Birthing Beautiful Ideas

I recently received a very thoughtful set of questions from reader Rachael N.:

I keep hearing this idea that women who have birth plans are women who end up having c-sections. I actually first heard it from my freestanding birthing center midwife, when I asked if she would recommend that I write a birth plan. On the one hand, I imagine that there may be some women who become so attached to their plan that they are unprepared for the unpredictability of labor itself. On the other hand, it sounds far more likely that the birth plan may be a convenient target for blame on those occasions when it was actually the system that did not serve the woman well. So my questions are: What’s up with this myth? Is there any actual research showing what the outcomes are when women have birth plans? And how should a woman build some flexibility into her birth plan, given that childbirth is an unpredictable process??

I’ve also heard and seen people express this sentiment before: namely, that women with birth plans (and, especially, long birth plans) are the ones who will end up with the most birth interventions.

Like many sweeping generalizations, I find that some of these sentiments gloss over a lot of much-needed nuance and sensitivity and attention to detail.  And this is troubling.  In fact, it does little, if not nothing, to empower or even help women who are preparing for the birth of their babies.

For instance, when Taffy Brodesser-Akner talked to Dr. Kimberly D. Gregory in an article in Self magazine, Dr. Gregory expressed the following reservations about birth plans:

“I think that birth should be a beautiful experience,” says obstetrician Kimberly D. Gregory, M.D. She’s the vice chair of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in L.A. “It should be exactly the way you want it, and doctors should intervene only to preserve the health or life of you or your baby.“

Naturally, one would assume that Dr. Gregory advocates birth plans. When I ask her this, she laughs. “We always say, ‘If you show up with a birth plan, just get the C-section room ready,’” she says. “You get everything on that list that you don’t want. It’s like a self-fulfilling prophecy.” Dr. Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan. The birth-plan group trended toward a higher C-section rate and more interventions. “There’s a certain personality type that tends to be more anxious. Maybe the anxiety hormones themselves put them at risk,” Dr. Gregory theorizes. “It seems that being open and honest and choosing the right doctor is probably a better option than writing everything down. Walking in with this list appears to set up an antagonistic relationship.”

For what it’s worth, I think that Dr. Gregory’s statements (which, to be fair,were probably edited for purposes of the article) include a mix of sweeping generalizations and helpful distinctions.

On the one hand, even if the hospital staff is joking when they claim that showing up with a birth plan entails a trip to the OR, the joke itself raises questions about just whose self-fulfilling prophesies are being fulfilled.  Not all birth plans are created equally–some are the result of an online, cookie-cutter checklist, and others are the result of careful research that a woman and her partner have discussed with their care provider, the hospital staff, and their pediatrician.

On the other hand, Dr. Gregory’s points about the relationship between anxiety and labor and the importance of finding a supportive care provider are spot on.  For if one envisions the hospital as a battle scene in which one must use a birth plan as a defensive shield, one might very well set oneself up for disappointment, and even the self-fulfilling prophesies to which Dr. Gregory alluded.

I was also able to dig up one published study that examined the disparities between patients’ and medical personnel’s perceptions of outcomes in women who use birth plan.  (Note that this is different from the actual outcomes of women who use birth plans.)  And the results were pretty fascinating:

Sixty-five percent of medical personnel vs. 2.4% of patients reported that patients with birth plans had overall worse obstetric outcomes than patients without a birth plan. There were 65.7% of health care providers vs, 8.7% of patients who reported that women with a birth plan had an increased rate of cesarean section. In addition, 53.4% of health care providers vs. 9.9% of antepartum patients reported a perceived increased rate of chorioamnionitis for women with birth plans. Statistically significant differences were also found between health care providers and patients in terms of their perceptions of the effect of birth plans on operative vaginal delivery, postpartum hemorrhage, episiotomy and length of hospital stay.

I do not doubt that these perceptions exist or that (as Dr. Gregory commented) birth plans created out of anxiety or antagonism can contribute to more complicated labors.  (Fear or anxiety-based stress effects everything from pregnancy to birth to breastfeeding negatively.)  But I also think that they/we need to make some clearer distinctions before drawing any hard and fast conclusions about the relative usefulness (or uselessness) of birth plans.

You see, I can understand why certain attitudes or expectations about birth plans might be more of a hindrance than a help to birthing women and their partners.  But this is entirely different from claiming that birth plans themselves are somehow responsible for a higher rate of complications and/or medical interventions.  And if this distinction (i.e. the one between attitudes and expectations about birth plans and birth plans themselves) is not made abundantly clear in the sort of statements described above, then women might be led to think that any and all articulation of their preferences for birth are counterproductive, useless, and even dangerous.

In my humble opinion, this thought is what is actually counterproductive, and even dangerous.

And that’s because there is a lot about birth plans that is a “good thing!”

Researching your birth preferences is a good thing.

(Who wants to find out the risks, benefits, and side effects of narcotic pain medication during a contraction, or, worse, while their baby is receiving medication because of the respiratory distress caused by the narcotic pain medication?)

Articulating your birth preferences is a good thing.

(How will your partner and/or the nurses know that you don’t want them to offer you pain medication unless you tell them so?)

And discussing these preferences (as early as possible) with your care provider, your hospital staff, and your pediatrician is an even better thing!

(Who wants to get to the hospital, in active labor, only to find out that their care provider doesn’t “allow” intermittent monitoring after all?  Or that the hospital doesn’t have tubs in every labor and delivery room?  Or that the staff will call Childrens Protective Services if parents refuse the erythromycin eye drops?)

But in order to create an effective birth plan–one that will communicate one’s wishes without working against one’s wishes–it is important to be mindful of the following:

1) A birth plan does not replace the need for birth preparation.

Going to an online “birth plan mill” and checking off a bunch of boxes (“yes” to the epidural!  “no” to the episiotomy!)  is not the same as preparing for birth.

A good childbirth education class can help you prepare for birth by helping you to discern what the protocols are in your chosen birth location, what the risks, benefits, and alternatives are of any birth intervention, and how you can cope with both the expected and unexpected during labor.

So can a good book (or set of books). (Please see my recommended reading list on the right sidebar.)

Or a good website (such as Childbirth Connection, Lamaze International, or Mother’s Advocate).

Or a good doula or other birth professional.

But a birth plan really doesn’t help all that much you if you haven’t yet determined why you want what you want–why you prefer intermittent monitoring over continuous monitoring, why you want to eat and drink during labor, why you want something different from your care provider’s or your hospital’s typical protocol.

2) A birth plan does not replace the need for a supportive care provider who is on board with your desires and preferences for your birth.

Even a well-researched birth plan will generally not stand up to a care provider who doesn’t allow anything stated on the birth plan.  And this is why it is crucial to discuss your birth preferences–and even get your list of preferences signed–with your care provider well before labor begins.

For instance, if you would prefer to tear rather than to undergo an episiotomy, but your care provider has an 85% episiotomy rate, then you might consider finding a care provider who has a much lower rate.

If your care provider does not “allow” some of your birth preferences (such as intermittent monitoring, eating and drinking during labor, etc.), then you might consider asking if s/he will make an exception in your case (and sign your birth plan!), or you might consider finding another care provider who does support these preferences.

In other words, a birth plan itself will not magically change the way your care provider practices when it comes to your birth!

And a care provider who is on board with your preferences is worth much more than a piece of paper expressing these preferences.

3) A birth plan cannot plan your birth–but it can help you to articulate and express your desires and preferences for your birth.

This is why I (and many others) like to refer to birth plans as “birth preference lists.”

Birth is inherently unpredictable, whether you have an unexpected unassisted birth at home or an elective cesarean section that you have planned for from the moment you knew you were pregnant.

Thus, you cannot plan the birth you want–you can only plan for the sort of birth that you would like and remain open to the possibility that your plans and preferences might need to change in light of the particular circumstances of your birth.

This is not to say that articulating your birth desires and preferences is useless.  To the contrary, this is an exceedingly useful exercise, one that can motivate you to research your options and to get a better feel for what you can expect from your care provider and from your birthing location.

But your attitudes about and expectations for your birth plan should reflect these sentiments: namely, that you cannot control your labor.  You cannot control birth itself.  But you can and even should empower yourself to make decisions about what you want for your birth, and how you would like others to accommodate your desires and preferences for your birth, and how you plan to remain flexible and open to the unpredictability of childbirth.

And care providers should be able to respect these sorts of preferences without pegging you as taking a one-way train to the operating room.

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If you’re looking for a helpful guide on writing a birth plan, Melissa, the L&D nurse blogger from Nursing Birth, wrote two fabulous posts on birth plans: one covering the general topic of birth plans, and the other offering more specific tips and pointers for writing a birth plan/preference list.

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I’m also interested in hearing your thoughts!  Have you heard that “the women with birth plans end up with the most interventions”?  Have you seen that in your experience as a birth professional?  What advice would you/do you give to women about birth plans based on your experience?

You can see more of this discussion over on my Facebook fan page!

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As many people might have seen in the news, on press releases, or on blog posts, the American College of Obstetrics and Gynecology (ACOG) just released a revised version of its VBAC practice bulletin.

This is big news.  It’s huge news.  And it’s particularly big and huge in light of the fact that two previous practice bulletins on VBAC (from 1999 and 2004) were instrumental in leading to the decrease in VBAC access and the swath of VBAC bans across the United States. What’s more, this current bulletin has the potential to reverse some of the effects of the previous bulletins.

And this is not because it will effect any immediate policy changes but because it gives women a tool to help them facilitate discussions with their care providers and/or their local hospitals so that they can advocate for their birthing options.

So while the current document is not perfect, it’s an improvement.  And a possibly giant improvement at that.

Just consider the introductory paragraph from the 2004 practice bulletin:

A trial of labor after previous cesarean delivery has been accepted as a way to reduce the overall cesarean delivery rate.  Although vaginal birth after cesarean delivery (VBAC) is appropriate for most women with a history of low-transverse cesarean delivery, several factors increase the likelihood of a failed trial of labor, which in turn leads to increased maternal and perinatal morbidity.  The purpose of this document is to review the current risks and benefits of VBAC in various situations and provide practical management guidelines.

And now the introductory paragraph from the new practice bulletin:

Trial of labor after previous cesarean delivery (TOLAC)* provides women who desire a vaginal delivery with the possibility of achieving that goal––a vaginal birth after cesarean delivery (VBAC)†. In addition to fulfilling a patient’s preference for vaginal delivery, at an individual level VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies. At a population level, VBAC also is associated with a decrease in the overall cesarean delivery rate (1, 2). Although TOLAC is appropriate for many women with a history of a cesarean delivery, several factors increase the likelihood of a failed trial of labor, which compared with VBAC, is associated with increased maternal and perinatal morbidity (3–5). Assessment of individual risks and the likelihood of VBAC is, therefore, important in determining who are appropriate candidates for TOLAC. The purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and provide practical guidelines for managing and counseling patients who will give birth after a previous cesarean delivery.

While some people may find the “managing” language to be off-putting, I think that the changes in this paragraph signal both an acknowledgment of women’s birthing preferences and desires and some much-needed nuanced distinctions regarding VBAC and repeat cesarean outcomes.  And an increased attention to detail and to women’s choices is a welcome difference.

Below, I’ve listed some additional major changes that ACOG has made to their practice bulletin on VBAC between 2004 and 2010.  If you are are having a difficult time finding a VBAC-supportive care provider in your area, you might be able to draw her or his attention to these changes in order to advocate for the birth that you want!

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On evaluating the risks and benefits of VBAC and elective repeat cesarean delivery

From the 2004 bulletin:

Neither elective repeat cesarean delivery nor VBAC is without risk.  Generally, successful VBAC is associated with shorter maternal hospitalizations, less blood loss and fewer transfusions, fewer infections, and fewer thromboembolic events than cesarean delivery.  However, a failed trial of labor may be associated with major maternal complications, such as uterine rupture, hysterectomy, and operative injury, as well as increased maternal infection and the need for transfusion.  Neonatal morbidity is also increased with a failed trial of labor, as evidenced by the increased incidence of arterial umbilical cord blood gas pH levels below 7, 5-minute Apgar scores below 7, and infection.  However, multiple cesarean deliveries also carry maternal risks, including an increased risk of placenta previa and accreta.

From the 2010 bulletin:

Neither elective repeat cesarean delivery nor TOLAC are without maternal or neonatal risk.  The risks of either approach include maternal hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death. Most maternal morbidity that occurs during TOLAC occurs when repeat cesarean delivery becomes necessary.  Thus, VBAC is associated with fewer complications, and a failed TOLAC is associated with more complications, than elective repeat cesarean delivery. Consequently, risk for maternal morbidity is integrally related to a woman’s probability of achieving VBAC…

…In addition to providing an option for those who want the experience of a vaginal birth, VBAC has several potential health advantages for women. Women who achieve VBAC avoid major abdominal surgery, resulting in lower rates of hemorrhage, infection, and a shorter recovery period compared with elective repeat cesarean delivery. Additionally, for those considering larger families, VBAC may avoid potential future maternal consequences of multiple cesarean deliveries such as hysterectomy, bowel or bladder injury, transfusion, infection, and abnormal placentation such as placenta previa and placenta accreta.

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On VBAC after multiple cesareans (or VBAmC)

From the 2004 bulletin:

Women who have had 2 previous low-transverse cesarean deliveries have traditionally been considered candidates for a trial of labor.  However, the few studies that address this issue report a risk of uterine rupture ranging between 1% and 3.7%.  In the only study that controlled for other potential confounding variables, the risk of uterine rupture during labor was nearly 5 times greater for women with 2 previous cesarean deliveries when compared with women who had 1 previous cesarean delivery.  Women with a previous vaginal delivery followed by a cesarean delivery were only approximately one fourth as likely to sustain uterine rupture during a trial of labor.  Therefore, for women with 2 prior cesarean deliveries, only those with a prior vaginal delivery should be considered candidates for a spontaneous trial of labor.

From the 2010 bulletin:

Studies addressing the risks and benefits of TOLAC in women with more than one cesarean delivery have
reported a risk of uterine rupture between 0.9% and 3.7%, but have not reached consistent conclusions regarding how this risk compares with women with only one prior uterine incision.  Two large studies, with sufficient size to control for confounding variables, reported on the risks for women with two previous cesarean deliveries undergoing TOLAC. One study found no increased risk of uterine rupture (0.9% versus 0.7%) in women with one versus multiple prior cesarean deliveries (66), whereas the other noted a risk of uterine rupture that increased from 0.9% to 1.8% in women with one versus two prior cesarean deliveries. Both studies reported some increased risk in morbidity among women with more than one prior cesarean delivery, although the absolute magnitude of the difference in these risks was relatively small (eg, 2.1% versus 3.2% composite major morbidity in one study).  Additionally, the chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery. Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.  Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited.

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On suspected macrosomia (or “big baby”)

From the 2004 bulletin:

Although macrosomia (usually birth weight greater than 4000 g or 4500 g, regardless of gestational age) is associated with a lower likelihood of successful VBAC, 60-90% of women attempting a trial of labor who give birth to infants with macrosomia are successful.  The rate of uterine rupture appears to be increased only in those women without a previous vaginal delivery.

From the 2010 bulletin:

Women undergoing TOLAC with a macrosomic fetus (defined variously as birth weight greater than 4,000–4,500 g) have a lower likelihood of VBAC than women attempting TOLAC who have a nonmacrosomic fetus. Similarly, women with a history of past cesarean delivery performed for the indication of dystocia, have a lower likelihood of VBAC if the current birth weight is greater than that of the index pregnancy with dystocia. Some limited evidence also suggests that the uterine rupture rate is increased (relative risk 2.3, P <.001) for women undergoing TOLAC without a prior vaginal delivery and neonatal birth weights greater than 4,000 g . These studies used actual birth weight as opposed to estimated fetal weight thus limiting the applicability of these data when making decisions regarding mode of delivery antenatally.  Despite this limitation, it remains appropriate for health care providers and patients to consider past and predicted birth weights when making decisions regarding TOLAC, but suspected macrosomia alone should not preclude the possibility of TOLAC.

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On the “immediately availability” of obstetrical and surgical teams during a VBAC

From the 2004 bulletin:

Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

From the 2010 bulletin:

A trial of labor after previous cesarean delivery should be undertaken at facilities capable of emergency deliveries.  Because of the risks associated with TOLAC and that uterine rupture and other
complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care. When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital’s resources and availability of obstetric, pediatric, anesthetic, and operating room staffs. Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.

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Depending on your perspective, the dust has either just begun to settle or just begun to get kicked up on the Kingsdale Gynecologic Associates’ doula ban and universal birth plan.

On the one hand, the dust is really swirling in the Columbus, Ohio media.  Two local news programs aired evening news segments on the ban, and the Columbus Dispatch ran a front page story on the issue just last week.  (Many, many thanks are owed to Columbus-area doula Catie Mehl for representing local doulas in all three of these stories!)

On the other hand, the dust in my own mind (a place that can get pretty darn dusty) is finally settling.  By that, I mean that I’ve finally been able to look at the doula ban and birth plan with less snark and shouting-from-the-rooftops and more reasoned, tempered outrage.  And because of this, I’m ready to address people’s questions about why Kingsdale’s recent decisions warrant any sort of outrage whatsoever.

And I understand–I really, truly do–why the source of this outrage isn’t immediately apparent to everyone who comes across this story.

For one, I understand why some people assert that Kingsdale has the right to practice as they choose.  (Though as I will explain later, this doesn’t necessarily mean that everything that they practice is respectful of women’s autonomy, devoid of any condescension or paternalism, or even evidence-based!)

What’s more, as a few people astutely pointed out in their comments, both documents (i.e. the doula ban letter and the Kingsdale birth plan) are worded so innocuously and even reassuringly that it might be difficult for many parents–regardless of their education levels–to note the glaring problems contained therein.

But the problems are there, and they are glaring to my eyes.

Here are the issues as I see them, in no particular order:

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Both Kingsdale documents are embarrassingly paternalistic.

Dr. Kimberly Shepherd, one of the OB/GYNs at Kingsdale, commented in the Columbus Dispatch that the accusations of paternalism and closed-mindedness were “hurtful.”

I, for one, did not intend to hurt anyone’s feelings by referring to the doula ban and birth plan as paternalistic, nor would I disagree that Dr. Shepherd and most (if not all) of her colleagues are nice people who do not deserve to have their feelings hurt.

Nonetheless, this does not change the fact that the documents are paternalistic.

Consider the following definition of paternalism from The Standford Encyclopedia of Philosophy:

Paternalism is the interference of a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm.

In a nutshell, then, paternalism describes when one interferes with another’s (or others’) freedom “for their own good” (or at least for what one thinks is another’s own good).

On a theoretical level, some people will agree that despite the value that “we” place on a person’s freedom to make choices about what they believe and how they act in the world, paternalism might be justified either when people lack the cognitive or emotional capacity to promote their well-being or when people act in ways that undermine their or others’ well-being.  Thus, the state mandates safety belt laws, and parents stop their kids from exercising their freedom to flush their brother’s puzzle down the toilet, and most people don’t raise a stink about it.  Except for the kid who really, really wanted to flush the puzzle down the toilet–you know, that kid who may or may not be related to me.

In any case, paternalism isn’t always so benign.  Consider this definition from Wikipedia (yes, I know):

The term may be used derogatorily to characterize attitudes or political systems that are thought to deprive individuals of freedom and responsibility, only nominally serving their interests, while in fact pursuing another agenda which is directly against the interests of the individuals.

I’ll stop with all of the highfalutin thinking (and the Wikipedia, oh my!) just to say that the Kingsdale doula ban and birth plan seem to fall somewhere between the more benign (though not-without-controversy) paternalism and the derogatory paternalism.

To explain, I’m sure that the Kingsdale physicians’  attempts to limit a woman’s choice to have a doula, or to forego an IV, or to eat and drink during labor, or to use intermittent fetal monitoring in low-risk labors are all decisions with the goal of “protecting women from harm.”   Nevertheless, these decisions are also, even if unwittingly, depriving the Kingsdale patients of freedom and responsibility and, in some cases, acting in ways that might not benefit women’s interests (which I will explain in more detail soon).

This is troubling.  It is highly troubling.  And it deserves a (carefully chosen) derogatory descriptor, regardless of whether that descriptor hurts people’s feelings.

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In some cases, the birth plan might offer false reassurance to the women under the care of Kingsdale Gynecologic Associates.

One of the first things that bothered me in the birth plan was the claim that Kingsdale’s universal birth plan would help to “minimize the work ahead” of the busy parents in their practice.

On one level, I get that.  I get that expectant parents are busy.  I’ve been an expectant parent–twice–and I was busy the first time and even busier the second time.  And I appreciate that Kingsdale wants to help minimize the work in lots of busy parents’ lives.

But they don’t have to minimize birth options in order to do so.

This doesn’t mean, of course, that I expect every pregnant woman and her partner to scour every single reputable book on pregnancy and birth, or to prepare for labor in the way one prepares for a dissertation.  But I do think that families should devote at least as much time researching labor and birth as they would to researching the new digital camera that they want to buy, or picking out their baby’s stroller/car seat combo, or whatever it is to which they devote their research energies.  Moreover, I think that families should be able to create birth preference lists–lists that don’t exactly map out or plan their births, but lists that help to explain their reasonable and researched wishes to their care providers.

So in an ideal world, if Kingsdale wanted to “minimize the work ahead,” they could make a list with the pros and cons or risks and benefits or alternatives and trade-offs of every single birth intervention they include on their list and then discuss these options with their patients in order to determine their patients’ birth preferences–preferences that might need to change based on the course of pregnancy and labor, but preferences that should be honored, when possible, based on a respect for women’s autonomy and informed consent.

(Okay, I think I’m veering off into dream-world here.)

One of the other (among many) false assurances I found in the Kingsdale birth plan was their claim that “the labor and delivery nurses and doctors together act as ‘doulas’ in a sense that we will be your advocate to provide positioning options, pain control and pushing techniques to make the process as easy as possible.”

I do not doubt that the nurses and doctors who support Kingsdale patients suggest positioning options, discuss options for pain control, and make recommendations regarding pushing techniques.  But I highly doubt that they offer continuous physical, emotional, and informational support during labor.  I doubt that they even have the time to function as a doula during their extraordinarily busy shifts!

And this is not a bad thing–it isn’t their job to be a doula.  And it isn’t a doula’s job to act as a nurse or midwife or doctor!  (For what it’s worth, I will agree with the Kingsdale doctors that any doula who tries to take on one of these roles is acting outside of her scope and should face some sort of reprimand, such as having a grievance filed against her with her certifying agency.)

But a doula does much more than tell a woman how to position herself and how to control her pain–we focus more on helping women to cope with pain, for what it’s worth–and I wish that the Kingsdale physicians would take this into account when they tell their patients that they can act as doulas.

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The doula ban and parts of the birth plan ignore and/or fail to mention evidence-based medicine and severely undermine a woman’s right to informed consent.

This one is the biggie.

It’s the problem that made me nearly jump out of my skin when I read the Kingsdale birth plan.

And it’s the problem that might go unnoticed to many people not well-versed in the birth research–and this would have included myself just over two years ago!

“Evidence based-medicine” refers to medical practices that are based on the highest-quality available research.  And sadly, many of the decisions included in the Kingsdale birth plan dismiss, ignore, or even contradict the most current evidence-based medicine.

Moreover, “informed consent” refers to a process of communication, full disclosure, and decision-making in which patients can not only learn the nature, purpose, and various risks and benefits of a recommended medication or procedure but also make a personal medical decision based on the information that they receive.  And sadly, the Kingsdale birth plan limits a woman’s ability to make a fully informed choice about the maternity care that she receives.

I could go on and on about how the Kingsdale documents effectively undermine women’s autonomy, the right to informed consent, and possibly women’s health in the most sinister and willfully ignorant ways.

But instead of allowing this post to balloon even further into a “Birthing Beautiful Ideas Rant-o-rama,” I’ll just let the evidence-based medicine speak for itself–the evidence that can help women to make better-informed decisions about their births.  And the evidence I cite below comes from the Cochrane Reviews database, a database that includes “all the existing primary research on a topic that meets certain criteria” which is then “searched for and collated, and then assessed using stringent guidelines, to establish whether or not there is conclusive evidence about a specific treatment.”

In other words, this is typically very high quality (and regularly updated) evidence.

And it’s the sort of stuff we want our doctors paying attention to.*

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On restricting nourishment (or oral fluid and food intake) during labor:

“In some cultures, food and drinks are consumed during labour for nourishment and comfort to help meet the demands of labour. However, in many birth settings, oral intake is restricted in response to work by Mendelson in the 1940s. Mendelson reported that during general anaesthesia, there was an increased risk of the stomach contents entering the lungs. The acid nature of the stomach liquid and the presence of food particles were particularly dangerous, and potentially could lead to severe lung disease or death. Since the 1940s, obstetrical anaesthesia has changed considerably, with better general anaesthetic techniques and a greater use of regional anaesthesia. These advances, and the reports by women that they found the restrictions unpleasant, have led to research looking at these restrictions.  In addition, poor nutritional balance may be associated with longer and more painful labours, and fasting does not guarantee an empty stomach or less acidity.  This review looked at any restriction of fluids and food in labour compared with women able to eat and drink. The review identified five studies involving 3130 women. Most studies had looked at specific foods being recommended, though one study let women to choose what they wished to eat and drink.  The review identified no benefits or harms of restricting foods and fluids during labour in women at low risk of needing anaesthesia. There were no studies identified on women at increased risk of needing anaesthesia. None of the studies looked at women’s views of restricting fluids and foods during labour. Thus, given these findings, women should be free to eat and drink in labour, or not, as they wish.”

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On epidural analgesia:

“Epidurals are widely used for pain relief in labour. There are various types, but all involve an injection into the lower back. The review of trials showed that epidurals relieve pain better than other types of pain medication, but they can lead to more use of instruments to assist with the birth. There was no difference in caesarean delivery rates, long-term backache, or effects on the baby soon after birth.  However, women who used epidurals were more likely to have a longer second stage of labour, need their labour contractions stimulated, experience very low blood pressure, be unable to move for a period of time after the birth, have problems passing urine, and suffer fever. Further research on reducing the adverse outcomes with epidurals would be helpful.”

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On continuous electronic fetal monitoring during labor:

“This review compared continuous CTG monitoring with intermittent auscultation (listening). It found 12 trials involving over 37,000 women. Most studies were not of high quality and the review is dominated by one large, well-conducted trial of almost 13,000 women who received care from one person throughout labour in a hospital where the membranes have either ruptured spontaneously or were artificial ruptured as early as possible and oxytocin stimulation of contractions was used in about a quarter of the women. There was no difference in the number of babies who died during or shortly after labour (about 1 in 300). Fits (neonatal seizures) in babies were rare (about 1 in 500 births), but they occurred significantly less often when continuous CTG was used to monitor fetal heart rate. There was no difference in the incidence of cerebral palsy, although other possible long-term effects have not been fully assessed and need further study. Continuous monitoring was associated with a significant increase in caesarean section and instrumental vaginal births. Both procedures are known to carry the risks associated with a surgical procedure although the specific adverse outcomes have not been assessed in the included studies.”

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On continuous labor support (from people who may or may not be doulas):

“Women who received continuous labour support were more likely to give birth ‘spontaneously’, i.e. give birth with neither caesarean nor vacuum nor forceps. In addition, women were less likely to use pain medications, were more likely to be satisfied, and had slightly shorter labours. In general, labour support appeared to be more effective when it was provided by women who were not part of the hospital staff. It also appeared to be more effective when commenced early in labour. No adverse effects were identified.”

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On episiotomy:

“Restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. Women experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days (reducing the risks by from 12% to 31%); with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth. Overall, women experienced more anterior perineal damage with restrictive episiotomy.”

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There are risks.  There are benefits.  There are pros and cons.  There are trade-offs.  There are even mentioned (and unmentioned) alternatives to the above-mentioned interventions and procedures.

And this is only some of the information–only a fraction of the research on obstetrical practices–that women should be able to learn before they decide their birth preferences and before they have these preferences chosen for them.

So why not allow women to seek out this information themselves?

Why not condense it or collate this information for them to make their decision-making process easier?

Why choose for all women’s births, even if they are healthy, low-risk moms?

Why not allow women to choose and decide and think for themselves?

(And now I’m officially (and finally) done blogging about the Kingsdale Gynecologic Associates’ doula ban and birth plan.)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

*Worth noting is that the evidence does not necessarily have to come directly from a Cochrane Review in order for it to be considered the sort of high-quality research needed to constitute “evidence-based medicine.”

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At the end of last month, Courtroom Mama wrote a chilling post on the even-more chilling film, “Crisis in the Crib: Saving Our Nation’s Babies.”  A 2009 documentary by Tonya Lewis-Lee, “Crisis in the Crib” focuses on the striking racial disparities found in U.S. infant mortality rate data.

Specifically, it focuses on the fact that as of 2006, black infants in the United States are more than twice as likely to die in their first year of life as white infants are.  The most frequent causes of these deaths are (in order from most frequent to less frequent): 1) low-birthweight, 2) congenital malformations, 3) sudden infant death syndrome (SIDS), and 4) maternal complications.

Notably, the infant mortality rate is higher for black infants even when one compares babies born to highly educated white and black mothers.

It is higher despite the fact that the smoking rate among white pregnant women is higher than it is among black pregnant women.

And it is higher no matter what the ages of the mothers in the comparison groups.

I have neither the skills nor the education to analyze this data–that is, the numbers themselves–in any meaningful sort of way.  Nonetheless, one does not need such skills in order to feel the deeply sobering effect of the data and the stories described in “Crisis in the Crib.”

And I, for one, felt very much like Courtroom Mama did after watching the film:

Watching “Crisis in the Crib,” I could see the water I swim in for a moment and realized that I sometimes have “birth blinders” on.  I care so much about unnecessary interventions and evidence-based care that it’s tempting to look at our flagging position in rank for maternal and infant health and say “see! It’s the unnecesareans and the pitocin and the EFM!” But the truth, as the documentary shows, is more complicated. The truth is a story that is so big and so awful that it crushes blogs under its tires and we can’t look at it for fear of turning to stone: we live in a nation where the legacy of slavery and segregation is a permanent invisible underclass. Mothers and babies are dying, and I, for one, am not caring enough about it. (emphasis added)

I’m not caring enough about it.

I’m not caring enough about the injustice of a society in which adequate access to transportation, affordable and nearby fresh produce and whole foods, employment options, childcare options, and prenatal care often play out as privileges and luxuries rather than absolute human rights.

I’m not caring enough about the outrage we all should feel over the fact that the stress of racism not only creates chronic stress for many (if not most) African-American women but also puts mothers and babies at greater risk for adverse pregnancy and birth outcomes.

I’m not caring enough about the fact that I’ve often failed to take into consideration the complexities and nuances of the injustices in the U.S. maternity care system in my own analyses and critiques of this system–that I’ve focused on the institutional sexism and ignored the institutional racism of this system.

And it’s certainly time to care more.

The Office of Minority Health (OMH) has a number of resources to get people caring more about the racial disparities in the infant mortality rate in the United States.  I don’t know if any of us can care enough about it, but caring more (and possibly doing something) is better than caring for and doing nothing at all.

• Do you have 30 minutes to spare? You can watch “Crisis in the Crib” and download relevant posters and brochures on the OMH website.  (And then you can send a link to this short film to all of your friends!)
• Do you represent a news outlet or other relevant media? A number of infant mortality experts are listed on the site and are available to do interviews on the topic.
• Do you have the time and the means to host a large event? OMH is seeking health professionals to hold A Healthy Baby Begins With You events in their communities.
• Do you have any interest in becoming a preconception peer educator? OMH is enlisting college-age minority students to serve as preconception peer educators to discuss everything from disparities in minority health to preconception health to HIV and STIs on college campuses and in the community at large.

(Many, many thanks to Courtroom Mama and Jill from the Unnecesarean for reminding me and many others just how much we should be caring about this issue.)

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Update: Apparently the Columbus media has been overwhelmed with the sheer volume of calls/emails regarding the doula ban.  The PR representative from DONA International has successfully scheduled several local media appearances for this week.  She respectfully asks that people now refrain calling the media at this point so that we don’t frustrate them and cause them to find doulas annoying (which is the very situation we are working against!).  Thanks for your understanding and support!

As promised, here are some of my favorite responses to the Kingsdale Gynecologic Associates’ Birth Plan-for-the-worst-and-we’ll-clean-up-the-mess.

Before I get to these “revisions,” might I just add that I have some of the world’s most intelligent, informed, witty, and hilarious readers?  What more could a little blogger like me ask for?!  In fact, I really wish I had the time right now to write paragraphs-long responses to each and every one of your comments: the funny ones, the angry ones, the heartbreaking ones, the insightful ones.  All of them.

So thanks to everyone who took the time to write these comments.  I know that some of you shared very personal, even traumatic stories and details about your births in these comments.  I hope that you find or have found a safe space for healing (Solace for Mothers is a great place to start), and I hope that women who come to the blog can learn from what everyone has written here.

And part of what all of us can take away from these posts and their comments is that we should get away–and FAST–from any maternity care practice that tries to squelch women’s choices and autonomy and that effectively mandates non-evidence based care for their patients.

So without further ado…

Kingsdale Birth Plan

(Revisions/edits/comments are in bold.  Where appropriate–and where I’ve remembered–I’ve linked these comments back to the commentator’s blog and/or website!)

The physicians at Kingsdale Gynecologic Associates are pleased that you have succumbed and will be remanding yourself into our hands. We congratulate you on your pregnancy and hope that your journey through pregnancy, labor, delivery and beyond is exactly what you wish for, as long as your wishes are exactly the same as ours.  Our primary goal is to provide you and your baby with the medical expertise, experience and support you need to have a healthy pregnancy, a safe delivery and a wonderful experience.  We know what’s best for not only your family, but every family. In fact, we know what’s best for the world.  And that is to turn back the clock on decades of progress on human rights, women’s rights, and consumer rights to a time when institutions and authority were respected.  By respect, we mean absolute control.   Because we are gods.  There, we said it.

We recognize that this is a very busy time for you and your family and wish to help minimize the work ahead of you by providing our advice and philosophy in this “birth plan.”  So please don’t bother to crack a book or do any prenatal education on your own because it is so much easier for us to work with clients with no opinions regarding their health care of that of their child. By understanding how we practice and why, we feel that any other formal birth plans (often recommended by books and websites) are unnecessary.  If you have specific requests not discussed in this birth plan, please speak directly with your care provider about them so that we may move you to “stage two” of our pregnancy care, Scheduled C-section.

IV’s: Patients often ask us if IV’s are necessary in labor.  The answer is “yes.”  Do you really think you could get by without one? Have you ever heard of a birth where an IV isn’t used? I mean, how could the baby even get out? Clearly, IV’s are absolutely necessary.

Although we usually give IV fluids through the “hepwell” to keep you hydrated and nourished through the labor process (because none of you are healthy women giving birth–you are all patients who need food through a tube), the most important part is the “hepwell” itself.  If we run into an emergency situation where your life (and the life of your baby) is in jeopardy, we do not want to lose time to intervene by not having IV access.  This is obviously a rare occurrence, but often an unexpected one.

Nourishment in labor: We usually limit women to ice chips and popsicles during labor.  This is not designed as an attempt to starve you.  Nor is it evidence-based. (Starvation is just a pesky side effect of a diet containing only ice chips and popsicles.)  Women often get nauseated, and sometimes vomit, during labor, which can be not only miserable but also dangerous.  It’s also really yucky and we don’t even want to think about cleaning up vomit. We are medical practitioners and went to school for far too long to have to that. Besides, it totally ruins my day when someone pukes on my shiny shoes.

We will also not explain that vomiting in labor is normal (and often a good sign that labor is progressing).  Don’t worry–throwing up bile feels so much better than throwing up food!

In addition, if emergency surgery is required, an empty stomach will predispose you to much less risk.  As a matter of fact, since you MIGHT get in a car accident on your way to work tomorrow, and if you’re in an accident you MIGHT get injured, and since that injury MIGHT require surgery, and since that surgery MIGHT require general anesthesia, and since while you’re under general anesthesia, you MIGHT vomit, and since if you vomit AND the anesthesiologist used archaic intubation methods you MIGHT aspirate your stomach contents into your lungs, and since aspiration IS a serious condition, you should eat only ice chips and popsicles for breakfast before driving to work tomorrow. And for lunch, before driving home. And for supper, before driving to the store. What the heck! Please refrain from eating anything but ice chips and popsicles forever–just to be safe.

Of course, we will give you nourishment and hydration through the IV as necessary.

Anesthesia: We respect a patient’s desire for pain control, or lack thereof, in labor.  The hospitals have multiple options for pain control including positioning techniques (birth balls, etc.), IV pain medication, and regional anesthesia.  Labor, unfortunately, is a painful process.  It is also an unpredictable process and we thus encourage you to have an open mind about your pain control needs.  Some labors are quite rapid and tolerable while others require a great deal of patience (which we lack) and therefore intervention (which we have in abundance).  Basically what we are saying is that the only labors that are tolerable (and therefore able to birth without an epidural) are short labors. If you have a long labor (and we know what constitutes a long vs short labor) we are going to give you pitocin and probably pressure you to get an epidural because when we say patience we really mean pitocin.

Labor without anesthesia: You aren’t really going to try this, are you?

If your goal is to labor without an epidural, we do recommend that you attend an in-depth birthing class that teaches you about focal points and breathing techniques.  The labor and delivery nurses are also quite skillful at helping women with alternative positioning that will help both with the labor and the birthing processes, when they have time in between all the other parts of their job they are doing.  Because they are not overworked at all. Although you will always be supported in your decision to labor without pain control, you can always change your mind if necessary.

IV pain medication: IV pain medication if available for use during labor.  Don’t use a shower, which offers about the same amount of pain relief: it would interfere with the rest of our requirements. The medication can often make women a little sleepy and is said to “take the edge off.”  It will not completely alleviate the discomfort of labor.  We try not to use IV pain medication close to the time of the actual delivery as it depress the baby’s drive to breathe.

Epidurals: Both Riverside Methodist Hospital and The Ohio State University Medical Center have anesthesiologists assigned to the labor and delivery unit who are readily available for the placement of epidurals.  There are unfortunately occasional delays in placement secondary to demand, but the anesthesiologists will always respond as quickly as possible.  The epidural anesthesia is the most common form of anesthesia for labor and delivery because it provides good pain control with little or no effect on the baby.  (Consider this the “informed” part of informed consent, and pay no attention to the list of possible side effects on the waiver we will have you sign during contractions.)

The epidural will make you somewhat numb from the waist down (only if your definition of “somewhat numb” is “I feel paralyzed and can’t move my legs, which now have the weight of a ton of bricks,” but that’s beside the point), therefore you are generally not able to walk after placement.  The nurses will continue to help you with position changes that will facilitate the birthing process.

The choice to use anesthesia or not is ultimately your choice.  There may be situations where we will recommend certain pain management options for you in order to provide the healthiest and safest option for you and your baby.  Ultimately, we want the birthing process to be one you can enjoy and remember fondly.

Fetal monitoring: In order to provide the safest possibly delivery, we feel that fetal monitoring is important during labor in order to assure that your baby is tolerating the process well.  We often accomplish this with continuous external monitors that are placed against your abdomen with elastic belts, despite the fact that continuous monitoring is neither evidence-based nor even required by ACOG guidelines for labors where women and babies are healthy and/or are not undergoing an induction. We will occasionally allow intermittent monitoring during walking and the hospitals have protocols for these times.  If we are concerned about the adequacy of labor or fetal wellbeing, we occasionally use internal monitors, which are more precise.  The intrauterine pressure catheter (IUPC) is a device that goes next to the baby to monitor the strength and frequency of contractions.  The fetal scalp electrode is applied superficially to a baby’s scalp to get the most accurate fetal heart monitoring.  We will not use these internal devices unless we feel they are medically indicated.

(What?  A hand-held doppler?  BWAHAHAHAHA!!!)

Labor support: We do recommend that you have a good support person or two during labor (but not a doula).  We recommend this person to be a spouse, partner, family member or close friend that you feel comfortable sharing such an important event with (but not a doula).  We recommend that you choose someone who will give you comfort when needed, let you rest when needed and who will add to your experience, not take away from it.  Doulas only take away from your experience. The labor and delivery nurses and doctors together act as “doulas” in a sense that we will be your advocate to provide positioning options, pain control and pushing techniques to make the process as easy as possible.  Your support person should be there to do just that–give support.  (You know, like a doula.  Oh wait, we’ve banned them.)

Mode of delivery: Our goal is to provide you and your baby the safest delivery.  We do occasionally need to do c-sections for delivery when it is necessary for you or your baby.  We never do c-sections for our own convenience, except when we do.  If it looks like this may be needed for delivery, we will of course discuss this with you and your support person in detail.  We occasionally need to use forceps and vacuum extraction devices to facilitate vaginal birth, but again, this is always for maternal or fetal indication and will be discussed with you and your support person at the time.

Episiotomies: During the pushing process, the labor and delivery nurse and/or physician will likely perform perineal massage in order to stretch the tissue to accommodate the baby’s head and reduce the risk of tearing.  Although we try to avoid cutting episiotomies, this safe procedure is sometimes required to facilitate birth and to avoid severe tearing and to fit in forceps or a vacuum extractor.  (And just so you know, the OBs at our practice have a 50% episiotomy rate with first-time mothers.) We promise to use our medical expertise and experience to make the best and safest decision for you and your baby.  (And look–you don’t even have to participate in this decision-making process!) The physicians at Kingsdale do not cut episiotomies solely due to “routine” practice.

After delivery: The birth of your child is truly an amazing event.  We want you to be able to bond with your baby as quickly as possible.  If the baby does not require immediate resuscitation, we will usually place the baby on your abdomen or chest, stimulate the baby there, and allow your support person to cut the umbilical cord.  Unfortunately there are situations that necessitate quick response from the pediatric staff in order to care for your baby.  This usually occurs in your room at the infant warmer.  If you and your baby are doing well after delivery, we will try to keep the baby in your room with you as long as possible, often transporting both of you to the postpartum floor together.  If desired, you may attempt “skin-to-skin” care and breastfeeding at this time.  We’re not actually there for this part, so if you want to try all that hippie touchy-feely stuff, we won’t be forced to watch your attempt. With c-sections it is often necessary to take the baby to the nursery prior to your own transport.  In these situations, we will try to get you to your room as quickly as possible to reunite you and your baby.

We hope that this clarifies many of the questions about the birthing process that you may have along the way.  Please feel free to ask questions and obtain clarification if needed from your individual provider.

“Birth is the sudden opening of a window, through which you look out upon a stupendous prospect.  For what has happened?  A miracle.  You have exchanged nothing for the possibility of everything.”   -William MacNeile Dixon

“No one likes change but babies in diapers.” –Barbara Johnson, American author

“History is written by the victors.” –Winston Churchill

There is a secret in our culture,

And it’s not that childbirth is painful,

It’s that women are strong.

-Laurie Stavoe Harm

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Update: Apparently the Columbus media has been overwhelmed with the sheer volume of calls/emails regarding the doula ban.  The PR representative from DONA International has successfully scheduled several local media appearances for this week.  She respectfully asks that people now refrain calling the media at this point so that we don’t frustrate them and cause them to find doulas annoying (which is the very situation we are working against!).  Thanks for your understanding and support!

Please protect yourself and your surroundings from a sudden head-explosion: the Kingsdale Gynecologic Associates Birth Decree of Doom Plan is in.

I’ve spent a good hour or two transcribing this beast, and now I fear that all my cleverness has been zapped into oblivion by its inanity.

I’ve got nothin’ left.

So I’m going to ask you all a big favor: just as I made my own “edits” to Kingsdale’s anti-doula letter, I’d like you to add your own (snarky, sarcastic, evidence-based, empowering, illuminating, etc.) edits to their birth plan in the comments section.  What’s more, I’ll feature your (and perhaps a few of my) edits in my next post.

Fun, right?  It will be like a carnival of humor and disgust and birth-empowerment, with a few Columbus, Ohio OB/GYNs featured as the carnival clowns.

So without further ado, LET THE SNARK (AND THE HEAD-EXPLODEY-SPLODE) BEGIN!

*

Kingsdale Birth Plan

The physicians at Kingsdale Gynecologic Associates congratulate you on your pregnancy and hope that your journey through pregnancy, labor, delivery and beyond is exactly what you wish for.  Our primary goal is to provide you and your baby with the medical expertise, experience and support you need to have a healthy pregnancy, a safe delivery and a wonderful experience.

We recognize that this is a very busy time for you and your family and wish to help minimize the work ahead of you by providing our advice and philosophy in this “birth plan.”  By understanding how we practice and why, we feel that any other formal birth plans (often recommended by books and websites) are unnecessary.  If you have specific requests not discussed in this birth plan, please speak directly with your care provider about them.

IV’s: Patients often ask us if IV’s are necessary in labor.  The answer is “yes.”  Although we usually give IV fluids through the “hepwell” to keep you hydrated and nourished through the labor process, the most important part is the “hepwell” itself.  If we run into an emergency situation where your life (and the life of your baby) is in jeopardy, we do not want to lose time to intervene by not having IV access.  This is obviously a rare occurrence, but often an unexpected one.

Nourishment in labor: We usually limit women to ice chips and popsicles during labor.  This is not designed as an attempt to starve you.  Women often get nauseated, and sometimes vomit, during labor, which can be not only miserable but also dangerous.  In addition, if emergency surgery is required, an empty stomach will predispose you to much less risk.  Of course, we will give you nourishment and hydration through the IV as necessary.

Anesthesia: We respect a patient’s desire for pain control, or lack thereof, in labor.  The hospitals have multiple options for pain control including positioning techniques (birth balls, etc.), IV pain medication, and regional anesthesia.  Labor, unfortunately, is a painful process.  It is also an unpredictable process and we thus encourage you to have an open mind about your pain control needs.  Some labors are quite rapid and tolerable while others require a great deal of patience and intervention.

Labor without anesthesia: If your goal is to labor without an epidural, we do recommend that you attend an in-depth birthing class that teaches you about focal points and breathing techniques.  The labor and delivery nurses are also quite skillful at helping women with alternative positioning that will help both with the labor and the birthing processes.  Although you will always be supported in your decision to labor without pain control, you can always change your mind if necessary.

IV pain medication: IV pain medication if available for use during labor.  The medication can often make women a little sleepy and is said to “take the edge off.”  It will not completely alleviate the discomfort of labor.  We try not to use IV pain medication close to the time of the actual delivery as it depress the baby’s drive to breathe.

Epidurals: Both Riverside Methodist Hospital and The Ohio State University Medical Center have anesthesiologists assigned to the labor and delivery unit who are readily available for the placement of epidurals.  There are unfortunately occasional delays in placement secondary to demand, but the anesthesiologists will always respond as quickly as possible.  The epidural anesthesia is the most common form of anesthesia for labor and delivery because it provides good pain control with little or no effect on the baby.  The epidural will make you somewhat numb from the waist down, therefore you are generally not able to walk after placement.  The nurses will continue to help you with position changes that will facilitate the birthing process.

The choice to use anesthesia or not is ultimately your choice.  There may be situations where we will recommend certain pain management options for you in order to provide the healthiest and safest option for you and your baby.  Ultimately, we want the birthing process to be one you can enjoy and remember fondly.

Fetal monitoring: In order to provide the safest possibly delivery, we feel that fetal monitoring is important during labor in order to assure that your baby is tolerating the process well.  We often accomplish this with continuous external monitors that are placed against your abdomen with elastic belts.  We will occasionally allow intermittent monitoring during walking and the hospitals have protocols for these times.  If we are concerned about the adequacy of labor or fetal wellbeing, we occasionally use internal monitors, which are more precise.  The intrauterine pressure catheter (IUPC) is a device that goes next to the baby to monitor the strength and frequency of contractions.  The fetal scalp electrode is applied superficially to a baby’s scalp to get the most accurate fetal heart monitoring.  We will not use these internal devices unless we feel they are medically indicated.

Labor support: We do recommend that you have a good support person or two during labor.  We recommend this person to be a spouse, partner, family member or close friend that you feel comfortable sharing such an important event with.  We recommend that you choose someone who will give you comfort when needed, let you rest when needed and who will add to your experience, not take away from it.  The labor and delivery nurses and doctors together act as “doulas” in a sense that we will be your advocate to provide positioning options, pain control and pushing techniques to make the process as easy as possible.  Your support person should be there to do just that–give support.

Mode of delivery: Our goal is to provide you and your baby the safest delivery.  We do occasionally need to do c-sections for delivery when it is necessary for you or your baby.  We never do c-sections for our own convenience.  If it looks like this may be needed for delivery, we will of course discuss this with you and your support person in detail.  We occasionally need to use forceps and vacuum extraction devices to facilitate vaginal birth, but again, this is always for maternal or fetal indication and will be discussed with you and your support person at the time.

Episiotomies: During the pushing process, the labor and delivery nurse and/or physician will likely perform perineal massage in order to stretch the tissue to accommodate the baby’s head and reduce the risk of tearing.  Although we try to avoid cutting episiotomies, this safe procedure is sometimes required to facilitate birth and to avoid severe tearing.  We promise to use our medical expertise and experience to make the best and safest decision for you and your baby.  The physicians at Kingsdale do not cut episiotomies solely due to “routine” practice.

After delivery: The birth of your child is truly an amazing event.  We want you to be able to bond with your baby as quickly as possible.  If the baby does not require immediate resuscitation, we will usually place the baby on your abdomen or chest, stimulate the baby there, and allow your support person to cut the umbilical cord.  Unfortunately there are situations that necessitate quick response from the pediatric staff in order to care for your baby.  This usually occurs in your room at the infant warmer.  If you and your baby are doing well after delivery, we will try to keep the baby in your room with you as long as possible, often transporting both of you to the postpartum floor together.  If desired, you may attempt “skin-to-skin” care and breastfeeding at this time.  With c-sections it is often necessary to take the baby to the nursery prior to your own transport.  In these situations, we will try to get you to your room as quickly as possible to reunite you and your baby.

We hope that this clarifies many of the questions about the birthing process that you may have along the way.  Please feel free to ask questions and obtain clarification if needed from your individual provider.

“Birth is the sudden opening of a window, through which you look out upon a stupendous prospect.  For what has happened?  A miracle.  You have exchanged nothing for the possibility of everything.”   -William MacNeile Dixon

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Update: Apparently the Columbus media has been overwhelmed with the sheer volume of calls/emails regarding the doula ban.  The PR representative from DONA International has successfully scheduled several local media appearances for this week.  She respectfully asks that people now refrain calling the media at this point so that we don’t frustrate them and cause them to find doulas annoying (which is the very situation we are working against!).  Thanks for your understanding and support!

Scores of pregnant women in the Central Ohio region recently received the following letter from their OB/GYN practice:

The team at Kingsdale Gynecologic Associates is so pleased that you are expecting.  We look forward to helping you enjoy your pregnancy and hope to provide a meaningful and safe birthing experience.

Because of concerns for increased risk to you or your baby, the doctors at KGA have made a thoughtful, unanimous decision not to allow doulas to participate in the birthing process.  It has been our experience that they may serve to create a state of confusion and tension in the delivery room, which may compromise our ability to provide the safest delivery situation possible for you and your baby.

Again, with safety in mind, we have created a Kingsdale Birth Plan (which can be viewed in the obstetric packet provided at your initial visit), outlining the philosophy of our doctors with regard to labor and delivery.  It is our opinion that other birth plans are unnecessary.  We feel that our many years of obstetric experience in a setting of modern day challenges (larger babies, more difficult deliveries) enable us to provide sound judgment with regard to each woman’s particular needs during her course of labor.

Thank you for your understanding in our hopes of facilitating a safe pregnancy and birth process.

___________________________

Patient’s signature

________________________

Date

*

Oh goodness me!  I think that the editor(s) of this letter forgot to include some very pertinent information in it.  And, to be fair, they’re human–they make mistakes.

Here, let me see if I can take my hand at it (edits in bold):

Dear mindless and will-less womb pod:

The team at Kingsdale Gynecologic Associates is so pleased that you are expecting.  We look forward to helping you enjoy your pregnancy and hope to provide a meaningful and safe birthing experience.  In fact, we hope to provide our own definitions of “meaningful” and “safe” for you.  (We’ll even pull some of these definitions out of a hat–like magic!)  So don’t worry–you won’t even need to use your brain at all when you seek care with us.

Because of concerns for increased risk to you or your baby, the doctors at KGA have made a thoughtful, unanimous decision not to allow doulas to participate in the birthing process.  Nevermind the research showing that doula support has been shown to decrease the use of pitocin, forceps, vacuum extraction, and cesarean section.   This research conflicts with our non-evidence-based worldview.  So we’re going to ignore it.  And come on, what’s so bad about pitocin, forceps, vacuum extraction, and cesarean section?

It has been our experience that doulas may serve to create a state of confusion and tension in the delivery room by encouraging their clients to ask pesky questions about their care and the interventions we suggest during labor.  This may compromise our ability to provide the safest delivery situation possible for you and your baby.  Just repeat after us: Questions are unsafe.  Resistance is futile.  Paternalism tastes like chocolate.

And no, we’re not willing to entertain the possibility of banning particular doulas who may have been practicing outside of their scope or recommending questionable practices to their clients.  No, we’ve made the unanimous decision to avoid nuance, the uniqueness of women’s circumstances, and the facilitation of any and all discussion with other birth professionals in the area.  IT’S UNSAFE!  IT MAKES US TENSE!  AND CONFUSED!

Again, with safety (and the aforementioned avoidance of nuance, discussion, and research we don’t “like”) in mind, we have created a Kingsdale Birth Plan (which can be viewed in the obstetric packet provided at your initial visit and on the blog of one of those pesky, tension-causing doulas after she receives it via email), outlining the philosophy and draconian decrees of our doctors with regard to labor and delivery.  It is our opinion that other birth plans are unnecessary.  We feel that our many years of obstetric experience (and not the many years of transformations in evidence-based maternity care) in a setting of modern day challenges (larger babies and more difficult deliveries that have nothing–we said NOTHING–to do with increased rates of induction, confining laboring women to hospital beds, and a skyrocketing cesarean rate) enable us to provide sound judgment with regard to each woman’s particular needs during her course of labor.  And because we care so much about each woman’s particular needs, we’ve created this birth plan and this doula ban so that we can paint all labors with one, monochrome, universalizing brush.  It’s called logik, people!

Thank you for your understanding in our hopes of facilitating a safe pregnancy and birth process.  And please, don’t go around searching for alternative definitions of “safe pregnancy and birth.”  THEY’RE LIES!  ALL LIES!  BWAHAHAHAHAHAHA!

___________________________

Womb-pod’s signature (preferably in blood)

________________________

Date in which you signed away all your rights as a birthing woman

*

So–do you think those edits are just about right?

Update: If you are in the Columbus area, are planning a hospital birth, and would like to find a practice that supports doulas AND birth plans, please see Emily Neiman, CNM’s comment below and consider transferring to her practice, Women’s Contemporary Health-Care.  This practice comes highly recommended from other local doulas and childbirth educators that I know!

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Remember the Obstetrics & Gynecology editorial on VBAC I wrote about a couple weeks ago?

As of just a few days ago, the online version of the editorial was not available to the public.

Until I wrote this letter:

Dear editorial staff at Obstetrics & Gynecology:

One of my friends recently (and generously) shared a copy of Dr. Scott’s
editorial (“Solving the Vaginal Birth after Cesarean Dilemma”) from the June
2010 issue of your publication.  As a doula, birth advocate, and mother who
had to fight hard to have a VBAC, I was heartened, even excited, by what Dr.
Scott wrote in his piece.  And as I’ve summarized the editorial to other
friends and fellow VBAC advocates, I’ve found that many others share my
enthusiasm.

I was wondering if there was any possibility that you could make the
editorial free to the public.  I don’t know what your protocol is for
expanding article availability in this way, but I do think that this piece
in particular would be enormously helpful for women who would like to
facilitate a reasoned and informed discussion about VBAC with their care
providers.

Sincerely,

Kristen Oganowski

And received this response yesterday evening:

Dear Ms. Oganowski:

Thank you for your message. We have considered your request. The editorial is now free to the public.

*

THE EDITORIAL IS NOW FREE TO THE PUBLIC!!!

Now please go and enjoy it in its entirety if you haven’t been able to read it yet!

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Each week, I get at least half-a-dozen searches to the blog related to pre-labor cervical dilatation.

Search terms/phrases like:

• dilated to a 4 and not in labor
• 0 cm 0 % effaced induction?
• 39 weeks and not dilated
• can you go into labor without your cervix being dilated?
• is it bad to have an “unfavorable cervix?”
• 37 weeks pregnant why aren’t I dilating?

And so on.

Whenever I read these phrases, I always feel a  bit sad and mystified.  Why are women so worried that their cervix isn’t dilating before labor?  Who is making them feel as if their bodies are inadequate, or not cooperating, or unprepared for birth?  Are they being misled by friends, family, popular culture, or even their care providers?  How many of them even have a legitimate medical reason (such as threatened premature labor or impending medically-necessary induction) for their pre-labor vaginal exams?

Here’s the thing: your pre-labor cervical dilation is not a Magic 8 Ball.  It cannot predict when you will go into labor.

Just ask around, and I’m sure you’ll find plenty of women (like myself before A’s birth, and like my mother before she gave birth to me) whose cervix was 0 centimeters dilated and 0% effaced less than 24 hours before their labors began.

I’m sure you’ll also find plenty of women (like my mother before my sister’s birth) whose cervix was 2, 3, 4, even 5 centimeters dilated for days, even weeks before their labors began.

And all of their pre-labor cervical dilatation (or lack thereof) was completely normal.

You might wonder, then, why care providers even perform vaginal exams prior to the onset of labor.

In some cases, there are legitimate reasons to evaluate cervical dilatation before labor.  Some medical conditions (such as threatened premature labor and/or suspected “incompetent cervix”) might warrant a pre-labor vaginal exam.  In addition, if a woman is planning an induction, it is crucial to know not only her cervical dilatation but also her cervical effacement, consistency, position, and the baby’s station so that her care provider can evaluate her Bishop’s Score.  (The higher the Bishop’s Score, the greater chance of a successful induction–or one that ends with a vaginal birth.  The lower the score, the greater the chance that the induction will end in a cesarean section, especially if this is the woman’s first birth.)

But other than these medical indications, most other pre-labor vaginal exams are performed either out of habit or to satisfy a woman’s curiosity–that is, without medical reason.

And in these cases, that “magic number” (only 1 cm?  already 4 cm?) cannot predict when a woman will go into labor–no matter what your family, friends, or care provider tell you!

So for those people who have found my blog using the aforementioned (or similar search terms), and to all of my readers who wonder just what sort of fortune-telling powers your cervix has prior to labor, I want you to gather ’round.

Closer.

Closer.

It is completely normal for your cervix not to have dilated by 37 weeks, 38 weeks, 39 weeks, 40 weeks, and even after your estimated due date!!!

There. Is. Nothing. Wrong. With. Your. Body.

Allow me to say that one more time.

THERE IS NOTHING WRONG WITH YOUR BODY!!!

So in sum, if there is a medical indication for a pre-labor cervical check, then by all means, consult your care provider about your medical condition and determine the relative necessity of your exam.

And please, please learn your Bishop’s Score before an induction, especially if you are planning a non-medically necessary induction!

But if there is no medical indication for a pre-labor vaginal exam, then know that it is entirely within your right to refuse to have such an exam!  (One of the best ways to refuse a pre-labor vaginal exam–besides politely telling your care provider that you do not want one–is to keep your clothes on in the exam room!)

And if you’d still prefer to have this exam–just to satisfy your curiosity (and trust me, I understand this curiosity completely)–then please remember that the number (or numbers) you hear at the end of the exam are not surefire predictors of when your labor will begin.

They’re not achievement awards or performance measures or signs on the Magic 8 Ball: they’re simply signals of the changes that your body is going through, or will go through soon.

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Did your cervix not dilate until you went into labor?  Were you walking around for days or weeks with a cervix dilated to 2, 3, 4, 5…or even 8?  Did you discuss your Bishop’s Score with your care provider before your induction?  Do you wish you would have?

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This morning, I will be sending out my doula certification packet to DONA International.  This moment has been a long time coming for me.  (Long story short, I moved to a new state less than two weeks after I attended my third birth, and this was over a year ago.  My own certification journey became a bit…delayed after the move.)  As part of my certification packet, I needed to write a 500-1000 word essay describing the purpose and value of doula support.  I am pretty pleased with my essay, and I’ve copied it here as a way to celebrate this moment.  Enjoy!  And wish me luck!

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In recent years, people have become more familiar with the concept of a “doula.”  They might know that doulas are women (and, though rarely, men) who offer continuous emotional, physical, and informational support to a laboring woman.  They might even know of some doulas who practice in their area.  What’s more, they might even have misconceptions about doulas: for instance, that doulas are only for women who want un-medicated births, or who want homebirths, or who are not planning a cesarean section.  But beyond these basic understandings and/or misconceptions, what many people do not yet know are the benefits of doula support—the purpose and value of having continuous support during  labor.

The benefits of doula support are well-documented.  According to a Cochrane Review of the research on continuous support during labor,[i] doula support has been shown to increase a woman’s likelihood of a spontaneous vaginal birth (i.e. a birth without forceps or vacuum extraction or cesarean section).  What’s more, women who have continuous support during labor—such as the support of a doula—are less likely to use pain medication, more likely to feel satisfied with their birth experience, and may have labors that are slightly shorter than the labors of those who do not receive continuous labor support.

But these measureable benefits do not exhaust all of the possible benefits that doula support can confer to a woman, her infant(s), and her family.

For it’s difficult to measure the exact amount of reassurance given to a woman when a doula holds her hand and reminds her that “she is doing it!” just as she doubts her ability to cope with the power of her labor.

It’s difficult to measure the joy of a father who tells his doula that “this was the first time that I didn’t feel like I was watching a medical event as my wife gave birth—this time, I felt like I was helping to bring our baby into the world.”

It’s difficult to measure the precise level of relief that the double-hip squeeze gives to a woman working through back labor or the specific level of empowerment that a woman feels when her doula has helped her to research her birth options or the particular type of love that a couple feels when their doula helps to maintain a compassionate and caring birthing atmosphere, no matter what unexpected situations arise.

But these benefits are real, intangible and resistant to measurement as they may be.

And so if I could teach people about the benefits of doula support, I would describe to them all of these benefits and more.  I would let them know of the documented and well-researched benefits of continuous support during labor—the increased likelihood of spontaneous vaginal birth, the decreased likelihood of pain medication, and so on.  But I would also give them at least a glimpse into those intangible benefits too—the ones that represent the love and kindness and humanity and joy that a doula can bring to a woman’s labor.

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[i] Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub2

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