication

• Limited interruptions

• More peaceful environment after the birth

Cons:

• No access to pain medication

• Greater parental responsibility for the preparation and safety of the birth

• Cost - ($2000-$4000+) though some insurance might cover home births and this fee is just a fraction of the cost of most weddings, new cars, vacations, etc.

• Limited access to life saving medical technology. Midwives usually have oxygen, some medications for hemorrhage and resuscitation equipment.

• Risk factors may make home birth less safe or inadvisable (for example: high blood pressure, premature labor, distance from a medical center, breech, twins, etc.). Each case should be evaluated individually and risk/benefits should be weighed.

Click here for a description of the different types of midwives.



Birth Center


Pros:

• Comfortable environment that is more home-like than a hospital

• Usually more privacy and intimacy than a hospital

• Freedom of movement, mother led

• Midwifery model of care

• Usually in close proximity to a hospital for transfer, if needed.

• Less medical interventions (such as routine I.V.'s, continuous fetal monitoring, strict time lines for delivery, etc.)

• Often covered by insurance.

Cons:

• Unlike a home birth, it does require mom to change locations during labor.

• Limited access to life saving medical technology. Birth centers will have some equipment and supplies do deal with emergencies such as oxygen, medications for hemorrhage and resuscitation equipment.

• Risk factors may make the birth center less safe or inadvisable (for example: high blood pressure, premature labor, breech, twins, etc.). Most Birth Centers are regulated and have strict guidelines for the type of Each case should be evaluated individually and risk/benefits should be weighed.

• Birth center policy may only allow for a short postpartum stay. Parents are sent home shortly after birth which may be overwhelming for some.

Hospital
Pros:

• Immediate access to medical technology, medications, and surgery if needed.

• Can be more comfortable for some women than a home or birth center birth

• Access to pain medications

• Safer for "high-risk" women

Cons:

• Typically encounter the Medical model or "managed" birth

• Subject to unnecessary interventions (routing I.V's, continuous fetal monitoring, time lines for progression or delivery)

• More likely to have an episiotomy.

• More likely to acquire an infection while at the hospital.

• More restrictions on movement and positions with the use of medical equipment (EFM, I.V., epidural, etc.)

• Foreign environment that can make the mother more fearful, anxious or uncomfortable, which can slow or stop her labor.

• More interruptions, less privacy and more variability of care. Parents may not know or have limited familiarity with the care provider on call.

• Food or drink may be limited or banned for the laboring woman.

• Many interruptions during the postpartum period. Mothers are more likely to be separated from the newborn. May be more difficult to establish breastfeeding.

So much to think about....

Choosing or changing care providers

How do you influence your birth experience?

Step one: Your choice of care provider

There is a range of attitudes about birth. Your care providers perspective on the process can have a HUGE impact on your birth. Is your care provider trusting of the natural process or does he/she prefer the medical approach of a "managed" birth? How do you tell???

Ask questions. Some examples are listed below with an explanation of what your care providers answers may mean. Please note, that the title of your care provider (Obstetrician, Family Practice, or Midwife, etc) should not be used to assume their perspective on birth (medically minded vs. physiologically minded). Some midwives practice "managed" care either dictated because of rules from their partners (Obstetricians or Family Practice Doctors), from the location where they attend births or from state laws. Some physicians practice "midwifery" like care and are very trusting of the natural process. It is up to you to find out what your care provider believes and how they typically practice. Your don't want to be in a position to have to fight for your preferences or try to change your care providers mind. You want someone who is on the same page and will openly support your choices during your birth.

Here are some questions to ask your care provider:

· What is your after hours procedure? (Will you be able to talk to your personal doctor/midwife or just the person on call?)

· What percentage of your patients births do you attend? (How individual is the care they offer? Do they make an attempt to attend most of their patients births themselves.)

· How many partners are in your practice? (If there are 10 doctors who rotate call then your not likely to know the person attending your birth. This also means that you are more likely to encounter someone who does not have the same philosophy about birth).

· What percentage of patients have a cesarean section in your practice? (This is a huge indicator of their trust in the natural process. The more interventions are used, the more likely a woman is to have a cesarean section. The World Health Organization recommends that the cesarean section rate be between 5-15%. Rates above 15% seem to do more harm than good (Althabe and Belizan 2006). Some practices have rates of 50% or more!!! The U.S. national rate for 2007 was 31.8%) Read more about C-section rates on childbirthconnection.org

· What percentage of patients have episiotomies? What is your suture rate? (This tells you how patient a care provider is during the pushing phase. It also tells you how likely they are to provide perineal support, to assist you in finding the best position to avoid an episiotomy and to avoid interventions that increase the chance of having an episiotomy [such as epidurals, forceps or vacuum extraction]).

· What is the most common choice for pain relief amongst your patients? (A provider who encourages pain relief or even chastises a woman for not have pain relief is not supportive of natural birth. There are many alternative to anesthesia or narcotics to help a woman cope with labor.)

· What percentage of patients have natural, spontaneous childbirth? (The higher the number, the higher your chances are of having a natural birth. Unfortunately, for many care providers this number is quite low.)

· What percentage of patients how have had a previous cesarean have VBAC's? (The option for a VBAC or Vaginal Birth After Cesarean, has been nearly eliminated for many women because of fears of malpractice and/or hospital bans on this type of birth due to liability. Check our ican-online.org for more info on VBAC's).

· What is your protocol for postdates (i.e. “overdue”)? What percentage of women are induced in your practice? (Do they routinely induce at 40, 41, 42 or 43 weeks? If the policy is to induce all patients at 40 or 41 weeks, then you greatly increase your chances of having a cesarean due to fetal distress or a failed induction.)

· What is your protocol for preventing and managing a breech? (Their knowledge of optimal fetal positioning techniques can help you reduce your chances of having a breech baby. Their willingness to attend a vaginal breech birth speaks to their skills, patience and understanding of the process of physiologic birth.)

· What is your protocol for preventing and managing a posterior position? (Again, knowledge of optimal fetal positioning techniques can help you avoid this presentation. Avoiding interventions [such as induction, augmentation with pitocin, artificially rupturing the membranes, etc] can reduce complications with a mal-positioned baby.)

· How many vaginal twin births have you attended? (The higher number the better! This rate shows your care providers trust in the natural process and their willingness to be flexible.)

· How much time is allowed for the natural delivery of the placenta? What do you do it this limit has expired? (Assuming a natural birth has occurred, what approach is used during 3rd stage? Is the natural process respected or is there a standard protocol? Is the mother encouraged to nurse and release her own naturally occurring hormones to help expel the placenta? Speaks to their attitude about birth.)

More steps to come soon!

The first blog

Wellspring Childbirth

Welcome! I am trying my hand at blogging. My goal is to write about the current issues surrounding pregnancy and birth for those who are looking for a more natural, physiologic and peaceful experience during this time in their lives. Birth does not have to be sterile, frightening or traumatic.

What is natural childbirth?

Natural childbirth is the act of giving birth without the use of any pain medication or medical interventions. Many women chose natural childbirth because they feel it offers the safest experience for both mother and baby. Read more about why to choose a natural birth at birthingnaturally.net

Two models of care

The Medical Model of Care typically approaches birth as a risky process which requires management of risks through the use of technology and medication. Care is routine for all women (office visits are short, leaving little time to make personal connections, ask questions, etc). There are high rates of interventions (induction, augmentation, epidurals, cesarean section, etc). Many women feel that their care provider is "in charge" of the process and they have little power, control or ability without medical assistance.

The Midwifery Model of Care typically approaches birth as a normal, physiologic process in which most women can successfully give birth with out the use of interventions. This model provides individualized care to each mother and care providers typically spend ample time at each prenatal visit to to get to know the woman and discuss her concerns or fears. Women, with the proper support and access to comfort measures, are are free to act as powerful birthers of their own babies.

While, most midwives fall into the category of offering the Midwifery Model of Care, not all function in the same way. The home birth midwife has the most flexibility in how she cares for a woman, while those who partner with physicians and attend births in a hospital, can be restricted in the type of care and service they provide. Similarily, some physicians offer care that is more like the Midwifery Model than the Medical Model. My next post will discuss how to ask the right questions to find out how your care provider (or a potential care provider that you are interviewing) feels about birth.

Here is a great review of research on the difference between the two models of care (from the Cochrane Library:

Midwife-led versus other models of care for childbearing women

Midwife-led care confers benefits for pregnant women and their babies and is recommended.In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called 'team' midwifery. Another model is 'caseload midwifery', where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects. The main benefits were a reduced risk of losing a baby before 24 weeks. Also during labour, there was a reduced use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman's chance of being cared for in labour by a midwife she had got to know. It also increased the chance of a spontaneous vaginal birth and initiation of breastfeeding. In addition, midwife-led care led to more women feeling they were in control during labour. There was no difference in risk of a mother losing her baby after 24 weeks. The review concluded that all women should be offered midwife-led models of care.

Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.