"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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How to Have a Natural Birth

Recently, I had a conversation with someone about wanting a natural birth and how hard it is to get that without a fight on your hands.  She asked the question, "Why can't you just say 'I don't want the drugs.'?"  It was an interesting question, really.  Why is it so difficult in American obstetrics to have a natural birth?

I think there are many factors here.  Fear is at the top of the list.  Fear of pain, fear of lawsuits, fear of the time commitment.  I think loss of control is also a factor.  We like to control everything.

And as much as we glorify the "superhero," we hate her when it comes to birth.  We want her to fail.  Her natural birth makes me feel bad about my medicated birth.  It's easier to believe that no one can do it than it is to believe I couldn't do it. 

The media is at fault here too, but it's largely because they feed the fear.  I have a mom right now doing Birth Boot Camp online classes that was thinking about transferring to a natural-birth-friendly hospital but it's an hour away.  We get this idea from all the sitcoms that the minute labor begins - or water breaks - the baby is going to fall out.  Women and men are fearful of a birth place that is more than a few minutes away. In reality, they could probably cross state lines with plenty of time to kill!

And then there's the noise factor that I've been talking about for years - the majority of the people at the hospital want you to have the drugs because of the noises you might be making, be it moaning, grunting, or even screaming.  Those noises make people uncomfortable when they are not used to hearing them. Personally, I like to hear the noises a woman is making in labor because you can tell how well she is handling things. Those noises let her support team know what she needs. Who needs a vaginal exam?!  Just listen to her!

In addition to making the laboring woman be quiet, the control is now shifted to the medical staff.  They do not have to wait for your labor to progress.  Like magic, they can force your uterus to contract whenever they want it to with pitocin.  What power!  The laboring woman is powerless at this point.

Frankly, people just don't understand why someone would want an unmedicated birth.  I was that way with my first baby.  I couldn't believe it when people would ask me if I was having the drugs.  Of course I'm having the drugs!  I get it.  I've heard a million different reasons for wanting a drug-free birth over the years, but in the end, a couple has to be willing to do what it takes.

HOW TO INCREASE YOUR CHANCES OF GETTING A NATURAL BIRTH

1.  Believe that your body and baby will work together.

2.  Choose a care provider very carefully.  They may make or break this experience.  If you have chosen wisely and you do have a cesarean or are encouraged to induce, you will not second guess them EVER.

3.  Take a thorough childbirth class.  As the founder of Birth Boot Camp®, I believe our 10-week curriculum is the best program out there, preparing both partners for an empowering birth experience. If there is not an instructor in your area, take the online course. After you have an amazing birth, become an instructor!

4.  Communicate with your partner.  This is an opportunity to grow closer together.  It's not every day you bring a baby into this world.

5.  Hire a doula.  She will help you achieve a drug-free birth.

6.  Know your options.  If your chosen birth place is not natural-birth-friendly, RUN.  If you take the attitude of  "I'll stay with my OB this time and switch to a midwife next time," they may set you on a path of cesareans that will make it harder next time around.

7.  Practice relaxation on a regular basis.  Eat well.  Stay fit.  If you become high-risk because you eat junk food and have a sedentary lifestyle, your plans for an intervention-free birth may go out the window.

8.  Surround yourself with people that believe in YOU!

9.  Don't be afraid to ask the hard questions and read between the lines with your care provider.  If you feel like you are jumping over red flags, you probably are.  As long as the baby is still inside of you, you have options.  Regardless of what you may have heard, it's never too late to switch care providers.

10. Read positive birth stories.  Read - and believe - affirmations that you can do this.  You are strong and capable.  Embrace this experience.  It is yours and yours alone.

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POOP

That's right, you read the title right. Let's talk about poop for a few minutes. Did you know that you might poop when you push your baby out? Most people never think about this, and others are completely obsessed with the possibility of this happening. I've even had one of my couples have a c-section over this topic. She made it to a 7, everything was going great, and she opted for a c-section. She just could never let go of the fear.

Approximately 30% of women poop when they push their baby out. There is a trend I'm starting to see pop up of offering/pushing enemas to women when they are in labor. I got an email from a friend this week and here is a portion of it: "They gave her an enema before starting pitocin because the doctor didn't want to be pooped on. Yes, he personally told the mom this."  Gotta love the OB that does things for his comfort and not the mom's. 

At any rate, the body, typically at the beginning of labor, will naturally get rid of waste.  She'll usually have loose bowels, sometimes even diarrhea.  She should eat and drink throughout her labor though, which means more waste.  And that's ok!  So, along with all the questions I've given you over the years to ask your care provider, here's another one:

"How do you feel about poop?"

If you are super concerned with pooping when you are pushing your baby out, do the enema.  If it makes you feel more confident, by all means.  Know that I am not advocating the enema whatsoever!  In fact, I'd really just like to see women comfortable with their bodies and not afraid to eat and possibly poop in labor.  But, like all interventions, I believe there is a time and place. 

Let's go back to the mom who just can't let it go, no matter how much her husband and care provider tells her it's ok, it's normal.  They don't care if she poops.  There are some other issues associated with this fear.  At the top of this list is sexual abuse.  Pooping during pushing is not about vanity.  I strongly suggest counseling in this situation.  To most, this topic is funny and only slightly embarrassing.  To others, it's completely paralyzing.  

Last I read, approximately 1 in 4 women have been sexually abused or molested.  Poop has the potential to be a big issue for many women -- even one million per year -- about to give birth.  I can't help but wonder about the women who elect to have a c-section and never experience any labor.  It's a question that simply cannot be asked, and yet, I can't help but wonder.  Is sexual abuse a part of their history?  Labor and birth is an extremely vulnerable time in a woman's life.  She is exposed in every way possible.  It's a lot for a woman who has not been abused or molested to come to grips with.  But for a woman who has endured abuse or molestation, vaginal birth  may be much too overwhelming.  

If you have seen Orgasmic Birth, they address sexual abuse and birth in a very tender story.  The woman is terrified to surrender to the power of her birth.  When she does, she comes out stronger on the other side.  If you have not seen the movie, check it out.  It's about much more than just "orgasmic" birth!

What started out as a funny post, took a very serious turn.  You know me, I can't end like this.  So, in class, the mamas planning a water birth always want to know about pooping in the water.  (My water birth is the only birth I didn't poop!)  I tell them that if they are really worried about it, if the dad will just throw a bunch of tootsie rolls in the water at the time of birth, she'll never know if she pooped or not.  (I've never had anyone actually do it, but it would be a very funny trick to play on a midwife.)

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Pushed into Supine Pushing Positions

When I was thinking about getting pregnant with my second baby, I visited my OB, Dr. Brian Wolsey, that "delivered" my first baby.  I had been gathering lots of information and knew I would do things differently with the second baby.  One of the questions I asked him was how he felt about me pushing in a different position besides flat on my back.  He got down on the floor (in his very nice clothes), and on one knee, contorted his body, and while looking and reaching up, said, "Well, it's kind of hard to catch a baby in this position."  He was more concerned with his comfort than mine when it came to pushing my baby out.

I never returned to his office.  

This is an important question to ask your care provider. The answer should be a respectful "Let's see how you feel when it comes time to push.  The benefits to using gravity and an upright position are ...    An example of when you might not want to use gravity is ..."

I've had a number of people return to class saying things like, "My doctor said I can hang from the rafters for all he cares" or "I can squat on the floor like I'm in the jungle!"  They seem happy with these responses, but in reality, your doctor is making fun of you.  He thinks its undignified and foolish.

If I am an OB -- or even a Certified Nurse Midwife -- working in a hospital, chances are, approximately 90% of the births I attend is with an epidural.  The mom is mostly on her back.  Like it or not, this is how I get used to catching babies.  This is what I am comfortable with.  Even to have a mom on hands and knees, well, this looks different to me, and I am not as comfortable with this situation.  I will find a way to get this mom on her back.  I will give her lots of excuses that sound really good, such as, "The baby is caught on the pubic bone and I need you to lean back."

If a woman is left alone to choose her birthing position, very often she will use gravity in some form or another.  Rarely will she lay flat on her back to push her baby out.  Squatting, for example, is known to widen the pelvis up to 30%.  Many OBs will not suggest a mom get up and squat, but instead, will cut an episiotomy to get the baby out quicker.  Or worse, perform a c-section because her hips were "too small."

I simply wanted to let women know that what position you birth your baby in is your choice.  This seems common sense, right?  I routinely hear women talk about their doctor wanting them in a certain position when it comes time to push.  Pushing while flat on her back can cause more problems that it fixes.  The only person benefiting from this position is the OB. 

When you ask your care provider this important question, listen for silly answers that are really meant to make fun of you.  Listen for responses that put his/her comfort above your own.  The good answers are the ones that inform and respect you and your comfort.  Follow what your body is telling you to do.  Don't let them push you around when it comes to pushing your baby out!  

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Sounding Your Labor: Are you In or Out of Control?

If you are a "birth junkie" you've probably watched dozens of birth videos.  Or maybe you are pregnant for the first time and are pretty freaked out to watch them!  So many of the birth videos out there seem to play serene music as the baby is born, dubbing over the sounds the mother may be making.  The viewer is left with this impression that the birthing woman peacefully -- and quietly -- pushed her baby out.

When I was pregnant with my second baby -- first unmedicated birth though -- my friend Janet told me that "sounding" her labor helped her so much.  I don't know that we spent much time talking about it, but I must have remembered her telling me that because I was definitely "sounding" out that labor!  At one point, my midwife could tell that this was helping me so much and she calmly said, "Donna, you sound fabulous.  Keep doing exactly what you are doing."  This was huge for me because in my head I thought I sounded like a lunatic, and yet, I didn't want to stop doing it because it was helping me stay calm and focused and relaxed.

As the baby descended and was coming through the birth canal, I got a little panicked and wild.  I screamed "IT BURNS!" when the baby's head crowned.  The whole scene was followed by lots of euphoric crying, "I did it!  You're here!"  Needless to say, my first birth video looks nothing like the pretty ones I show in class!

Despite my midwife's words, I spent years feeling bad for sounding out my labor and especially for screaming the way I did when her head was crowning.  I felt that I should have been quiet and turned inward, welcoming my baby into a quiet dark room -- just like the women in the videos.

To this day, that birth video is still the most emotional to watch and listen to.  I just love it.  I love the way I sound when I hold my baby skin to skin, fresh from my womb.  I went from the most intense and painful thing I'd ever experienced to absolute euphoria and joy!  And I can hear every bit of it!

My 3rd baby, if you've read my birth stories, was the hardest of them all, simply because I didn't prepare on any level.  I was a know-it-all.  I hollered so loud when that baby came through, I scared the mailman right off our porch!  I yelled because it hurt, but looking back on it 10 years later, I think it's also because I was so angry at myself for letting myself  begin labor without even preparing for it.  I hate listening to that video.  I sound awful.  It is so obvious that I was struggling.  There was no euphoric "You're here!" when the baby was out.  I was just so unbelievably grateful that it was over.  Completely exhausted.

By the 4th baby, I was fairly comfortable with the fact that I am a what-I-call "vocal birther".  I had been teaching childbirth classes for a couple of years by the time I had her and talked about this in class.  I had attended a handful of births as well and learned quite a bit about this "sounding".

Several days ago, I asked on my Facebook page if anyone had any topics they'd like me to write about, and one of the midwives I work a lot with, Melody, asked me to write on this topic of sounding out your labor:  

"... Making noise and being "open" in labor! So many mommies think they didn't "birth well" because they thought they were loud or " out of control" when they are comparing with birth videos etc. It's not uncommon for women to apologize for how they responded or the noise they made. I would love to see a post on this topic!"

I could relate to this sentiment because I felt the same way with two of my babies.  The truth is actually quite the opposite.  I spend 12 weeks teaching relaxation - physical, mental, and emotional.  Sounding is so closely tied to physical relaxation.  When a dad calls me when they are in labor, if I can hear the laboring woman, I can tell how well she is handling contractions.  How?

OK, from your computer, do this with me.  Reading this on your phone in Walmart at the check-out?  You might wait till you are in the car!

Take a regular breath and let out a high-pitched "aaahhh".  This is the sound that many women make on TV when they are in labor.  It's high-pitched and obvious that she is in pain.  In fact, we are all in pain from listening to her!

Now take a good deep breath from the abdomen, open your throat, and let out a low-pitched "aaahhh".  Let your shoulders drop.  As the laboring woman peeks in her contractions, this sound will like get louder and longer, and hopefully lower.  The lower the sound, the more open her throat, the more relaxed and deep her breathing, the more her shoulders and jaw drop.  Without the noise, she simply cannot be this relaxed.

A person can lay perfectly still and quiet and be completely tense.  Noise is good.  It's good for mom.  It's good for baby.  If mom is taking these good, deep, long breaths during contractions, baby is getting good oxygen.  If she is chest-breathing and letting out short, high-pitched sounds, baby is not getting good oxygen and mom is tensing up in the shoulders, the jaw, and the abdomen, and therefore the uterus.  Sounding is even good for your midwife!  It helps her know how you are doing and perhaps how she can help you.  It also helps her know where you are in your labor.  By the 3rd baby, David knew exactly when that baby was on it's way out by the sounds I was making!

Think O-P-E-N and L-O-W sounds.  Should the mom sounding out labor feel bad about the sounds she's making?  No way!  Giving birth is, in the words of my last midwife, Barb Pepper, "animalistic".  She'd tell me to make some noise, let it out!  It's normal, it's healthy, and it's expected.

So what about those birth videos?  What should we do about them?  They are great visually, but they do women a disservice by editing the audio.  Hearing birth is equally important.  This is one reason I strongly suggest my students watch Orgasmic Birth.  We get to hear birth and lots of it!  It's real.  Don't be afraid of the name, if you haven't seen it.  It's a fabulous film on many levels, but for the purpose of this post, we're just focusing on the sounds of a laboring woman.  Dads should watch this movie too.  Many men are uncomfortable with the sounds their wife might make in labor, and it is so important that they become acquainted with these sounds and welcome them.  Recognize the high and low pitches and help her stay low and open. 

Most importantly, this is your labor.  No one will ever give birth exactly like you.  You can't do it wrong.  You may not be a "vocal birther" like me.  You may be very quiet and do all your relaxing through your breath.  That is OK too.  Find your ritual and run with it.  If sounding is a part of that ritual that helps your through labor and birth, great!  "Sound" loud and proud, Mama!

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The Mother-Friendly What?

When I got together with a couple other ladies from my community to start a chapter of BirthNetwork National a year-and-a-half ago, we only had an inkling of what it would involve.  We have grown to be the largest chapter in the country with nearly 100 members and have accomplished some amazing things in our community.  If you are in the Fort Worth area, I would like to invite you to be a part of this growing movement.

Our chapter is the Tarrant County Birth Network.  This spring, we published a book of birth stories called The Birth Next Door, which is available for sale, benefiting TCBN .  We hold free monthly meetings on a variety of topics based on the MFCI (we'll get to that in a minute).  Visit our website for topics and location.

We are currently in the process of gearing up for the 2nd year of BOLD Fort Worth 2011, consisting of a play, Birth, by Karen Brody and a Birth & Family Expo.  Mark your calendar for September 23-24.  If you have a Mother-Friendly business you'd like to advertise in TCBN's Resource Guide (distribution 10,000), there is still time!  Here is a link that will tell you everything you need to know.  Deadline is August 1st.

The foundation of the Birth Network is solid and this is really what I wanted to discuss in this post.  We throw a lot of terms around and people tend to glaze over.  For example, the 10 Steps of the Mother-Friendly Childbirth Initiative (MFCI) written by CIMS, or the Coalition for Improving Maternity Services, is the basis of everything we do, nationally and locally.  The 10 Steps are evidence-based and have shown that if followed, maternity care will be improved for the entire family.  I encourage you to read through these steps and check out the CIMS website.  There are useful downloads there as well, including topics such as breastfeeding, induction, and risks of cesarean section. 

Many people are aware of, or at least have heard of, the Baby-Friendly Hospital Initiative, written by WHO-UNICEF.  I have discovered most people don't really know what that means, but it sounds good, doesn't it?  There are 10 steps to being Baby-Friendly, and basically, it has to do with breastfeeding support -- not separating mom and baby, not offering bottles or pacifiers, and all around encouragement of breastfeeding.

The Baby-Friendly Hospital Initiative is a part of something much bigger -- it is the 10th Step to the Mother-Friendly Childbirth Initiative.  I want to very briefly, in my own words, tell you what these steps are:

To be Mother-Friendly, a birth place must carry out these philosophical principles:

1.  Anyone can be with the mother at all times if she so chooses, including a doula.  She should have access to professional midwifery care.  (Hospitals who do not employ midwives are not Mother-Friendly.)


2.  Statistics are easy to come by.


3.  Is respectful of differing cultures, customs, and religions. 


4.  Mom has the freedom to move as she wishes and is not forced to be in any position she does not choose.


5.  If transfer of care becomes necessary, everyone is treated with respect and the mother receives respectful care throughout the process.


6.  Routine interventions are not used unless medically indicated.  Key statistics include:  induction rate of 10% or less, episiotomy rate of 20% or less with a goal of less than 5%, c-section rate of 10% or less and 15% or less in high-risk hospitals, VBAC rate of 60% or more with a goal of more than 75%.


7.  Staff is educated in non-drug methods of helping the laboring woman and does not encourage the use of drugs.


8.  Staff encourages family members to hold, touch, and care for their baby, including premature or sick infants.


9.  Discourages non-religious circumcision.


10.  Baby-Friendly Hospital Initiative -- Breastfeed, breastfeed, breastfeed!


I hope you will press your care provider and birth places on these steps and if they are following them.  The more we talk about Mother-Friendly Maternity care, the more common it will become.


If you are interested in finding a local chapter of BirthNetwork National, visit their website.  There may be one near you.  If not, start one! 

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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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The Doula -- or "Dude-la" -- Post

Some of you might remember reading about one of my couples that accidentally gave birth at home last year.    The plan was to have their doula - who was at the birth - have a doula-in-training shadow her at this upcoming hospital birth.  Frank, the father-to-be, referred to the student doula as "the dude-la" -- she was to be his doula!  His "dude-la" was actually at another birth when Nancy gave birth at home, much to Frank's dismay.  I wish I could take credit for coining this term, but I have to give credit where credit is due.  It makes me laugh every time I think of it.

I always have a couple of doulas that I refer my students to, usually for a bargain price, as my students are usually very prepared for labor and birth.  A bit less work for her -- certainly less educating on her part.  I am very picky about who those doulas are.  Like lactation consultants, doulas are not all created equal.  I knew of a doula in Albuquerque that had a 90% epidural rate! Certainly not the doula I wanted for my students!

The first question I always ask is why she wants to be or why she became a doula.  I am amazed at how many women become doulas because of a personal traumatic birth experience.  They want to help other women not go through what they went through.  That is totally respectable, but not necessarily who I want at my couple's births.  She will often be defensive and looking for things to go wrong.  Her "bad" birth experience led her down this road and she is, in my opinion, trying to right a wrong.

I have been writing about the birth team a lot lately -- doulas, midwives, and OBs.  I've decided that it is 50% of the "requirement" to having a happy birth experience.  Education is great, an absolute must, but if you are surrounded by people who do not believe in your ability to birth your baby without medication or intervention, you likely will not be doing so, no matter how prepared you and your partner are.

If I were looking for a doula, these are things I would want to know:


Has your doula given birth?  (It is hard for someone who has not gone through labor and birth to understand the thoughts that go through a woman's head during labor.)


Where did she give birth and why did she choose that location? (If you are planning a homebirth and you are hiring a doula who has only given birth in a hospital, you might ask her why she chose to not birth at home.  She may, deep down, be fearful of birth.  Or maybe it was an issue with insurance.  Or maybe her husband was too fearful.  Find out why she birthed where she did.)

Did she have medication or intervention?  (When the going got tough, how did she handle contractions?  What seems to be her general attitude about medications and interventions in labor?  Does she really believe that these things are usually not needed?  On the flip side, is she willing to use intervention if required?  Does she recognize that sometimes a woman may need intervention or medication?)


Has she ever been "overdue" and how did she deal with that?  (A woman will naturally doubt her body's ability to start labor on its own towards the end of pregnancy.  Having an encouraging doula by her side, reminding her that her baby and body knows just when the time is right, is crucial.  The "overdue" woman is bombarded with questions of when she is going to finally induce, and her doula will be her rock in refusing induction.)


How long were her labors?  (There is an emotional tug-of-war here.  Most women hope for a short labor, but that is often much harder, physically, than a longer one.  A long labor is not only physically challenging, but very mentally difficult.  It's just interesting to hear her perspective on length of labor.)

What is her c-section rate?  Epidural rate?  (Some things are obviously out of her control, but if her rates are higher than you think they should be, she may not know how to really help a laboring woman - which may be a physical or mental issue.  If she doesn't know her rate, ask her to figure it out.  You'll be doing her a favor, trust me.  She should know this information if she's never figured it out.  If her rates are high, she can evaluate what she can/should do differently, and if they are low, it will help her in talking to potential clients.)


Where is her favorite place to doula?  Hospital, home, or birth center? (Listen to her answer on this one.  This tells you who is the most supportive of doulas at a birth.  It's usually the places where she feels like she has the freedom to work with a couple and her opinions and experience is valued.  These are usually good places to birth.  If a doctor or hospital is not at the top of her list, it's usually because they have policies and procedures in place that make it hard for her to really help you. They are usually resentful of her presence and feel that she is interfering with their work.)


Does she have backup with similar rates and philosophies?  (I don't want certain doulas at my student's births, so I want my doulas-of-choice to have doulas backing them up with similar styles and philosophies.  Things come up in life, and your doula could have the flu the day you start labor.  Ask about her backups.  You will all be more comfortable if you know these things in advance.)
  

Does she have "time limits" of being away from home (nursing baby, child care, husband's job, etc.)?  This is one reason I don't doula.  I have lots of kids, all attending different schools.  I don't let them ride the bus, so I spend half my day in the car.  I don't live near family to depend on either.   Oh yeah, and I have a husband with a demanding job.  Lastly, I don't have the patience necessary to be good doula!  If she does have "time limits" she may be very distracted.  Know what the issues are and how she deals with them.  For example, she may need to pump breastmilk every 4 hours during your labor.  If you are fine with that, great.  If that will drive you crazy, she's not the doula for you.)

Lastly, ask her what she literally brings to a birth? (One of "my" doulas is a massage therapist so she doesn't bring a lot of physical items to a birth.  She brings her hands, ready to work.  She knows acupressure points that stimulate labor and actively uses them throughout labor.  Other doulas have a bag that they bring, full of "birth toys" to help throughout labor.) 

It's nice to know what your doula brings to a birth, both literally and figuratively.

I hope this list helps you in your search for a doula.  They are such an important part of the birth team.  I see more epidurals and c-sections at births without a doula than those than have a doula.  And if your husband is resistant and wants the job all to himself, start calling the doula a "dude-la" and remind him that she is there as much for him as she is for you!

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Why I Recommend the UNT Midwives

I am doing something quite different for this post. Instead of picking a topic, I've chosen a group of local midwives to write about. I am continuously sending natural birthing couples their way and I decided to make a post out of it. If you do not live in the Ft. Worth area, I suggest you use this standard in finding a similar type group in your area. I have nothing to gain by promoting this group, by the way. Simply giving information on a group of midwives who are working hard to provide Mother-Friendly care.

If you read my blog regularly, you know how I feel about homebirth. About 25% of the couples that take my class do give birth outside of the hospital. But that leaves 75% in the hospital. That is alright. I understand, having had 2 hospital births before my two homebirths, why couples want to birth in the hospital. The hospitals, however, are not all created equal.

Let me tell you, in a nutshell, why I am singling the UNT Midwives out for this post. They are all CNMs, or Certified Nurse Midwives, and there are five in the group. To be perfectly honest, some are more medically minded than others, as in any group.

There are three reasons I choose this group over the other CNM groups in the area:

1) They are doing water birth at the hospital. Even if you do not think that you want to have a water birth, the fact that you have this option is huge. It's all about options, really. They are not telling you, like the majority of the other hospitals, that they want you chained to a monitor in the bed. Water birth, or at least laboring in water (often called "a midwife's epidural") is a lovely option for moms and babies, and it's wonderful that it has become an option in a hospital setting.

2) They give you the full 14 days "over" your "due date" before they start talking induction. I have decided in my seven years of teaching that the majority of women truly believe that this won't happen to them. "Going 'overdue' and long labors are things that happen to other women, not to me." OK, it's not said outloud or sometimes even consciously, but it's real. So many women are not prepared for this possibility at the end of pregnancy. So much can happen in those extra days that the UNT midwives are willing to give you. A lot of other groups and/or hospitals have a 7-10 day rule. Me no likey.

3) They are VBAC friendly and so is the doctor that backs them. Again, huge. Even if you have never had a c-section and are not having a VBAC, this philosophy, mindset, and belief is important to all pregnant women. No one wants to have a doctor who has a no-VBAC policy. He or she is preoccupied with legal issues and does not believe in the inherent safety of birth. They have a what-if mindset. A woman with a doctor like that will have a c-section. Also, their back-up doctors believe in their midwives. There are other local CNMs that are not "allowed" by their back-up doctors to do VBACs. Huge. This might seem like a big who-cares, but it's not. It speaks volumes about what is going on in their hospitals.

Ultimately, you do not have to fight to have a natural birth. As long as you do not have drugs, you will have intermittent monitoring, allowing you the freedom to walk or be in the water. You will be encouraged to eat and drink. You will have very limited vaginal exams. Other hospitals require an IV, continuous fetal monitoring, no walking if your water has broken, and vaginal exams every two hours. These "policies" contribute to the high c-section rates.

I should mention that not every experience at Harris has been great. I have had a handful of couples birth there where I was disappointed in how things were handled. Overall, however, these instances have been few and far between. I also believe that they are working extra hard to lower their rates of intervention, including c-sections. Bottom line: if you are birthing in a hospital in the Ft. Worth area, I am most comfortable with how the UNT Midwives do things.

I had a couple give birth with the UNT midwives this past weekend and I would just briefly like to share why they did not have a c-section. I believe that just about any other hospital in the area, she'd be recovering from surgery this week.

This mom had been having some strong contractions about 7-8 minutes apart for about 4 days. She had had a difficult time sleeping and was exhausted by the time she showed up at the hospital Saturday morning. She had some Demerol to help her sleep and by late afternoon without a whole lot of dilation, she had an epidural. Eventually, she had pitocin to pick things up, but the baby didn't like that so much. Instead of doing a c-section -- as just about any care provider around would have done, calling it fetal distress and fearing a lawsuit -- the midwife turned off the pitocin and told this mom to go back to sleep. They'd try again later.

Eventually, the epidural wore off, after the mom had gotten in some good sleep, and she was able to squat her baby out! Her midwife believed in her ability to do have a vaginal birth. Except for exhaustion, mom was fine and baby was fine. She recognized what was working for them and what wasn't.

I also must add, when her doula showed up at the hospital, all the lights were on, monitors beeping loudly, and family all standing around watching this laboring woman. Her wise doula created an atmosphere of quietness, dim lighting, head massage, snuggle time with the hubby, and things moved along quickly afterwards. She probably should have been there sooner!

"I like my doctor" is not a reason to stay at your hospital. He or she will very likely not be at your birth. The nurses run the show at the hospital. You want nurses who are used to working with midwives and have a respect and belief in the natural process of birth. If all they ever see is inductions, epidurals, and c-sections, this is what they are comfortable with. Get the heck out of Dodge and run over to the UNT Midwives.

Now, if you decide to birth outside of the hospital, you have lots more options available to you. That's another story for another day!

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Questions to Ask Your Doctor or Midwife

I am routinely asked this question: "What kinds of questions should I ask my doctor/midwife?" There is a great list put out by CIMS (Coalition for Improving Maternity Services) titled: "Having a Baby? Ten Questions to Ask." I would strongly recommend you look those over if you are expecting a baby.

I would like to add a question though: "What made you decide to become an OB/Midwife?"

Recently, I was reading a local magazine article about an OB-GYN and she was asked this question. Her answer, in my eyes, raised a huge red flag. She said she was doing her medical rotation and it was during a c-section that she decided that this was the profession she wanted to be in. It wasn't witnessing a natural, unmedicated birth and the awe of a woman's body that she felt inspired by -- it was a surgical procedure where she "rescued" the baby from the woman's body. This is what she enjoyed -- surgery!

Ultimately, this question will let you know if they feel the need or desire to intervene in the natural process with lots of testing and procedures. You'll know if they view pregnancy, labor, and birth as a normal healthy process, or if the medical profession improves upon the natural process. (Sometimes this is true, but in less than 20% of pregnancies.) It's all about their viewpoint.

It's a harmless question full of enlightening information.

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