I'm Pregnant, Now What?? Choices in Childbirth

It finally happen. The double pink line or the "+" appeared on the test. You are pregnant!! Congratulations!

Now what?!?!

After you've celebrated and shared the news, the next call you make is to your doctor to schedule your first appointment. It makes sense right? This is the doctor you've been seeing for your well woman visits and you do plan on giving birth at the closest hospital, right? That's what you should do, right? It's what everyone does, right?

Not that your doctor who you've been seeing for the last few years won't deliver your baby and not that you won't go to the hospital that is 5 minutes from your home, but you have other options. This is your birth and you DO have choices.

Did you know that you do not have to deliver laying on your back like you see in the movie?

Did you know that you can and it is often helpful to move throughout labor?

Did you know that there are trained healthcare professionals that specialize in normal childbirth?

Did you know that you do not have to have constant electronic fetal monitoring?

Did you know that the hospital is not the only option you have to give birth?

Take as much time deciding which stroller your baby will ride in as who will be apart of your healthcare team when he or she is born.

The Coalition for Improving Maternity Services has put together 10 questions to ask your healthcare providers that might help you as you explore your birth options. The questions include everything from who can be with you while you give birth to what you can expect while you are in labor.

Learn your options. Educate yourself. Become empowered so that you can make the best decisions for you and your family.

Foto Friday

I'm starting a regular series called Foto Friday where weekly I will share images capturing pregnancy, birth and babies. It is with great pleasure that I start my series by sharing a photograph taken by my friend Amy Goalen and displayed on the cover of her new book Mother's Milk. Amy's photographs are truly special capturing the intimacy and quiet moments between mothers and their babies in a snapshot of their breastfeeding journey. The photographs are stunning and are accompanied by words from the mothers themselves detailing their breastfeeding relationship. Mother's Milk can be purchased through Blurb.com.

Less Restrictive Guidelines for VBAC

With the cesarean section rate in our country reaching an alarming 31% The American College of Obstetricians and Gynecologists (ACOG) has issued new guidelines in hopes to allow greater access to vaginal birth after cesarean (VBAC). In a statement issued today, ACOG says:

"The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns," said Richard N. Waldman, MD, president of The College. "These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

The World Health Organization (WHO) recommends that for the best maternal and fetal outcomes that cesarean rates in industrialized countries should be no more than 10-15%. ACOG's recommendation is a step in the right direction to allowing more women the choice of a VBAC. While it moves us forward, we still need to keep the doors of communication open between women and their doctors and fully support their childbirth options. You can find the full text of the press release from ACOG here.

Celebrating Memorial Day & Doula-ing for Our Troops

While you are enjoying your time off, grilling with family and friends or relaxing at the beach, take a moment to remember our brave men and women who put their lives on the line everyday for our freedom. They do so without hesitation and with great sacrifice. I have family and friends who have served in the armed forces and I am a proud volunteer doula with Operation Special Delivery. OSD provides doulas for pregnant moms whose husbands or partners are deployed or have been severely injured serving our country. If you or someone you know is pregnant and their spouse is deployed please visit Operation Special Delivery to learn more about the program. If you don't qualify for OSD, I do offer a discount for military families. It's just my small way of saying thank you for all that you do!

Mother & Baby Friendly Cesarean

The United States cesarean section rate is rising at an alarming pace. While we need to educate ourselves about and discourage the use of unnecessary cesareans, the medical necessity of the procedure has allowed for healthy outcomes for countless mothers and babies. (me to be included!)

For those mothers and babies that medically require delivery by cesarean I argue that we should explore the option of a mother/baby friendly experience. The Natural Cesarean: A Woman-Centred Technique (pdf file) is an article published in the BJOG: An International Journal of Obstetrics and Gynaecology exploring the option of the parents being active participants in the birth of their baby.

What would a mother/baby friendly cesarean look like? According to the authors of the article:

• The drape would be lowered and the mother's headed elevated so that she may witness the birth.
• The partner would be allowed to observe as well
• Baby would be allowed to slowly emerge helping to expel liquid from its lungs as it would during a vaginal birth
• Rest of delivery is allowed to occur passively as the uterus continues to contract
• Clamping of the cord is done in front of both parents and the partner is permitted to cut if desired
• Baby is brought between the mother's breasts for immediate skin to skin contact and offered a chance to suckle
• Baby is allowed to remain on mother's chest until the surgery is complete. Procedures (labeling, Vitamin K, etc.) that can be completed in this position are.
• Once surgery is complete, partner accompanies baby for weighing and remaining procedures
• Upon completion of procedures, baby is immediately returned to mother for skin-to-skin contact

A cesarean section is major abdominal surgery. This birth experience is not suitable for all cesarean births, but I think, as suggested by the authors of the article, this option can be explored for non emergent situations. The International Cesarean Awareness Network has also written details about how to have a family centered cesarean.

If your medical situation dictates that a cesarean is the safest way to deliver your baby discuss your options with your doctor.

Don't Be Quiet - Share Your Amazing Birth Story!

You know if you're pregnant everyone has some advice for you. How you should do this or how you should do that. The other thing that often happens is that you will start to hear more birth stories. Not to make lite of the individuals who have had difficult births or things they wish they could change about their experience, but I think it's time to celebrate our amazing births.

If you had an inspirational birth tell your story. Don't be shy. Share what made your birth experience incredible. It doesn't have to be the birth you dreamed of or the one that was carefully laid out in your birth plan, but share it nonetheless. Your words of wisdom could help to empower and inspire other women throughout their pregnancy.

Don't be quiet. SHARE your amazing birth story!

Here. I'll start.......

While the birth of my twins was by no means the birth I thought I was going to have when I found out I was pregnant, it was very empowering. I went into labor on my own, I was able to see them being born via c-section and I had the support of my husband and amazing nurses that I had gotten to know during my antepartum stay in the hospital. If you wish to read the birth story of my twins visit my Twins Make 5 Blog. My experience was empowering because I was educated about my pregnancy and birth options and I strongly advocated to let my body and my boys make the decision about when they were going to come.

Pregnant? Consider a Midwife

Our Bodies Ourselves has posted a video on their blog asking the question "Why Choose a Midwife?" The video is mainly being used to address legislation in Massachusetts governing midwives, but it has the added benefit of detailing the benefits of the midwifery model of care.

Parts of the video are drawn from Natural Born Babies which is told by 10 mothers describing their journey to have a natural childbirth. The video is amazing! I promise I'm not just saying that because I'm biased having worked with Executive Producer, Lorri Walker at South Coast Midwifery & Women’s Health Care or having had the blessed opportunity to serve as doula to the family who helped direct the film. If you are pregnant and are looking for a healthcare provider these films will give you pause and a reason to consider hiring a midwife.

Are You Familiar With The Mother-Friendly Childbirth Initiative?

If you are pregnant or trying to conceive take the time to familiarize yourself with The Mother-Friendly Childbirth Initiative (MFCI). It is the first and only consensus document on maternity care in the United States. MFCI is evidence based and focuses on prevention and wellness while promoting a mother, baby and family friendly model. MFCI takes the approach the childbirth is a normal, natural and healthy process and should be respected as such.

Mother-Friendly Childbirth Initiative

Consensus Document by the Coalition for Improving Maternity Services

A mother-friendly hospital, birth center, or home birth service:

1. Offers all birthing mothers:

• Unrestricted access to the birth companions of her choice, including fathers, partners, children, family members, and friends;
• Unrestricted access to continuous emotional and physical support from a skilled woman—for example, a doula,* or labor-support professional;
• Access to professional midwifery care.

1. Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.
2. Provides culturally competent care—that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother’s ethnicity and religion.
3. Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on back with legs elevated) position.
4. Has clearly defined policies and procedures for:

• collaborating and consulting throughout the perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary;
• linking the mother and baby to appropriate community resources, including prenatal and post-discharge follow-up and breastfeeding support.

1. Does not routinely employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following:

• shaving;
• enemas;
• IVs (intravenous drip);
• withholding nourishment or water;
• early rupture of membranes*;
• electronic fetal monitoring;

1. other interventions are limited as follows:

• Has an induction* rate of 10% or less;†
• Has an episiotomy* rate of 20% or less, with a goal of 5% or less;
• Has a total cesarean rate of 10% or less in community hospitals, and 15% or less in tertiary care (high-risk) hospitals;
• Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.

1. Educates staff in non-drug methods of pain relief, and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.
2. Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.
3. Discourages non-religious circumcision of the newborn.
4. Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital Initiative” to promote successful breastfeeding:

• Have a written breastfeeding policy that is routinely communicated to all health care staff;
• Train all health care staff in skills necessary to implement this policy;
• Inform all pregnant women about the benefits and management of breastfeeding;
• Help mothers initiate breastfeeding within a half-hour of birth;
• Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants;
• Give newborn infants no food or drink other than breast milk unless medically indicated;
• Practice rooming in: allow mothers and infants to remain together 24 hours a day;
• Encourage breastfeeding on demand;
• Give no artificial teat or pacifiers (also called dummies or soothers) to breastfeeding infants;
• Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospitals or clinics

As you look for healthcare providers talk with them about their approach to the Mother-Friendly Childbirth Initiative. Here are 10 questions to ask and help as you explore your options.

The Realities of Working and Breastfeeding

"When providing breastfeeding support we must listen to the mother and meet her where she is."

Last month I attended the Breastfeeding and Feminism 2010 Symposium: Informing Public Health Approaches. It was an inspiring and educational conference. This is the quote that came from my workgroup at the conference that really spoke to me. It is where I believe all individuals need to come from when working with a breastfeeding mother.

As I look at breastfeeding and work there are certain realities that we cannot escape. One of the most recent breastfeeding accomplishments in public health was the health care reform law that allows women employed in businesses with over 50 employees to be permitted to pump and have a place to do so. This is an amazing accomplishment that we need to applaud, but at the same time we must also recognize the limitations of this legislation and work with breastfeeding mothers to help them overcome whatever obstacles prevent them from continuing a breastfeeding relationship.

I returned to work when my oldest son was 3 months. I had an office job that allowed me the flexibility to pump when I needed. Even when I was on the traveling, I built in time to pump. I also worked from home a few days a week, so I had the added benefit of being able to breastfeed my son and not pump at least one day a week. Like many, I struggled with supply issues here and there, but I was able to recover and continued pumping until he turned 1. Our breastfeeding relationship continued until he was 22 months. I was lucky. I had an ideal pumping and breastfeeding scenario. Sure I pumped in the car before a meeting, while typing an email to a coworker and while on a conference call (muted of course-have you heard how loud the pumps can be?). However, I fully recognize how lucky I was.

If my scenario was perfect, what happens in real life? What happens if the breastfeeding mother is:

• The teacher who needs to be in her classroom for the majority of the day?
• The doctor or nurse who works a 12 hour shift?
• A waitress who has customers to attend to during her entire shift?
• A woman who works in the chicken processing plant who never freely walks off the production line?

These scenarios assume that mother is fully able to breastfeed? What happens if:

• Baby never learned to latch so mom needs to exclusively pump?
• Mom's supply starts to wain?
• Mom wants support in combining breastfeeding and formula?

How can we help these women? This goes back to my initial quote. We must listen to the mother. What does she need? As a doula I know the logistics. I know the positions. I know the how and why of breastfeeding, but I don't have all the answers. I know we must listen to her and help support her whatever she needs.

I do know that there are somethings we can do in our day to day lives to help. We can help normalize nursing and continue to make it easier for mothers who want to continue to support policies that encourage breastfeeding when mom returns to work.

Breastfeeding Mothers WIN in Health Care Reform!

Returning to work and continuing to breastfeeding just got easier! No matter what side of the political fence you are on, it is clear that the recently passed health care legislation is a HUGE win for breastfeeding mothers and their babies!!!

Section 4207, entitled Reasonable Break Time for Nursing Mothers, allows a breastfeeding mother to take a break to pump. It requires business with more than 50 employees to provide a private space to pump, that is not a bathroom.

Previously, while 44 states, Puerto Rico and the District of Columbia, protect women's rights to breastfeed in public, less than half of the states have laws on the books relating to breastfeeding in the workplace.

The health care reform legislation has changed that! Text from the legislation is as follows:

SEC. 4207. REASONABLE BREAK TIME FOR NURSING MOTHERS.

Section 7 of the Fair Labor Standards Act of 1938 (29 U.S.C. 207) is amended by adding at the end the following:

(r)(1) An employer shall provide—

(A) a reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth each time such employee has need to express the milk; and

(B) a place, other than a bathroom, that is shielded from view and free from intrusion from co-workers and the public, which may be used by an employee to express breast milk.

(2) An employer shall not be required to compensate

an employee receiving reasonable break time under paragraph (1) for any work time spent for such purpose.

(3) An employer that employs less than 50 employees

shall not be subject to the requirements of this subsection,

if such requirements would impose an undue hardship by

causing the employer significant difficulty or expense when

considered in relation to the size, financial resources, nature, or structure of the employer’s business.

(4) Nothing in this subsection shall preempt a State

law that provides greater protections to employees than the

protections provided for under this subsection.’’

This is a giant leap forward for mother's who want to continue to breastfeed their babies once they return to work. If you are mom preparing to return to work and are looking for additional resources on pumping check out La Leche League, Kellymom.com and Ameda.

Breastfeeding in Public - What's the big deal?

I am saddend every time I hear another story of a mother who is shunned and unable to breastfeed her child in public. Can someone please explain to me what is the big deal? Here's the story of a woman, in my home state of North Carolina, who is trying to look for job at the Employment Security Commssion. She is asked to nurse her child elsewhere for the comfort of the men in the office. What?!?!

When are we as a society going to accept that a mother giving her child nourishment, comforting her baby, using her breasts as nature intended is normal and should be encouraged and not shunned?

I applaud and celebrate all the mothers I know who are able and desire to breastfeed their babies in public. For those who struggle with whether to breastfeed in public or for those who just don't understand, please check out this video designed by the Nursing is Normal (NIN) project. It's inspirational, it's beautiful, it's normal!

Doula-ing Offers Sling Safety Tips

The U.S. Consumer Product Safety Commission recently issued a safety warning about sling carriers. As an avid babywearer I was very interested in learning about the concerns surrounding slings. The CPSC did not issue a warning about a particular sling, but cautions about potential suffocation hazards due to improper positioning of the baby in the slings. The CPSC goes on to express concerns about premature twins and babies of low birth weight.

Babywearing offers many benefits for parents and for babies. Whether its soothing a fussy baby, offering close physical contact for a premature infant, or allowing mom and dad a free hand to cook dinner, proper babywearing can be an invaluable tool for many parents.

I personally, have enjoyed wearing my all three of my children and have found it an absolute necessity with my twins. The New Native sling has been my "must have" baby item since they were a few months old. One of the things I love about the New Native sling is that they give very detailed safety instructions and also tell you what to look out for if baby is not positioned properly. They also offer an "infant support pillow" for newborns to help ensure proper positioning.

Proper positioning is extremely important while wearing the baby in any sort of sling. Here are a few tips on how to ensure proper usage of a sling.

From Babywearing International:

1. Make sure your baby can breathe. Baby carriers allow parents to be hands-free to do other things … but you must always remain active in caring for your child. No baby carrier can ensure that your baby always has an open airway; that’s your job.

a. Never allow a baby to be carried, held, or placed in such a way that his chin is curled against his chest. This rule applies to babies being held in arms, in baby carriers, in infant car seats, or in any other kind of seat or situation. This position can restrict the baby’s ability to breathe. Newborns lack the muscle control to open their airways. They need good back support in carriers so that they don’t slump into the chin-to-chest position.

b. Never allow a baby’s head and face to be covered with fabric. Covering a baby’s head and face can cause her to “rebreathe” the same air, which is a dangerous situation. Also, covering her head and face keeps you from being able to check on her. Always make sure your baby has plenty of airflow. Check on her frequently.

2. Never jog, run, jump on a trampoline, or do any other activity that subjects your baby to similar shaking or bouncing motion. “This motion can do damage to the baby’s neck, spine and/or brain,” explains the American Chiropractic Association.

3. Never use a baby carrier when riding in a car. Soft baby carriers provide none of the protection that car seats provide.

4. Use only carriers that are appropriate for your baby’s age and weight. For example, frame backpacks can be useful for hiking with older babies and toddlers but aren’t appropriate for babies who can’t sit unassisted for extended periods. Front packs usually have a weight range of 8 to 20 pounds; smaller babies may slip out of the carrier, and larger babies will almost certainly cause back discomfort for the person using the carrier.

Also, there are many other babywearing options. I have used both a Moby Wrap and an Ergo Baby Carrier, but there are lots to choose from.

If you live in the Raleigh, Durham, Chapel Hill area please checkout Triangle Babywearers. You can try out a variety of carriers and also get great tips on proper babywearing techniques.

The NIH VBAC Conference Hits Close to Home

As a mother who had a vaginal birth for my first child, and due to umbilical cord entanglement, had a cesarean for my twins, I've been following the National Institutes of Health Consensus Development Conference on Vaginal Birth After Cesarean with great interest. It has recently hit me that if my husband and I decide to expand our family, that I cannot go to just any healthcare provider. Not all physicians in the Raleigh area would be supportive of my decision to attempt a vaginal birth. That idea is mind boggling! The thought that a doctor or hospital would not support my birth choice is something I never imagined that I would have to deal with.

The NIH conference earlier this week examined the availability and access to VBAC for pregnant women The panel reiterated what many evidence-based practitioners believe, that expectant mothers should have the option to pursue a vaginal birth after a having had prior cesarean. Seems like a no brainer, right?

Unfortunately, while 60% to 80% of women who attempt a VBAC have a successful vaginal birth, the reality is that there are hospitals and care providers that limit that option for mothers. Some facilities and doctors ban the procedure outright. The risk of uterine rupture, which is often stated as a reason not to pursue a VBAC, is less than 1%. Not to minimize that small percentage, but is the fear of litigation a reason to limit this birth option for millions of women? The panel recognizes the medical and legal issues surrounding VBAC, but urges all stakeholders to overcome the barriers to allow access for pregnant women.

You an read the panels draft report here. The conference was an excellent opportunity to shine a spotlight on the availability of VBAC, maternal care and birth options in our country. It is an important discussion that we as birth professionals, mothers and healthcare providers need to work together to move forward.

The Conference is available by webcast at the NIH website.

Savoring Those First Few Moments - Umbilical Cord Care

For hundreds of years, midwives have practiced delaying the clamping of the umbilical cord after birth. The delay has proven harmless to baby and mother and offered the benefit of allowing for additional bonding time for the family.

A recent study published in the American Medical Association Journal by a group of pediatricians suggests that premature clamping of the cord is actually harmful and delaying clamping may help prevent respiratory distress syndrome.

As reported in Time:

Delay allows a gradual change from fetal to regular circulation without putting stress on blood vessels in the lungs and elsewhere in the body. The carefree manner in which the newly born infant is "disconnected" from his mother, concludes the report, "is in sharp contrast to the meticulous care with which the thoracic surgeon separates his patient from the heart-lung machine."

Ask your health care provider about their policies on cord clamping and discus with them the option of delaying the procedure. There is no rush.

Breastfeeding Gets the Colbert Bump (Again)

Is Stephen Colbert a closet breastfeeding advocate? Maybe not so closet. In an interview with Michael Pollan, natural food advocate and author of "In Defense of Food," Colbert questions Pollan about whether he was breastfeed. During his Better Know a District series, he is concerned about Representative Carolyn Maloney's proposal to prevent discrimination against using breast pumps at work. Most recently, Colbert apologized for not breastfeeding his one day old Grammy.

As a member of the Colbert Nation, I think it's time Stephen come out of the closest and proudly proclaim his support for breastfeeding moms!

The Colbert Report	Mon - Thurs 11:30pm / 10:30c
Stephen Apologizes for Feeding His Grammy Baby Food
www.colbertnation.com
Colbert Report Full Episodes Political Humor Skate Expectations

Birthing Choices and C-Sections - Why I Became a Doula

Doula-ing was born out of my desire to help educate and empower woman about their birthing choices. On the surface it appears very cut and dry. I peed on a stick, it came back positive, I go see my OB and nine months later my baby is born. Ok, maybe I’m over simplifying it a bit, but you get the point.

It’s not that cut and dry. From deciding which healthcare provider will care for you and your baby (obstetrician, certified nurses midwife, certified professional midwife) to where you will give birth (hospital, home, birth center) there are hundreds of decisions that aren’t so clearly defined that each woman should examine and decide which ones are best for her. As a doula, I want to provide as much information to help my clients make the best decisions for her and her family.

Blogger The Unnecesarean posted the map above showing the 2007 Cesarean Rates by state. It is important to note the the World Health Organization (WHO) recommends that for the best maternal and fetal outcomes that cesarean rates in industrialized countries should be no more than 10-15%. The map indicates that in 2007 the rate in my state of North Carolina was between 2.5 to 3 times what is recommended. According to the North Carolina State Center for Health Statistics, in 2008 the Wake County cesarean rate was 32%.

If Raleigh and Wake County’s rate is 3 times higher than is recommended for the healthiest outcomes for both mother and baby, shouldn’t we be asking questions? Shouldn’t we be asking why is the rate so high and by many accounts increasing? As an expectant mother, ask your healthcare provider what their rate of cesarean births are. Ask what their policy is regarding vaginal births after a cesarean (VBAC). Inquire about their rate of inductions and how many of those lead to c-sections. Educate yourself about your options. Ask questions. This is your pregnancy, your baby, and you are your best advocate.

Don’t misunderstand my questioning as a sign of not understanding the importance of a c-section. I am the mother of twin boys who very well might not be here if it was not for a c-section. My boys were in the same sac without a separating membrane. This rare twinning meant that their umbilical cords were in a knot and they were at risk of cord compression. Because of the knot, if they were not born via c-section, one or both of them may not be here. As a doula I have also attended necessary c-sections births.

C-sections are necessary medical procedures, but we as women and mothers need to educate ourselves about the medical situations that dictate the necessity and unnecessary interventions that can ultimately lead to a cesarean birth.

For additional resources visit The International Cesearn Awareness Network ICAN.