Back in the Birth World

It has been months since I've really felt like a doula. My summer and fall of moving a lot and starting graduate school had me on an extended hiatus. Although I kept a connection to all things birthy through this blog and keeping up with my favorite online blogs, I haven't really felt as much a part of the birth world as I did last spring.... until this week! And I'll tell you why.

Since moving here I have had a couple failed attempts to do some birth networking. It is very slow-going. I did meet a couple doulas at a maternal and child health meeting, which was nice, but they told me there was no nice doula network in Tampa because although there were many doulas, they are apparently quite divided (home birth only/extremely anti medical vs supportive of hospital/medical options). But thanks to the wonders of the internet, I met a really great local doula through our blogs! She followed my blog and when I checked out hers I realized she was local and we decided to connect in real life!

She invited me to attend a weekly prenatal class given by a nearby pregnancy help center. It is a small weekly class that is given for free to women no matter what age they are or what number pregnancy or child they are having. She and I had a really great time getting to know one another, and it was so fun to just babble on about birth and breastfeeding with someone who shared my interests! The class was also really great - it is so interesting to see what is being taught to (what I interpreted as) low income, mostly minority pregnant women and how it is discussed. The discussion was great and I loved listening to what everyone had to say. The women all had diverse experiences and input. We learned mainly about nutrition during pregnancy, and then we had a nutritious dinner together. I had a great time and I got to hold an adorable fat baby!

If you are reading this, my new doula friend, hello! :)

In addition to the above, I also attended a really great maternal and child health symposium at my college of public health with really awesome and diverse speakers. The main topic tended to be preterm birth prevention and the role of obstetrical management in the late preterm period.

Some things I learned which I will share with you -

• The Big 5 states (Florida, Texas, Illinois, New York and California) account for 38% of births and 40% of total Cesarean sections in the country.

• There is a huge initiative to reduce elective deliveries before 39 weeks at hospital, health system and statewide levels. Past and current initiatives have been shown to be create effective change if physicians are held accountable, nurses were empowered and guidelines were enforced. 

•  Why are non-medically indicated (elective/planned) deliveries increasing in frequency?

• advanced planning
• mother lives far away and/or has a history of quick labors
• wants baby delivered by her doctor and no one else
• maternal intolerance to late pregnancy (ie backache, indigestion, insomnia)
• prior bad pregnancy/birth outcome (ie stillbirth)
• and...

• Women's birth perceptions regarding the safety of births at various gestational ages - study found that majority of women think that baby is at term after 37 weeks (ITS NOT!!) and many thought that even after 35 weeks it was OK

• Ultrasound for measuring the baby's weight can be 1-1.5 lbs off

• Inducing early does not lower risk of macrosomia, preeclampsia, or lower stillbirth rates
• Fear with macrosomia is shoulder dystocia - early induction does not reduce risk of shoulder dystocia

• Complications of Non-medically indicated deliveries between 37 and 39 weeks:
• increased NICU admissions
• increased transient tachypnea of the newborn
• increased respiratory distress syndrome
• increased ventilator support
• increased suspected of proven sepsis
• increased newborn feeding problems and other transition issues
• Morbidity rates double for each gestational week earlier than 38 weeks

• Timing of Fetal Brain Development: cortex volume increases by 50% between 34 and 40 weeks gestation, brain volume increases at a rate of 15mL/week between 29 and 40 weeks gestation
• A baby's brain at 35 weeks weights only 2/3 of what it will weigh at 39-40 weeks.

It is just great to be in a room where everyone is discussing things like "episiotomy rates in primips" and so forth. It all made me really excited to be both studying and working for better births.

It feels awesome to be back in academia, and back in the world of birth!

Weekend Movie: Home Birth vs Hospital Debate

Home Birth vs Hospital Birth debate outlined for you in animation:

Where's the Evidence-Based Medicine?

Birth Advocates are always saying that obstetricians shouldn't be doing such-and-such routine procedure anymore, because it is not the best for mother and baby. Doulas always talk with their clients (and anyone who will listen) about how unnecessary and unhelpful episiotomies, continuous electronic fetal monitoring and pushing on your back, just to name a few examples. But we are frustrated time and again by obstetricians (and sometimes midwives) who do them anyway! And we ask, "Why don''t they follow evidence-based medicine?!"

So have you ever wondered what exactly IS the evidence?Well, thanks to the Midwife Next Door, I didn't have to go find all the studies myself!

Complete with references, here are 10 Common Obstetric Procedures Not Supported By Science  (Please note:  many of these procedures are beneficial in specific situations.  It is their routine use without medical indication that is being addressed here) 

 

1.  Inductions/elective c-sections for suspected macrosomia (big baby): The Cochrane Database reports “no evidence of improved outcomes following induction of labour for non-diabetic women who are thought to be carrying large babies. Babies who are very large (macrosomic – over 4500 g) can sometimes have difficult and, occasionally, traumatic births. One suggestion to try to reduce this trauma and to reduce operative births has been to induce labour before the baby grows too big. However, the estimation of the baby’s weight in utero is difficult and not very accurate. Clinical estimations are based on feeling the uterus and measuring the height of the fundus of the uterus, and both are subject to considerable variation. Ultrasound scanning is also not accurate.”

• Cochrane Database of Systematic Reviews.  Induction of labor for suspected fetal macrosomia.  http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD000938/pdf_fs.html
• Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM.  Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines.  Am J Obstet Gynecol.2006 Sep;195(3):657-72. Epub 2006 Apr 21.

2.  Pitocin to speed labor: I am referring here to the routine use of pitocin to speed up a normal labor.  Unfortunately, this happens more frequently than one might think.  Doctors and midwives have lives outside the hospital, and the temptation to speed labor in order to get home sooner is difficult to resist when you’re tired and anxious to get home.  Evidence shows:  “Early amniotomy and high doses of oxytocin may both increase the risk of fetal heart rate anomalies, but are both useful for avoiding prolonged labour.” 

• Verspyck E, Sentilhes L.  Abnormal fetal heart rate patterns associated with different labour managements and intrauterine resuscitation techniques.  J Gynecol Obstet Biol Reprod (Paris).2008 Feb;37 Suppl 1:S56-64. Epub 2008 Jan 9.
• Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E. A guide to effective care in pregnancy and childbirth. 2000et al. New York: Oxford University Press.
• Fraser W, Turcot L, Krauss I, Brisson-Carrol G. Amniotomy for shortening spontaneous labour. The Cochrane Database of Systematic Reviews. 1999;4:CD000015.F.
• Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol. 2009; 200(1):35.e1–6.

3.  Amniotomy to speed labor: The Cochrane Library reports:  “Evidence does not support the routine breaking the waters for women in spontaneous labour.  The aim of breaking the waters (also known as artificial rupture of the membranes, ARM, or amniotomy), is to speed up and strengthen contractions, and thus shorten the length of labour. The membranes are punctured with a crochet-like long-handled hook during a vaginal examination, and the amniotic fluid floods out. Rupturing the membranes is thought to release chemicals and hormones that stimulate contractions. Amniotomy has been standard practice in recent years in many countries around the world. In some centres it is advocated and performed routinely in all women, and in many centres it is used for women whose labours have become prolonged. However, there is little evidence that a shorter labour has benefits for the mother or the baby. There are a number of potential important but rare risks associated with amniotomy, including problems with the umbilical cord or the baby’s heart rate.  The review of studies assessed the use of amniotomy routinely in all labours that started spontaneously. It also assessed the use of amniotomy in labours that started spontaneously but had become prolonged. There were 14 studies identified, involving 4893 women, none of which assessed whether amniotomy increased women’s pain in labour. The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.”

• The Cochrane Library.  Amniotomy for shortening spontaneous labor.  http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD006167/frame.html

4.  Continuous electronic fetal monitoring:  The American Congress of Obstetricians and Gynecologists (2005) recommends that healthy women with no complications may be monitored with intermittent auscultation or with EFM. Intermittent auscultation instead of EFM may safely reduce the cesarean rate.

• American College of Obstetricians and Gynecologists [ACOG]. (2005). ACOG practice bulletin #70: Intrapartum fetal heart rate monitoring. Obstetrics and Gynecology, 106(6), 1453–1460.
• Gourounti, K., & Sandall, J. (2007). Admission cardiotocographyversus intermittent auscultation of  fetal heart rate: Effects on neonatal Apgar score, on the rate of caesarean sections and on the rate of instrumentaldelivery—A systematic review. InternationalJournal of Nursing Studies, 44(6), 1029–1035.

5.  Requirement of “immediate” emergency services for women attempting a VBAC.  The recent NICHD consensus statement speaks:  “Given the low level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.”

• Consensus Development Conference Panel Final Statement on VBAC.  http://consensus.nih.gov/2010/vbacstatement.htm

6.  Routine Episiotomy:  None of the following studies found a benefit to routine episiotomy.  Current recommendations are to use episiotomy when there are  indications of fetal distress and birth does not appear to be imminent.

•  Dannecker, C., Hillemanns, P., Strauss, A., Hasbargen, U., Hepp, H., & Anthuber, C. (2004). Episiotomy and perineal tears presumed to be imminent: Randomized controlled trial.Acta Obstetricia et Gynecologica Scandinavica, 83(4), 364–368.
• Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., & Lohr, K. N. (2005). Outcomes of routine episiotomy: A systematic review. Journal of the American Medical Association, 293(17), 2141–2148.
• Klein, M., Gauthier, R., Robbins, J., Kaczorowski, J., Jorgensen, S., Franco, E., et al. (1994). Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. American Journal of Obstetrics and Gynecology, 171(3), 591–598.

7.  Routine ultrasound to estimate fetal size:“Fetal weight estimation is inaccurate, with poor sensitivity for prediction of fetal compromise.”  (Dudley 2005).  “Prediction of fetal macrosomia remains an inaccurate task even with modern ultrasound equipment” (Henrickson2oo8). ”Considerable error in fetal weight estimations. . .may limit the accuracy and clinical utility of these measurements” (Landon 2000).

• Dudley NJ.  A systematic review of the ultrasound estimation of fetal weight.  Ultrasound Obstet Gynecol. 2005 Jan;25(1):80-9.
• Henrickson T.  The macrosomic fetus: a challenge in current obstetrics.  Acta Obstet Gynecol Scand. 2008;87(2):134-45.
• Landon MB.  Prenatal diagnosis of macrosomia in pregnancy complicated by diabetes mellitus.  J Matern Fetal Med. 2000 Jan-Feb;9(1):52-4.

8.  Immediate cord clamping:  “Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy” (Hutton & Hassan 2007).

• Hutton, E. K., & Hassan, E. S. (2007). Late vs early clamping of the umbilical cord in full-term neonates: Systematic review and meta-analysis of controlled trials. JAMA, 297(11), 1241-1252.

9. Directed (purple) pushing:  The following studies concluded that allowing the mother to push spontaneously (when, how long, and how hard to push are left up to the mother rather than directing her how to push), is superior to directed pushing.  Directed pushing is not recommended as there is greater risk of perineal trauma, fetal distress, and it does not significantly shorten the pushing phase of labor.

• A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194(1), 10–13
• Mayberry, L. J., Wood, S. H., Strange, L. B., Lee, L., Heisler, D. R., & Nielsen-Smith, K. (2000). Second-stage management: Promotion of evidence-based practice and a collaborative approach to patient care. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).
• Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.
• Schaffer, J., Bloom, S., Casey, B., McIntire, D., Nihira, M., & Leveno, K. (2006). A randomized trial of the effects of coached vs. uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function. American Journal of Obstetrics and Gynecology, 192(5), 1692–1696.

10. Supine Pushing:  This, along with routine amniotomy and continuous fetal monitoring, is used in the vast majority of hospital births.  The following studies concluded that supine pushing is not beneficial and can even be harmful to the mother, by working against gravity, decreasing blood pressure which can lead to fetal intolerance of labor, increased episiotomy, increased use of vacuum/forceps, and increased pain for the mother.

• Gupta, J. K., Hofmeyr, G. J., & Smyth, R. (2004). Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD002006.
• Johnson, N., Johnson, V., & Gupta, J. (1991). Maternal positions during labor. Obstetrical and Gynecological Survey, 46(7), 428–434.
• Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.

Vernix Caseosa

Vernix caseosa, also known simply as vernix, is the white waxy-looking substance covering a newborn baby. Many people say it looks kind of like cheese. This substance, made up of the skin oil and dead cells that the baby has shed in the womb, keeps the baby's skin hydrated and protected from immersion in the amniotic fluid. It also aids in the passage through the birth canal.

photo credit

Preterm babies are born with more vernix on their skin than at-term babies. 

Vernix is a wonderful substance that exhibits antioxidant, cleansing,  temperature-regulating and antibacterial properties. It colonizes the skin with microorganisms after birth and prevents peeling of newborn skin. Also, a baby that still has vernix on her hands will find the breast much easier all on her own by using smell.

A study published in The American Journal of Obstetrics and Gynecology in 2004 that found

that the innate immune proteins found in vernix and amniotic fluid are similar to those found in breast milk. As the baby prepares for extrauterine life, pulmonary surfactant (a substance produced by the maturing fetal lungs) increases in the amniotic fluid, resulting in the detachment of vernix from the skin. The vernix mixes with the amniotic fluid and is swallowed by the growing fetus. Given the antimicrobial properties of this mixture, the authors conclude that there is “considerable functional and structural synergism between the prenatal biology of vernix caseosa and the postnatal biology of breast milk.

Rather than bathing the newborn immediately after birth (routine practice in the hospital), moms should rub that wonderful vernix caseosa into baby's skin!

photo credit

Operation Special Delivery

Are you or someone you know in the U.S. military whose partner is about to have a baby? 

Did you know that there is an organization that can provide you with a doula to support you during pregnancy and birth while your partner is away on duty, free of charge?


This organization is called Operation Special Delivery, or OSD, and I am a member.

Operation Special Delivery provides trained volunteer doulas for pregnant women whose husbands or partners have been severely injured or who have lost their lives due to the current war on terror, or who will be deployed at the time that they are due to give birth.  To be eligible for a volunteer doula from OSD an applicant must be unable to afford to hire a doula privately and be without reliable or sufficient labor and birth support.

OSD is run through CAPPA, but you don't have to be a CAPPA-trained doula to volunteer with OSD. If you have completed any doula training you can apply to volunteer with OSD!

Unfortunately I have not yet been called for an OSD birth. Though OSD volunteers across the country have attended over 1000 births, most military soon-to-be-moms do not know anything about the initiative. We need to help spread the word! If you know of anyone who might qualify for a free doula through Operation Special Delivery, please let them know that there are Coordinators in every state in the U.S.

If you are a military mom, apply for volunteer labor doula services here!

If you are a doula who would like to volunteer for OSD, apply here!

Birth Around the World

Rixa at Stand and Deliver recently did a series about pregnancy, birth, and breastfeeding practices around the world. The links to her posts are below - Enjoy!

 

Birth Around the World: Nursing in public around the world 

To start, I'm featuring a feature written by a mother of three. From Lesotho to Uruguay, Germany to Mexico, in front of ambassadors to kings, she has nursed anywhere and everywhere. A Breast With a View: NIP Around the World was originally published at Lactivist Leanings and is reposted with permission. 

Birth Around the World: Peace Corps volunteer in Paraguay

"Chingona" served as a volunteer for the Peace Corps in Paraguay and describes her recollections of the local birth culture. (Reposted from the comments section of the call for submissions).

Birth Around the World: Birth at a midwife clinic in Japan

Sarah of Delightful Pregnancy gave me permission to repost Jamie's birth story. Jamie (who blogs at High Countries) gave birth in Japan to her second baby at her midwife's house. Sarah wrote to me in an email: "Not mentioned in my post are other tidbits from Jamie about her experience, including that during her stay at the midwifes home for several days postpartum, the midwife made her 3 home-made meals every day! Love that personal nurturing...every woman should receive this kind of care. Jamie even sent me some pictures of her meals, which I didn't post because of space, but they looked delicious." 

Birth Around the World: Birth Center in Guadalajara, Mexico

In 2009, Carly gave birth in the Plenitud birth center in Guadalajara, Mexico. The birth center is the first of its kind in Mexico and unlike almost anything found in the US. It's housed in its own wing in a hospital, but is run independently by a team of midwives, childbirth educators, doulas, OBs (José Luis Grefnes), and pediatricians. To read the story of how the birth center came to be, click here (Word document).

Birth Around the World: Origins of Plenitude birth center

This is a long, but fascinating, account of the origins of the Plenitud birth center in Guadalajara, Mexico. It was written by Joni Nichols in 2004 and reposted here with permission. You'll read about how women began leaving their physicians and changing hospitals in favor of Dr. José Luis. You'll see the transformation of a physician as he learns what undisturbed birth really looks and sounds like. You'll gain glimpses into the institutional protocols of Mexican hospitals and understand how truly different the Plenitud birth center is.

Community-Based Doula Programs

I love that a Senator is a supporter of doula programs! 





COMMUNITY-BASED DOULA PROGRAMS WORK!
from the American Public Health Association

Maternal and Child Health
Section Newsletter
Fall 2010

Community-based doula programs, which have made a big splash in the news media and on the federal stage in the past year, improve infant health, strengthen families, and establish supports to ensure ongoing family success – including improved prenatal care, fewer pre-term births, increased breastfeeding rates, increased birth weight, fewer medical interventions, fewer c-section deliveries, more positive birth experiences, increased mother-child interaction, and improved parenting skills.

What is a community-based doula? Across the nation, HealthConnect One (HC One) connects mothers-to-be in under-served communities with other women in their community who are specially trained to provide support during pregnancy, birth and the early months of parenting. We focus on this sensitive period in a family's life, when intervention makes the most difference, creating long-term linkages to networks of support. Our programs succeed because the doulas are of and from the same community as their clients and are able to bridge language and cultural barriers in order to meet health needs. This is the power of peer-to-peer support!

HC One community-based doula programs include five essential components:

1. Employ women who are trusted members of the target community.
2. Extend and intensify the role of doula with families from early pregnancy through the first months postpartum.
3. Collaborate with community stakeholders/institutions and use a diverse team approach.
4. Facilitate experiential learning using popular education techniques and the HC One training curriculum.
5. Value the doulas' work with salary, supervision, and support.


The success of these programs was recognized on the Senate Floor by Sen. Richard J. Durbin (D-IL), a longtime champion of the community-based doula program, during Senate debate of the Health Reform legislation, on Dec. 23, 2009, when he said:

"I am encouraged by the language in Section 5313 of the Patient Protection and Affordable Care Act, Grants to Promote the Community Health Workforce, and want to ensure that the definition of community health worker includes community-based doulas. The Federal Government currently funds community-based doula programs through the Maternal and Child Health Bureau's Special Projects of Regional and National Significance. Expanding the definition of community health workers in the reform bill will give these evidence-based programs greater support to meet the needs of families in under-served communities."


We are very grateful for the support of Senator Durbin and the work of his staff. We are beginning now to advocate with the Department of Health and Human Services as they design health reform to ensure that community-based doula programs will be eligible for the HRSA Grants to Promote the Community Health Workforce. To participate in this effort, click to contact Mac Grambauer or call (773) 728-0271.


With the passage of the Affordable Care Act, and a growing understanding of the need to incorporate community health workers into mainstream health systems, HC One has decided to move our conference to D.C. We are now planning our fifth national conference, Birth, Breastfeeding and Beyond: Sustaining Community-Based Practices, for March 21-23, 2011, to be held at the Arlington Hilton just outside Washington, D.C. This conference is currently scheduled to open with a session on community health workers in health reform and will close with legislative lobbying and congressional meetings. This will be the first time we pair our national conference, which gathers energy over two days and culminates in advocacy training, with our now-annual Lobby Day. We hope you will consider joining us. For more information on the conference, click here or contact Conference Co-coordinator RoiAnn Phillips.



Additional Resources:

Doula becoming a household name (ABC News Chicago, May 2010)


There's No Place Like Home (Center for American Progress - Jan. 5, 2010)


Doulas Support Young Moms (The National Clearinghouse for Families & Youth - December 2009)

How To Avoid a C-section

The Cesarean section is something that many women list as one of their number one fears of birth. Many women dread the possibility of a c-section and want to avoid them at all costs. Of course we all acknowledge that in a true obstetrical emergency the c-section can be a lifesaver, but most women would rather not be part of the growing number of iatrogenic, arguably unnecessary, cesarean sections.

Many, many months ago the Midwife that writes Birth Sense wrote a post on things you can do to avoid your first cesarean section. Shortly after that, the childbirth educator at Banned From Baby Showers wrote a follow-up post listing a few things she would add to the list of things you can do to avoid a c-section. Both posts are included below.

I've also included a link at the bottom to a list of questions you should ask your care provider before choosing one for your prenatal care and birth!

Avoiding the first c-section: Five simple precautions to take

by the Midwife Nextdoor

• It’s major abdominal surgery, and carries increased risks for mother and baby
• It often puts the mother in the position of having repeat c-sections, because she cannot find support for vaginal delivery after a cesarean
• It increases the risk of abnormal implantation of the placenta, which can lead to hemorrhaging or need for hysterectomy
• It increases the risk of unexplained stillbirth in a subsequent child.

No one will argue that c-sections can be lifesaving under certain circumstances.  Placental separation, placenta previa, cord prolapse, and certain abnormal presentations of the baby might cause injury or death to mother and child if it were not for the ability to deliver a baby by cesarean.  I am thankful we have the ability to perform this surgery in a very safe manner.  However, the majority of c-sections are not done for emergent, life-saving reasons.  It’s those c-sections I want to focus on preventing.

Since most women having a primary (first-time) c-section are also having their first baby, I have five simple precautions that have been invaluable in my practice in helping women to avoid a c-section.  I am writing from the perspective of hospital birth, knowing that the majority of women will not choose home birth, although I believe this is the number one way to avoid a c-section:

1.  Stay at home in labor as long as possible, and consider giving birth at home.     Why? 

• Consider an animal in labor.  If you’ve ever observed a cat or dog preparing to give birth, you may have noticed that they seek solitude.  If they are disturbed during labor, they ahve a natural “fight or flight” reflex that slows or halts labor, allowing them to move to a safer location.  While we as human women can intellectually understand the reasons for moving to another location (the hospital) to give birth, our bodies may still respond with a slowing of the labor process.     
• It is understood that pain relieving medications can have a slowing effect on the process of labor.  Epidurals are associated with a higher rate of vacuum, forceps and cesarean births in some studies.  Yet it is difficult for a woman in hard labor to resist the offering of total relief of her pain.  When you are at home, you know the pain medication is not available, and so the mind does not focus on it.  It is easier to work with the contractions when you aren’t constantly thinking of the epidural available to you in only minutes.
• Staying home in the earlier stages of labor helps you to avoid the urge that hospital staff will feel to “speed things along” if your first part of labor takes many hours.  It is common for dilation from zero to four or five centimeters to take many hours, and sometimes more than one day.  If you are in the hospital and you are not yet dilated to four centimeters and having contractions three or four minutes apart, you are not in active labor.  This part of labor is best spent at home.

2.  Hire a doula if you can possibly afford it.  If not, seek out an older woman who has had several children naturally herself, or has been present at several natural births, to be with you at home until you decide to go to the hospital. 

• A woman who is familiar with the process of a normal birth will be invaluable to you in helping you know when it is time to got to the hospital.  She can reassure you that what you are feeling is normal, that you can do it, and that you are stronger than you think.
• Many women are afraid to stay home in labor.  A doula or experienced woman will be aware of the normal process of labor and be able to help you feel calm about laboring at home.

3.  Find a practitioner who does not put arbitrary time limits on how long you can be in labor.  If you are feeling strong, the baby is doing well, and you want to keep going, there should be nor reason to rush to a c-section simply because the labor is taking longer than average.  

4.  Carry on your usual activities as long as possible.  Far too many first-timers make the mistake of doing everything they can to speed labor along.  All too often, their efforts succeed at nothing but making them miserable and exhausted.  Allow labor to unfold in its own time.  Ignore the contractions until you are physically incapable of doing anything else during a contraction as well as in between  contractions.  This is where many women take their labor too seriously.  They think because they have to breathe with a contraction, they are in hard labor.  The actions of the mother between contractions are more indicative of the stage of labor.  During the latter stages of dilation, the woman is usually quiet, tired, and may even fall asleep between contractions.  She does not feel like talking much, or doing anything but resting before the next contraction.   If your labor starts in the day, do what you normally would have been doing if you’d not started labor.  If your labor starts at night, stay in bed and try to sleep, at least between contractions.  If you cannot sleep, at least rest until your normal getting-up time.

5.  Stay off the fetal monitor!  The American Congress of Obstetricians and Gynecologists has published guidelines for intermittent auscultation of the baby, stating that it is just as safe for low-risk pregnancies as continual monitoring.  It has the added benefit of having a lower c-section rate.  This suggests that many c-sections are done for “fetal distress” seen on the monitor tracing, when the baby is actually fine.  Once you allow someone to connect you to the continual monitor, you most likely won’t be off of it for the rest of your labor.  What is intermittent auscultation?  It is not being connected tot he monitor for 20 minutes out of every hour, as many hospitals’ protocols require.  Rather, it is listening to the baby’s heart rate with a hand-held doppler before, during, and after a couple of contractions every 15-30 minutes during the first stage of labor.  A skilled practitioner can determine if the criteria indicating fetal well-being are present, even with a hand-held doppler.

MY List of Things You Can Do to Avoid a C-section
By Donna at Banned from Baby Showers


I've seen a couple of lists lately about the top 5 things a woman can do to avoid a c-section. While I think these lists are good, they differ from my personal list. I thought I'd take the time to write out my list. I guess I'll keep it to a top 5 as well, so as to not overwhelm anyone.

Education for both husband and wife: Some women are able to advocate for themselves in labor, but most are not. Preparation on the front-end is huge. Dad needs to know what is going on and how he can help. He needs to know what's normal and what's not. He needs to know the questions to ask. Having a doula will help with a lot of this. The doula cannot speak for mom, but dad can. I love The Bradley Method for this reason. Both individuals take responsibility for their role in the birth.


Careful Choosing of a Care Provider: Also huge. All the education and preparation in the world won't matter a bit if you have chosen a care provider and/or hospital who is determined that you need to be rescued from your pregnancy, labor and/or birth. This is the step where, if you ignore the red flags popping up during the education/preparation phase, it will bite you in the end. If you are getting information and statistics about your doctor or hospital that make you second-guess their philosophies, don't ignore them. It's never too late to switch care providers. I've had people change in the middle of labor! Typically, care providers like to see you for the last month of your pregnancy. I changed care providers at 33 weeks with my third pregnancy. A bit nerve-racking, but worth it for a great outcome. You will only give birth to this baby one time. Don't take on the "maybe for the next baby" attitude. Do it this time! Do it for thisbaby! If you don't know where to start, ask your out-of-hospital educator or doula for referrals.


Keep Moving - Don't Lay Down and Take It: Remaining in a hospital bed is one of the worst things you can do. They can/will strap a monitor on you and "watch" you from the nurses station. Health care at its finest! Laying around for your labor leaves it all up to your baby to make its way out. Baby needs movement. He is moving around, changing position, trying to find the easiest, most comfortable way out. If mom is moving -- walking, sitting on birth ball, pelvic rocking, rotating hips, even standing -- she's using gravity and movement of the pelvis to help her baby descend and get into a good position. Mom will have less vaginal exams (which often lead to Failure to Progress diagnosis), less time on a monitor (which often leads to a false-positive signaling fetal distress), and usually a more comfortable and faster labor. What's good for mom is usually what's best for baby.


Drug-Free Birth: I'm not just talking epidurals here. I'm talking inductions as well. Pitocin is a drug. Prostaglandins (cervical ripeners) are drugs. Baby may react "fine" to induction drugs, and he may not. There's no way to know how your baby will react. So trust in your body to start labor on its own. Don't be induced. Stadol, Nubain, Demerol -- they are all drugs that go to the baby. There will be physical results to the baby when they are born if they received these drugs -- more sleepiness, "laziness" at the breast, depressed breathing. If mom had educated and prepared herself during the pregnancy, she probably skipped this step. It's a tough thing to hear a mom's birth story and realize that her c-section was a direct result of her own actions -- induction, pain-relieving drugs, trusting her doctor, and not educating themselves on the normal process and what to do and what not to do.A woman is 50% more likely to have a c-section if she is induced, and four times as likely to have a c-section if she has an epidural. These are numbers that we simply cannot ignore.


Remain Low-Risk: If you do not take care of yourself and become high-risk, you give up a lot of power. You need to physically prepare your body to give birth by regularly doing pregnancy exercises. You need to eat the required nutrition to grow a healthy baby. A well-balanced diet with plenty of protein will benefit both mom and baby. The old saying "eating for two" does not mean eating for two adults! Be wise and mindful in your life choices. Practice relaxation every day. This will help with all aspects of your life, even after the baby comes. Keep stress out of your life as much as possible. Choose pre-natal tests wisely. There are so many that are done these days. Find out why it's being done and what they expect to do with the results. You can opt NOT to do them. Some may unnecessarily put you in the high-risk category if you test positive.


Of course, I must mention that every now and then I do have couples that do everything right and still have a c-section. I recently had one of these and it broke my heart. This mom worked so hard. I truly do not know what she could have done differently. You can't feel bad about a c-section that comes out of a situation like that. I feel sad for her. She really wanted a natural, unmedicated birth, and was so prepared. ICAN will be an important part of her healing. 

Please See "In Search of Doctor Right: 11 Questions to Ask"

Weekend Movie: "Infant Mortality: Causes and Prevention"

Reducing Infant Mortality and Improving the Health of Babies

Listen to Obstetricians, Doulas, Neonatologists, Midwives, Psychologists, Pediatricians, and other Physicians explain how our health care system is failing babies and mothers and what we can do about it. 

http://www.reducinginfantmortality.com/

Reducing Infant Mortality from Debby Takikawa on Vimeo.

"Of the most common procedures in the hospital the top 6 come out of maternity care" 

"We're making it more technologically advanced in our country and we're not doing any better, and we're actually getting worse."

"The rate of prematuriy in the US has increased by 36% since the 1980's"

"Where we get into problems is when we decide that other women then those that are clearly indicated to need them, need to have interventions."

"Most maternity practices that are commonly used in the hospital were never designed to be used at the frequency we're seeing them used now..."

"We have become a little bit cavalier..." 

"It is estimated that for every week that a baby is born before term that they double their risk of having problems..." 

"We know that the use of narcotics at any point interferes with breastfeeding"

"Studies now that show that when women have interventions there are deficits in maternal infant attachment and in breastfeeding as well..."

"Among African American women, breastfeeding numbers are the lowest" 

"Midwives and family doctors primarily are the providers that we've seen in the research have the best outcomes." 

"You do not need someone with the skills of a board certified OB/GYN to do a normal vaginal birth"

"The US is the only industrialized country in the world that uses surgeons to attend normal childbirth."

 "And then we look at those other countries and we see that their healthcare costs are lower..."

"If the system is set up properly where you have a there's a safety net where you work in collaboration and have a nice team effort I think it can be a safe process"

 "A collaborative process...will give patients a better opportunity to have better outcomes."

"There are entire states where midwives are unable to find an OB/GYN who is willing to be available should a woman need to go to the hospital and access those services."