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.

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.

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.

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 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.

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.