A Letter to My Former OB

I have a great story. It's about a couple who educated themselves and broke free of their OB at over 39 weeks.  It was the difference between a vaginal birth and a c-section.  She was planning to give birth at the hospital where we did our rally last year - the worst in the area, as far as I'm concerned.  I wish I could tell you our rally made all these great changes in our community, but all it did was cause more animosity and bitterness - on both sides.  

I was so proud of this woman, not only for hiring a new care provider so late in her pregnancy, but also for writing this letter afterwards:

*This letter is shared with permission by the author.

As you may already be aware, I discontinued my prenatal care with your practice at 39 weeks on September 16, 2010. I am writing this letter to give brief explanation as to why, in the hopes that a better understanding of the situation will positively affect the care of current and future patients.

Until September 16th, I had been a patient with Dr. Udell for 10 years, I trusted her and respected her opinion. So when I found out that I was pregnant on January 10, 2010, it only made sense for me to continue my care with her. However, I was deeply interested in keeping my prenatal care as natural as possible. I am of the belief that my body was designed to create, carry, and deliver a baby with limited outsider involvement. This is not to say that I am completely against medical advancements and screenings, but I do not subscribe to inductions and cesarean sections when one or both lives are not potentially in jeopardy.  I do not agree that there is a sound medical reason for the cesarean rate in America being well over 30%. Being that I had done significant research on pregnancy and birth, I was well aware of possible complications that could happen and the implications carried with each of them. This being said, I made my wishes very clear to Dr. Udell early on in my pregnancy. Dr. Udell was agreeable and said she would do whatever I wanted as long as I kept in mind she was going to do whatever it took to keep both mother and baby safe.

When my husband and I took the tour of the hospital on June 13, 2010, we were unsettled by the policies surrounding labor and delivery at Medical Center of Arlington. The fact that the hospital did not seem to have any “pro-baby” policies, but instead had very rigid policies that were very counter intuitive made us very nervous about our impending delivery. The requirements for continuous fetal monitoring, and baby being taken from the room for 3 – 4 hours following birth, are the two that stand out in my mind at this time. However, the most unsettling issue was the statement, “Most of our births are scheduled inductions or cesareans.” The fact that Monica, our nurse tour guide, gave Dr. Udell a glowing review, was about the only saving grace for the entire tour. 

I felt secure in the fact that Dr. Udell was going to do exactly what she said. It wasn’t until my 30 week ultrasound on July 15, 2010, when my suspicions were confirmed that my son was going to be large, that my confidence began to waver.  I explained to Dr. Udell that both my sister and I had above average birth weights and my husband at the higher end of the average as well. She seemed to accept this response at the time, however getting a baby that was too big seemed to remain a recurring theme for the rest of my visits. It was not until my 37 week appointment, August 30, 2010, that I started to truly doubt Dr. Udell’s word.  I remember the comment that planted the seeds of doubt specifically, “I find that it’s best when somebody goes into labor naturally at 38 weeks, otherwise you run the risk of baby that can be too big.” At the time, I wrote it off and prepared for my 38 week exam.

At my 38 week exam, I expected a vaginal exam that was similar to the two I had already had on April 12, 2010 and August 24, 2010.  Instead, what I got was a very painful experience that resulted in spotting. I fully understand that vaginal exams are painful and can often result in spotting, the statement that Dr. Udell made, “You’re thinning, but not dilated. I tried to push through, but couldn’t,” was what worried me the most.  In hindsight, I should have asked her what she meant immediately. However, I was too shaken up by the whole experience to think about it at the time. When I called and spoke to Amy, her initial response was something along the lines of, “Dr. Udell was just trying to get things started.” Then when I mentioned that I did not want anything like that it became the standard of care.  Several times during the phone call I felt as though I was being made to feel like I wouldn’t know the difference because I was a first time mother. This, combined with my 39 week visit, where I was called out in the waiting room by Dr. Udell, told that she was feeling for the baby’s head, reassured that she woulddo whatever I wanted,  then told me whether I liked it or not to expect the next visit to be rough.  After that visit, I was very confused.  I got the answer that I ultimately wanted – I will do whatever you want- but it was followed by another comment that conflicted with the last.

In the end, the combination of the poor policies at Medical Center of Arlington and thecontradicting statements I got late in my prenatal care with Dr. Udell led me to believe thatthe likelihood that my birth would turn into a Cesarean section very quickly and easily. After my 39 week visit on September 13, 2010, an opportunity presented itself to switch to the Certified Nurse Midwives at Harris Methodist Fort Worth.  After several days of conversations with my husband and the midwives office, I made the decision that their philosophy of limited medical interventions, limited vaginal exams, intermittent monitoring,  clear fluids, and the option of hydrotherapy during labor were exactly what I was wanting. That combined with the fact that Harris Methodist Hospital was a “pro-baby” hospital, and had a wide array of policies that supported the birth that I wanted, including the fact that all testing immediately following birth are performed in room with the parents present.

I am happy to report, that on September 27, 2010 at 0130, I spontaneously went into labor, during which I was allowed to and instructed to freely walk the halls after my water broke,  I was able to have clear liquids, and use the tub for pain management. After being allowed to labor down for an hour and pushing for almost 3.5 hours, at 1552 on September 28, 2010 I vaginally delivered a 10lb 3.9oz baby boy.  While he was posterior until the last hour of second stage labor; we did not experience shoulder dystocia despite his above average birth weight.

While the prenatal care I received at your office was great, medically, I believe that it was the lack of confidence in the natural process and in my intuition in my body’s abilities that finally ended my care with your practice. I do continue to believe that if I had stayed with your practice this delivery would have definitely turned into a c-section and I would be fighting for my VBAC on the next one.

Thank you ,

Tiffany C.

If you were dissatisfied - or satisfied! - with your care provider, I encourage you also to write a note explaining why. Take it a step further and take a few minutes to fill out The Birth Survey.  In my humble opinion, this is how change takes place.  

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"Have it Your Way" - Choosing an Appropriate Care Provider for Your Birth by Rachel Zimmer, CNM

Rachel Zimmer, DNP, CNM

If you want a hamburger, do not go to a vegan restaurant.  If you do choose to go to a vegan restaurant, arguing with the chef about making you a hamburger will do no good. Therefore, do not be surprised if you choose to stay at the vegan restaurant if you do not get a hamburger. You just set yourself up to be disappointed. Sounds silly right? 

If you are an expectant mom who wants an un-medicated birth, or a birth without interventions, this is exactly what you are doing by staying with your current provider (assuming your current provider is not supportive of your birth preferences).  Let me tell you how it goes. Mom says to her OB: I would really like to have freedom of movement during my labor and deliver in a position other than my back.  OB says: “OK, we’ll see how it goes. We want to have a safe delivery.”   So what is the reality here? The reality is mom has done some reading and knows that changing positions during labor and birth can help promote a good position for baby as well as decrease her discomfort…  This OB does not care one way or another what mom does during labor and believes she will be just like 90 percent of the moms in the practice and end up with an epidural and on her back anyways.  Want to hear a response from a provider supportive of your low intervention birth plan? How about: “That sounds like a great plan, intermittent monitoring is part of my routine practice. Let’s talk about ways to help keep this pregnancy low-risk so that you can avoid an induction and meet your birth goals.” So moms I am here to tell you, if you don’t get the answer that you are looking for……FIND ANOTHER PROVIDER!  So why do women stay? These are some answers I hear…

“I’ve seen my OB since my very first pap smear…” ie loyalty. I guarantee that this means nothing to your provider. They will still check out at the end of the day and let one of their partners catch your baby.  I am not saying there is anything wrong with that, no one can work 24/7. The point is, so what? Your provider does not remember any of the pap smears that they have done for you and will not miss doing them in the future. That is assuming they will even notice you are gone, which they probably will not. Most OBs see 150-200 women every week and you are not special to them.

“I need to deliver my baby at such and such hospital because it is closest to my house….or because they have a special postpartum suite that I want to have”. Most first time moms are in labor an average of 18-24 hours. Unless you are planning to deliver in El Paso, you will have time to get there.   Your baby will benefit from the decisions you make surrounding your birth and none of this has anything to do with the size of your postpartum room, color of the walls, or if they serve you lobster after your birth.

“My OB delivered my last baby…..or all the babies in my whole family”… This is great, you know what to expect! If you were happy with your previous birth experience then by all means stay right where you are! If you are looking for something different, go elsewhere! Your OB has not changed their practices recently.

“It will be fine, I have a doula this time who will make sure my birth plan is followed”… I LOVE doulas and I think all 1st time moms, if not all moms should have one! BUT most OBs don’t understand the role of the doula and don’t like them let alone respect them. Nor will they pay any attention to them as they advocate for your birth plan.  It’s like arguing with the vegan chef to make you a burger… pointless. And, why do you want to fight to get what you want???? Birth should be a time where your birth team is supporting you and working with you, not against you. Doulas are truly amazing BUT your birth experience will be a million times better if you also have an OB or midwife who is ALSO on board with your plan!

“My family is not supportive of me seeing a midwife”… No one said you have to switch to a midwife. There are some great OBs out there who will support your plans for birth. It is absolutely true that midwives are generally less interventional than OBs and more supportive of practices that promote un-medicated birth. But, there is something different for everyone! Ask about interviews, many midwives will offer “meet and greet” visits or interviews that are free and are an opportunity for you and your partner to meet them, see that they’re not crazy witch doctors, and find out if they are right for you. If not, keep moving on!

As OB providers, we attend anywhere from 50-300 births per year…sometimes more! You as an expectant mom, will experience childbirth once, twice, or sometimes more in your whole lifetime. This is YOUR experience. Don’t let any of the above reasons stop you! Choose people to be part of your birth team that want to help support your goals. C’mon moms! YOUR BIRTH MATTERS! Your OB provider MIGHT remember if the baby they put onto your chest (hopefully) was a boy or a girl. You will remember your birth experience for the rest of your life…

Rachel grew up in the Dallas area and is a graduate of The University of Texas at Arlington majoring in nursing. Rachel has a special interest in music, sports, and Spanish. Rachel attended Baylor University Louise Herrington School of Nursing beginning 2008 and graduated in 2011 with her Doctor of Nursing Practice (DNP) degree in Nurse-Midwifery. Baylor University was the first school in the United States to offer the DNP/Nurse-Midwifery program. She then received certification through the American Midwifery Certification Board (AMCB) and is an active member of the American College of Nurse-Midwives (ACNM). During her graduate studies she performed clinical rotations at Parkland Health and Hospital System in Dallas and completed her residency here at MacArthur OB/GYN and Baylor Medical Center at Irving. The focus of her graduate project was utilizing social media to provide childbirth education to women.

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The Birth Nazi

I am continuously amazed at the way people twist my words all around.  I have a friend that said that to me the other day.  She said the comments I get on my blog are consistently 50/50 -- some supportive, some thinking I'm void of any compassion whatsoever and have totally lost my marbles.

Most of you don't know me in real life, but suffice it to say, I am very much the same sitting here at the computer as I am in person.  I will tell you what I think, and I'm OK with you telling me what you think, as long as it is kept respectful.  That's why I do not delete comments from my blog, even the ones that more or less call me a Birth Nazi.  You have the right to your opinion, just as I have the right to mine.

Before I go any further, I want to address my use of the word "Nazi" in this post.  I am using this word because I have heard myself referred to in this manner.  The "Soup Nazi" episode of Seinfeld has been laughed about for years, but when used in this manner, it's not funny.  At least I don't think it's funny.  I, personally, am quite offended by the use of the word, especially in reference to myself.  

Let's address a very interesting topic that I read several blog posts and Facebook statuses about this week:  Is it OK, even good, to expect a good birth experience?  According to most of them, no!  At least this is my interpretation:  You shouldn't get your hopes up because you might be let down.

A very fast recap of my birth experiences:  I have had 4 different births.  My first was an epidural birth where I narrowly escaped a c-section.  My second was my most emotional where I definitely experienced that "birth high." My third sucked and was my hardest (no one's fault but my own), and my fourth was the "easiest" but emotionally hard knowing it was my last and my son would never have a brother.  The only birth I cried tears of joy was my second.  The others, I was just mostly glad they were over.  Does that mean they were bad births because I didn't weep with joy?  Of course not.  They were all just different.  I learned very different things from each experience.  I hope those things I learned, I am able to pass on to my students.  Sometimes it's a case of "Do as I say, not as I did!"

There is this idea that Donna Ryan is an unforgiving natural childbirth educator.  If you have an epidural, I will make you feel awful about it.  And a c-section, forget it!  You might-as-well crawl into a hole!

OK, this is what Donna Ryan teaches.  Pay attention, Donna-haters!  I believe that there are some really awful OBs out there that are happiest when they are performing surgery.  They know nothing about natural childbirth and frankly, don't want to know.  They will scare you into an induction or make you beg for an epidural ("haha, let's keep her pit turned high and strap her to a monitor!"), or they will give you an episiotomy so long you will wish you had a c-section.  (Yes, I've heard a nurse say she heard an OB say this.) Are all OBs like this?  Of course not.  They do exist.  I think that the majority of them have not attended natural, intervention-free births enough to know what that looks like, sounds like, or how to help and encourage a couple on this journey.  Most of them will find a way to put you on their turf, where they are comfortable -- in a bed, strapped to a monitor, legs in stirrups, epidural, pitocin, etc.  See past blog post.

There are other resources in your community.  You may have to dig around to find them, but they likely exist.  Resources that support and encourage natural normal birth.  In Fort Worth, Texas there are so many resources available to families -- amazing midwives, in and out of the hospital.  With choices available, you need to use them.  These are the people who will help you have the birth you want -- or in some cases avoid the birth you don't want!  They encourage you to do the opposite of the (bad) OBs;  things like walking, intermittent monitoring, light food and drink throughout labor, choice of pushing positions, and just plain ole encouragement!  What a difference between a nurse (or midwife) saying, "You got this!  You sound wonderful.  Keep making those low, slow sounds," and "Oh, honey, if you think this is hard now, just wait till you're an 8!  Are you sure you don't want an epidural?"  Well, when you put it that way, of course I want an epidural!

I expect my couples to make the appropriate changes if necessary.  Don't ignore the red flags!  Nearly everyone that sits through my class does change their care provider and/or hospital if they see those red flags.  If you ignore them -- now, this does sound harsh, but it's true -- you have no one to blame but yourself for a "bad" birth if you do not make the necessary changes during the pregnancy.  It's not much fun to be left wondering if that c-section really was necessary. 

Your labor should be a wonderful, yet challenging, time in your life.  Your birth team is critical.  I've said that a million times here over the last three years.  Birth is probably the hardest thing you will ever do.  I never paint a rosy picture.  We don't get to pick the way your birth is going to play out, but you will have a very good idea of what normal birth looks like.  We go through lots of variations of normal too.

This is what I teach about an epidural:  You know what normal birth looks like.  You know what to do, what not to do, you have prepared in every way possible (birth team, relaxation, exercise, nutrition, hired a doula), and you know when you are out of the "normal" range, which can mean a lot of different things.  You have the education to know when you are on the path to a c-section.  Many an epidural has saved a mom from a c-section.  We all hope that an epidural is not a part of the birth equation, but sometimes it is, and sometimes it's even a good thing, a necessary intervention that saves a mom from a c-section.

I have never -- not even once -- told a mom that she failed when she had that epidural.  Or a c-section.  I would never do that.  In many instances, I've put myself in their shoes, and have no doubt that I would have made the exact same decision.  Now, I can't say that a mom won't beat herself up over it, but it's not because I made her feel bad. 

Here's the reality:  When people sit through my class and do all the "right" things and their birth does not go as they had hoped (epidural, transfer, c-section), rarely do I have someone seem to dwell on it and have a hard time getting over it.  Most people know that there are things in birth that are not within our control, but you do your part, roll with the punches, understand why those things became necessary in your birth, and move on!  Learn from them.  Don't become a victim of your birth!  I am seeing this all the time.  It's exhausting.  Your birth does not define who you are as a person.  How you deal with things that happen in your life is more important than the actual things that happen. 

There are some midwives that have told me that the reason they refer to my classes is not necessarily because they love The Bradley Method®, but because my couples seem to bounce back easier when things go differently from their original plans.  My couples also know that they can trust them to help them on this road and if they say they need intervention or medication, it's OK to trust them.  Attitude is everything.

I simply want to see women believe in themselves enough to give birth their all.  Sometimes, that may not mean an unmedicated birth.  It might even mean a c-section in the end.  But if you do your part -- not just become a victim of a very broken maternity system -- you will have a good birth!  Does that make me a Birth Nazi?  Then so be it.

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Why the Closest Hospital May NOT be the Best Place to Have Your Baby

When I was pregnant with my first baby, I was asked a number of times during the pregnancy where I was planning to have my baby.  I thought this was about the dumbest question ever (next to "Are you having the drugs?").  Obviously, I was having my baby at the closest hospital.  I'd seen enough TV shows and movies to know that I would have to get there really fast, so it just made sense to pick the closest one.  It wasn't until I was pregnant with my second baby that I discovered the significance of choosing a hospital wisely -- that maybe distance was not the top priority after all.

When people email me or call me about classes, one of my first questions is "Where are you currently planning to having your baby?"  The word "currently" throws them off, but I want them to know upfront that it's not set in stone.  More than 50% of people that take my class do switch their care provider and/or birth place. 

It seems that most people choose their hospital because that is where their OB delivers.  They've been with him/her for years and just loves him!  They honestly believe that their OB will support their decision to have a natural birth.  This post is not about your OB however, but the hospital.

Fact:  You are more likely to have a c-section in a busy hospital than elsewhere.  Define busy?  Well, the hospital I had Daymon averages 30 babies a day.  I'd call that pretty darn busy.  There's a hospital in the Ft. Worth area that touted more than 5000 babies a year on a billboard.  It is normal to think, Oh good, they do this a lot, so they must be really good at it.  Practice make perfect, right?  If you do the math, that average is almost 14 babies a day.  Doesn't sound so bad after the average of 30 a day I just threw out!  This particular hospital's c-section rate is 35-40% -- straight from the horse's mouth.

But does practice make perfect?  Why would a busy hospital have a higher c-section rate?  Let's face it -- it's like the Olive Garden (I worked there for  4 years and love the OG, so this is not a slam on them!) and you cannot sit at a table all night.  We need your table.  The lobby is filling up and your server needs to make money.  We cannot allow you to take up this table any longer!

And so it is with labor.  They simply will not allow you to occupy a room longer than a day.  At 24 hours, or very close to it, your time is up.  The OB can make up a million reasons why you need a c-section (fetal distress, baby too big, water broken for 24 hours, failure to progress, maternal exhaustion, the list goes on and on), but ultimately, your time is up.  You failed to progress on our time frame.

If you've seen Born In The USA, a PBS documentary, you've witnessed the scene where the residents are sitting around a conference room discussing a particular labor where the woman had a c-section because her time limit was up on pushing (my words, not theirs).  Part of that dialogue includes an OB explaining that it goes against their very nature to not do anything in the hospitals.  She explained that in the hospital, nurses and doctors are constantly monitoring and assessing, monitoring and assessing. They will not just sit around and wait on your labor.  You expect a baby out of this, and darn it, we will be the ones to do that for you!

So, we have imposed time limits.  Next, we simply have hospital policies.  Things such as:  continuous electronic fetal monitoring (EFM), routine vaginal exams (usually every 2-4 hours), no walking after water breaks (which you're not doing anyway if you have EFM), and a routine IV.  I talk about all of these things at length in class, so I don't want to spoil all the fun here.  Suffice to say, none of these things are good for your labor.  You are more likely to have a c-section when these policies are in place.  These are red flags!  Run!  The local hospitals that have these policies have 60% c-section rates.  Ultimately, your baby is left to figure labor and birth out on his own.  You will not be moving around, changing positions, rotating hips, or using gravity to assist the baby on his way down and out.  Labor is harder for mom and baby under these conditions.

Another red flag along the lines of policies are no VBACs (Vaginal Birth After Cesarean).  Over 800 US hospitals banned VBACs in the last decade.  ACOGs recent statement said that women should be given a "trial of labor" -- don't get me started! -- but I haven't seen any change as of yet.  A hospital who does VBACs is hopefully following evidence-based maternity care in other areas as well (allowing women to eat and drink in labor, intermittent fetal monitoring, hep-lock instead of IV, and no routine vaginal exams).

Honestly, I believe you are more likely to find this type of care with a midwife than an OB.  The vast majority of OBs simply are not trained in normality.  They are trained in the management of labor and birth.  And make no mistake -- they will manage your birth.  If your hospital does not even have midwives, this is also another red flag.  Midwives bring a different attitude and philosophy of birth to a hospital.  As long as the staff is open and willing to listen to the evidence, midwives can make a huge impact.  If the doctors won't listen to the midwives and let them be midwives, again, run. 

Birth is very political.  I was speaking with a CNM the other day about this topic.  She's only been out of school for about a year.  She said they didn't talk about how political things are in birth while she was in school and she's been shocked by it since working in the field.  It's like I always say, as long as the baby is still inside, you have options. I've had a handful of women change their plans in the middle of labor!  Don't let your birth be a political battlefield.  Fighting with the staff is not an option.  This also is not good for mom or baby and is not how anyone should remember their labor.

No matter how scary you think it may be, changing care providers or hospitals (or even switching to a home birth!) can be the difference between a c-section and a vaginal birth.  If you have an outcome you are not happy with, you will always wonder what would have happened if you had switched to a better birth place.  Like Tim sings, "There's no such thing as what might have been, That's a waste of time, drive you outta' your mind."  (Had to sneak him in there!)

You might have to drive a titch further, but in the long run, you'll only give birth to this baby one time.  Regret is a yucky thing, especially when you had the red flags laid out before you and you chose to tie your blindfold on and hope for the best.  Don't be a victim of bad hospital policies!

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Vaginal Tearing -- What You Should Know For Your Next Birth

When couples show up for the first night of childbirth classes, they want to know 3 things:  1) When do we go to the hospital?  2) What if my water breaks?, and 3) My mom says an episiotomy is better than tearing.  I don't want either.  Of course, I make them sit through 4 weeks of classes before we get to "the good stuff."  By the time we get there, they have a really good foundation.  For this post, we'll concentrate on item number 3.  (Yes, I've been inspired by my good friend, Sarah Clark, aka Mama Birth, with the humorous photos.)

Obviously, the tearing of the vagina as the baby is crowing does not sound enjoyable.  There is a lot of fear surrounding the possibility of this occurring.  The good news and bad news is all rolled into one sentence concerning this fear:  You'll think you tore, even if you didn't.  Some women feel better after learning this and some don't.  The skin typically burns (thus, the "ring of fire") as it stretches over the baby's head.  Once it is stretched, the skin is pretty numb, but before this, you will likely think that you tore.   I thought that with every baby and I've never torn. 

So what can you do to prevent tearing?

I live in the Fort Worth area now, but I lived in Albuquerque before moving here.  NM has almost the lowest  c-section rate in the country.  No coincidence that one in every three births is attended by a midwife.  When I taught Bradley® classes in Albuquerque, I had a number of students participate in a study that the midwives were conducting at UNMH (University of New Mexico Hospital).  The study was trying to find out what method at the time of birth was the most effective at protecting the perineum.  If you chose to participate, you were given one of three envelopes at the time of birth with one of the following options written on it:  1.) Do nothing as the baby emerges; 2.) Use perineal massage; or 3.) Use warm compresses on the perineum as the woman is pushing.

I always like to share a funny story in class from my third -- and hardest -- birth.  As I was pushing, my midwife was applying pressure to the perineum. She asked me if I wanted her to keep doing that -- actually, her exact words were, "Do you feel like your butt is going to blow out?"  Yes, that's exactly how I feel, and yes, please keep doing that!  Emotionally and physically I felt like I had something to push against.  I think women are always surprised at how hard they are pushing.  I have always been a big fan of warm compresses or support of the perineum, much more so than perineal massage.  I must admit, I thought warm compresses would be the big winner of the UNMH study.

I have someone in my current class that recently looked up the study.  Yes, I'm embarrassed to admit that I never looked it up to see the results.  Let me give you a few more details about the study before the exciting results.

Data was collected from 1211 births over a 3 year period.  There were several bits of data collected including maternal age, parity, race, years completed of education, body mass index, weight gain in pregnancy, and use of antepartum perineal massage (during the pregnancy).  Variables included use of pitocin and epidural, length of 2nd stage, style of pushing (coached or self-paced without prolonged breath-holding), position of the baby (compound presentation or posterior), and complications or unexpected birth events.

The most interesting thing about this entire study is the probably the c-section rate:  Of 1211 births, 98%, or 1187 had a spontaneous vaginal birth.  Only 25 of these women -- 2% -- had an operative delivery!  Nine cesareans occurred in late labor, and 16 women had vaginal operative births (3 by forceps and 13 by vacuum).  ONLY 9 CESAREANS IN 1211 BIRTHS WITH THE MIDWIVES! 

Take a minute to recover from that and let's move on.  There are a number of other items I found interesting within the study.  The first one is that 13% of the women that were receiving perineal massage requested that the midwife "stop."  With the other two methods, it was 2.2% (warm compresses) and 1.7% (hands off).  Again, I'm not a fan of perineal massage (I think I've said that a time or two!) and neither were 54 of the 400 women who drew this envelope.

*Less than 40% of the women in each group had an epidural and the use of pitocin was between 32-36%. 

*At least 77% from each group gave birth sitting upright.  About 10% were flat on their backs with stirrups.  Less than 1% in each group gave birth in a squatting, hands and knees, or standing position.

*The vast majority (each group over 77%) did not participate in Valsalva pushing (holding breath excessively long causing capillaries to burst, etc.) and between 30-34% of the mothers delivered the head between contractions.

*Approximately 94% of the babies was born in an occiput anterior position, while about 10% were born with a compound presentation (hand by the baby's head).

Other things that should be noted:  40% of the participants were first-time mothers.  There was a wide range of ethnic diversity as well.

Some interestingly low numbers include:

*92 births with nuchal cord
*42 births had meconium
*34 with extreme fetal heart rate abnormalities
*10 with postpartum hemorrhage
*9 with shoulder dystocia (.7%)  -- Side note -- I hear this all the time for a reason for c-section or induction.  True shoulder dystocia is rare!
*2 with manual removal of placenta

The Results:

*Only 10 episiotomies were performed, due to severe fetal heart rate abnormalities.

*23% off all women experienced no trauma at all to the genital tract, regardless of which envelope they drew.

*20% had major trauma, defined as 2nd, 3rd, or 4th degree tearing.

*57% had minor trauma, defined as 1st degree tearing, affecting the external genitalia, or the outer vagina.

Other studies have defined an intact genital tract as "no trauma, or minor and unsutured trauma."  If this definition was applied to this study, the midwives' rate of "intact" would be a whopping 73%!  In all fairness, too, these 12 midwives who were involved in this study already had a high degree of expertise at minimizing trauma in vaginal birth.  I met with a couple of them when I was teaching in Albuquerque and was extremely impressed.  In fact, the obstetric culture at UNM teaching hospital is patient, calm and controlled, and emphasizes slow expulsion of the baby. 

Ultimately, there were 2 care measures that were associated with a lower risk of genital tract trauma.  1.) "A sitting position allows the mother greater comfort and autonomy at delivery.  It allows face-to-face proximity and direct visual contact between the mother and midwife."  2.) "Delivery of the head between contractions requires communication, synchrony, and shared responsibility for a slow and gentle expulsion of the infant."  


So ladies, be patient at the time of birth.  Ban the cheerleaders!  Don't let anyone count to 10 for you like they do in the movies.  Just let the baby come.

As for the 3 methods?  It's really up to the woman and her midwife.  The results were all similar in findings.  If you'd like to read more about the study, you can find it here.

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The OB at 38 weeks

I am not out to make anyone a bad guy here.  OK, maybe a little.  I have worked as a Natural Childbirth Educator for long enough to make some generalities and feel pretty comfortable with saying them.  I am fully aware that there are exceptions to what I am about to say, but they are so few and far between.  I hope what I am about to say will be listened to and not just heard.

There are two types of maternity care:  the Medical Model and the Midwifery Model.  Briefly, the Medical Model perceives pregnancy, labor, and birth as a disaster waiting to happen;  something a woman needs to be rescued from.  Medicine improves upon the "natural" process.  Labor is all about the cervix and birth canal, always looking for something to go wrong.

The Midwifery Model of Care, on the other hand, trusts a woman's body to grow her baby, start labor at the appropriate time, and labor without time constraints.  A midwife takes into consideration, not just the cervix and birth canal, but the entire woman and her environment.  Birth is as much mental as it is physical.  Medical doctors almost always ignore this fact, usually because the hormones are not working properly when a woman has an epidural.  They just don't see natural normal birth often enough to know what to do -- or more appropriately, what not to do! 

So when couples come to take my Bradley class, I worry about those that have an OB.  And rightfully so.  Most of them will see the light and switch to a midwife, but sometimes the couple is fed so many lines by their OB and hospital nurses, they don't switch, believing their doctor is different. 

From the L&D nurses:

"We have birth balls, showers, tubs, squat bars, dim lights -- everything you want for your natural birth."  (In labor, these things are nowhere to be found.  Only one room has a tub that works, no one can find the squat bar, lights are bright so the doctor can see -- it's all about him, right?  The atmosphere is not what was promised.)


Some of my favorite lines from OBs are:

"As long as everything is going fine, you can do whatever you want."


"As long as your water isn't broken, you can walk around as much as you want."


"We can do intermittent monitoring as long as baby is handling labor okay."

"We don't need to talk about induction unless you are more than a week past your due date."  (No one thinks they will be 'overdue' when they are pregnant.  No one.  They believe this won't apply to them.)


Don't these sound great?  I've got a great OB, right?  Did you hear the clause in each statement?  Remember, an OB is trained to look for things to go wrong.  Statements like these pacify the pregnant woman at monthly/weekly appointments because it seems like she is hearing what she wants to hear.  The problem is, an OB can make up all kinds of reasons to keep you on a monitor in labor, or restrict food and water, or induce labor for a million different reasons.  Seeing this as often as I do, a local doula called this the "Bait and Switch."

Something happens at 38 weeks with an OB, where all-of-a-sudden pregnancy becomes very dangerous.  The placenta starts to deteriorate, amniotic fluid levels rapidly drop, blood pressure is through the roof, and vaginal exams must be done to ensure that your body knows what to do.  Oh yeah, and your baby is getting much too big to fit through your pelvis.  We either need to look at inducing right away or just scheduling a c-section to save you from having to go through the trials of labor.  You'll probably just end up with surgery anyway.

I wish I was making this stuff up.  I'm not.  I see it all the time.  If you stay with an OB who makes "reassuring" statements with a clause and you ignore these red flags, and then you have a c-section, you will always wonder if you really "needed" surgery.  If you change care, even at 39 weeks, to a midwife who trusts birth and encourages you along the way, and then end up with surgery, then you probably did need it. 

I recently had a mom who changed care from an OB at 39.3 weeks to a group of CNMs.  Her baby was over 10 pounds and she pushed for nearly 4 hours.  She had back labor most of her labor and did have an epidural.  Had she stayed with the OB, I am 100% certain she would have had surgery.  Her previous hospital has a 60% c-section rate and they would never have allowed her to push that long.  Sure, she did not have an unmedicated birth, but the switch saved her from surgery.  A good move.

Be on the lookout for these statements from your OB.  The end of pregnancy is so exciting.  You are about to meet your baby for the first time!  A good care provider will reassure you that your baby and body know just when the time is right for labor to begin.  Your care provider should fill you with reassurance, not fear.  And that, really, is the difference between a good care provider and a bad one.

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Want an Unmedicated Birth -- Or Even Just a Vaginal Birth? Hire a Midwife and a Doula

I have recently had a bad run -- lots of cesareans and epidural births.  I've thought about them a lot over the last several days and weeks, and there are some significant numbers that I want to share.

Up to now, my stats have been about 79% of people that take my class give birth without medication.  14% have a cesarean, and about 7% have an epidural, the majority of the time to avoid a c-section.

These last few months have been the worst statistics I've had in over seven years of teaching.  It's hard for me to put this out there, but I've gone back about 4 months to include a couple of classes and several DVD couples.  There are some interesting things to note, and I hope this improves future outcomes.

In the last 4 months, I've had 23 couples give birth.
10 had unmedicated vaginal births.
5 had epidurals (but still had a vaginal birth).
8 had c-sections. 

Let's break this down, starting with the 10 unmedicated vaginal births.  (This is what everyone was shooting for.)
6 hired midwives (mix of CNMs and CPMs).
4 hired an OB.
6 hired a doula.

Of the 5 epidural births:
3 had a midwife.
2 had an OB.    
Only one of these women hired a doula.  
It should be noted that a few of these women started with OBs and switched to midwives.   Length of labor and/or pushing would have certainly resulted in c-sections had they stayed with their original OBs and hospitals.
 

Of the 8 c-sections:
2 had a midwife.
6 had an OB.
Only 2 of these women hired a doula, and only one had her doula present.
Obviously, these c-sections happened for a variety of reasons, some valid, some not-so-much.  Can't ignore that 80% were with OBs.  Honestly question if they would have happened with a midwife.

Summary:  If you want an unmedicated birth, your birth team is crucial.  All the education in the world won't matter if you have a doctor who is determined that you or your baby "need" a c-section.  As for a doula, the statistics speak for themselves.  A woman who has the support of another woman in labor will almost always have a better outcome, or at least feel better about doing all that she could do to prevent having an epidural or a c-section. 

If you are birthing in a hospital, you need to hire a midwife instead of an OB and you need a doula by your side.  End of story.

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Centering

Centering is coming to Fort Worth!  No, it's not a yoga pose.   It is actually a method of maternity care.  I hope this post explains the Centering program and you will be as excited as I am.

Centering is typically done by midwives -- at least I haven't heard of any OBs doing it.  In very simple terms, it's group prenatal care.  Often, "patients" have the option of doing their prenatal appointments in this manner where it is offered.  If a woman chooses to "center" she'll be put in a group with other women who are due about the same time or month, depending on the size of the practice. 

The women arrive at the same time at the clinic, birth center, or office.  They will each weigh themselves, as well chart their own blood pressure and do their own "pee stick."  This puts their health care directly in their own hands.  Then, each will have a couple of minutes with the midwife to measure fundal height and listen to the baby. The midwife will typically ask if she has anything she wants to talk about that is too personal for the group.  If not, she goes to the circle and waits for the other women to join the group.

The group usually sits in a circle.  It is not a classroom by any means!  There will usually be a topic, such as the size of the baby, typical pregnancy symptoms, etc.  Your midwife is sitting eye to eye with the group.  This puts her on a different level with her clients.  She has the opportunity to get to know these women in a very different setting than a  provider-patient setting.

Because less than 1/4 of pregnant women take a childbirth class, this also meets a need -- whether they know it or not! -- to become educated on the process of labor and birth.  This is very empowering to have this knowledge.  Many women find that the fears they previously felt about giving birth are replaced with excitement and anticipation.

The group cheers each other on.  They become a resource and support for one another.  The midwife may not know the best place to buy a nursing bra, but I bet someone in the group does!

The appointments run about an hour in length.  94% of women who have centered say they would do it again.  From a business standpoint, this is such a smart model.  It saves the midwife hours in her day.  Centering groups are usually made up of 8-12 women.  From the consumer standpoint, women are not sitting in a waiting room and then only getting their provider's attention for a few minutes each month. 

The UNT Midwives are beginning Centering in August.  There are midwives practicing Centering all over the country, with great success.  I expect we will start seeing more and more of this trend.  It's a good thing and I am grateful it has found its way to Fort Worth!

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