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 Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan.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!

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

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

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?

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.

My in-laws (and my entire family, for that matter) have been a huge support to me during my journey as a doula and birth and breastfeeding advocate.

In fact, they were with me during one of the key moments that ignited my birth advocacy.  And on that night when I vowed, at 36 weeks pregnant, to leave my then-current OB/GYN in search of a more VBAC-friendly care provider, they raised their glasses to me and toasted “to me, our family, and to VBACs!”

Yes, they are fabulous people.  I’m a lucky daughter-in-law.

And I guess it’s no surprise that, given their support and the ways in which my birth-related passions often weave their ways into my conversations with others, my in-laws have become mini-birth advocates in their own right.

Just a couple nights ago, my father-in-law was telling us about how the woman who cuts his hair is pregnant.  During their haircut chit-chat, he mentioned something about my work as a doula.

Because his stylist had never heard of a doula before, my father-in-law proceeded to tell her a bit about doula support: what we do, what our purpose is, etc.  And then he described, somewhat nonchalantly, the fact that she has “all sorts of options that she can choose for her birth!”

(What wonderfully empowering language, right?!)

And she was, in my father-in-law’s words, “completely mystified.”  She was shocked that she could bring additional labor support for her child’s birth.  She was amazed that she had a multitude of comfort measure options.  She was astounded that she had options for her baby’s birth.

Now I don’t know if the hair-stylist at Upscale Male in Naperville, IL went straight home and Googled “doula support” later that evening.  I don’t know if she looked up comfort measures for labor.  I don’t know if she found out her care provider’s cesarean section rate or if she’s even interested in finding out that information.  I don’t even know if she’s going to take a childbirth education class.

But she at least knows now that she has options.

That’s a pretty big deal.  It’s a big deal because it’s something that she didn’t know before she spoke with my father-in-law.  And it’s a big deal because so many women wish we did know this before we birthed our babies.

And on behalf of all birthing women, I’ve got to thank my father-in-law for that.

grandpa and and doula-supporter extraordinaire

Amy Romano and I are currently in the process of collecting and editing all of the fantastic contributions to the NIH VBAC Statement Primer.

As we get closer to publishing the primer on the new Lamaze community site, Giving Birth with Confidence, we’re also starting to think about the sorts of images we’d like to include in this project.

Although Amy and the site administrators at Giving Birth with Confidence do have a good number of stock images related to pregnancy and childbirth at their disposal, we’d like to keep with the grassroots spirit of this project and include some personal photographs in the primer.

And we’d like to receive some of these photos from you!

Do you have pregnancy pictures you’d be willing to share?

Cesarean section pictures?

Pictures of you during labor?

Pictures of you and/or your family with your VBAC baby?

Pictures from the NIH Consensus Development Conference on VBAC?

Pictures of you at an ICAN meeting, a birth rally, or any other pregnancy and childbirth-related event?

If you’d be willing to include any of these photos in the online version of the NIH VBAC Statement Primer (which, to reiterate, will be housed on the Giving Birth with Confidence site), then please send them via email to me at:

koganowski (at) gmail (dot) com

Just to be as clear as possible, these images will be shared on a public site, so please don’t send any photographs that you wish to keep relatively private.

I look forward to hearing from you!

Women making a difference! Jen Kamel (from VBACfacts.com), Desirre Andrews (president of ICAN and contributor to the primer), Gina Crosley-Corcoran (The Feminist Breeder), and yours truly at the NIH Consensus Development Conference on VBAC.

First thing’s first: the lucky winner (chosen at random on random.org) of a copy of Penny Simkin’s remarkable book, The Birth Partner, is…Jillian, who commented on Facebook that, “Doulas are for women who are trained in the medical field, especially those that provide care for others during the time surrounding pregnancy and infancy. Sometimes knowing too much, especially about potential complications, can lead to a lot of anxiety. A doula encourages the quieting of mental noise through reassurance and empowerment, so relaxation and and trusting in instinctual body urges can take over.”  Congratulations, Jillian!

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I have been so moved and inspired by all of the entries to my giveaway contest for International Doula Month.

When I first came up with the idea for this contest, I thought that people would offer up simple statements in their entries: that doulas are for moms of singletons, or moms of multiples, or teen moms, or moms over 40, or women who are birthing in a hospital, or women who are birthing at home, or women birthing with midwives, or women birthing with obstetricians, and so on.

All of these statements are just as important, just as crucial to the public understanding of doula support, as any of the statements that you all sent in to me.

But the ones that you did send were especially thoughtful.

So thank you to all of those who entered the contest.  For those of you who didn’t win, I hope that the statements below are enough of a gift back to you, whether you are a mother, a birth professional, or even simply a friend of birthing women.

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Doulas are for women who want to have an empowering childbirth experience!

Whether through information, support, encouragement, processing, and so forth, a doula helps a woman realize that she has more strength than she ever knew!

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Doulas are for women who miss their mothers.

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For many women and their partners, the cost of doula support (which can range anywhere from a couple hundred to a couple thousand dollars) can seem quite prohibitive.

This is often the case even if they value the commitment and work that a doula offers to each of her clients and even if they already know about the invaluable benefits that doula support confers to laboring women.

But even with limited funds, it can be possible for almost any woman who wants a doula to hire one.  Here’s how.

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Consider hiring a certifying doula.

Doulas who are in the process of certifying will often offer reduced fees or even free services to their clients.  Finding a certifying doula can be a wonderful route to take if you are seeking out more affordable doula support!

Some women have success finding certifying doulas on Craigslist or other local community boards where new (and more experienced doulas) will advertise their services.

As with any other doula search, you can also check Doula Match to find new doulas offering reduced rates in your area.  In addition, you can send an email to doulareferrals@dona.org to request a list of uncertified DONA International member doulas in your area.

For what it’s worth, don’t be worried that you will automatically receive “inferior” support from a new doula.  Finding the right doula is more about finding the person who you feel most comfortable with than finding the person who has attended hundreds of births.  And a new doula might end up being just the perfect doula for you!

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Find a local doula who will barter for part (or all) of her fee.

Do you or your partner make things?  Fix things?  Sell things?

Are you handy with a paintbrush, a wrench, or a sewing machine?

Do you clean houses, cook meals, or offer massage therapy?

Then you might be able to find a doula who is willing to barter with you in exchange for her services!  And especially if your service is pregnancy, parenting, or breastfeeding-relevant, you might even develop a good business relationship in the process.

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Simply ask for a payment plan, a reduced fee, or sliding scale based on your income.

Many doulas will offer a reduced fee to women or families who cannot afford the regular fee.  Many are also willing to set up a contractual payment plan so that you can spread the payments out over time rather than paying the doula fee in one or two large installments.  It never hurts to ask one or more of your local doulas if they are willing to offer these payment options to you!

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Seek out a local or national volunteer doula organization.

Radical Doula created a fabulous list of volunteer doula organizations throughout the United States and Canada.  (Make sure to check out the comments section for further contributions to this list!)

Thus far, the only national program on the list is Operation Special Delivery, an organization that provides volunteer doulas to women whose partners who will be deployed at the time of birth or who have been severely injured or lost their lives during the current wars in the U.S.  I’m not aware of any others, but if you know of one (or more), please let me know!

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So don’t think that a doula isn’t for you just because you don’t think that you can afford one.  With just the right research and just the right questions, you might be able to find low-cost or even free labor support from a doula near you!

This post is a part of my “Doulas are for All Types of Women” series honoring International Doula Month.  I’m also giving away a copy of The Birth Partner by Penny Simkin for International Doula Month.  Please see my original post in this series to find out how you can win!

“My husband/partner is going to be right with me during my labor.  S/he even took the whole childbirth class with me!  Why would we ever want or need a doula?!”

I’ve heard and seen many pregnant women ask themselves this very question.  Most of the time (though certainly not all), I think that this question rests on a few misconceptions about childbirth, doula support, the expectations we have of “inexperienced” birth support people, and the realities of birthing in a hospital.

In other words, even if you think that your own personal birth partner negates the need for doula support during your baby’s birth, you might be surprised about just how much you might want a doula when you’re actually in labor!

This isn’t to say that you might find that when it comes to labor, you personally don’t really need or want a doula.

Maybe your partner is a “natural” when it comes to birth support.  Maybe your care provider is one who has the time to stay with you throughout your labor and support you and your partner as you bring your child into the world.  Maybe you are birthing at a place where the staff also has the time to offer you continuous support throughout your labor.  Or maybe you’ve chosen to birth unassisted!

But before you dismiss doula support entirely, please consider the following reasons why you still might want–or even need–a doula when the big day arrives–even if you have a wonderfully supportive partner right by your side.

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Doulas don’t just support the laboring women–they also support their partners.

Without a doubt, the person working the hardest on any “birthing” day is the woman giving birth.  (And before anyone gets the silly idea that the surgeon is the person “working the hardest” during a c-section, let me just remind you that s/he probably doesn’t have to recover from major abdominal surgery and care for a newborn after the surgery is over!)

But this doesn’t mean that the laboring woman is the only person who might need or want support.

A doula can gently remind the woman’s partner to take “nutrition breaks” to keep up his or her energy for the work ahead.  (I even keep a few Luna Bars in my doula bag so that dads and/or other partners–including myself–have something to snack on!)

A doula can model various massage techniques or other comfort measures so that the mother’s partner can know (and have the confidence) to do them him or herself.

My husband and my doula--my perfect partners!

A doula can reassure a woman’s partner about the “normalcy” of the birth process.  A woman’s sounds, her movements, her intensity, her bodily functions, and her vulnerability during labor might be unusual and even scary to her partner in any other situation.  But during birth, these behaviors are quite normal.  And  doula can help a partner not to be overly frightened or bothered by the work and sights and behavior of birth.

Of course, when birth is not “normal”–when something unexpected, such as a cesarean section and/or an emergency, occurs–a doula can continue to offer emotional support, encouragement, and appropriate reassurance to both the laboring woman and her partner.

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A doula can help you and your partner have a more intimate birth experience.

Some couples are afraid that a doula will interfere in an experience that they want to be wholly intimate and personal.

But unless the couple is birthing in a birth center or at home, they might not realize that birth in a hospital is often not intimate and personal.  Between the triage units, the monitoring machines, the rotating cast of hospital staff, nurse shift changes, paperwork requirements, hospital protocol, and the typical noises and hustle and bustle of the hospital, intimacy can be hard to come by on a labor and delivery floor.

Perhaps surprisingly, adding a doula to the mix can help a couple to protect the intimacy of their hospital birth as much as possible.

For instance, if a woman and her partner are sharing a particularly close moment, their doula can wait outside their room and kindly ask any hospital staff or care providers to wait to enter the room for a few more minutes (barring any urgent needs, of course).

A doula can even help to “set the tone” for a birth by maintaining a calm presence throughout a woman’s labor.  Without a calm and peaceful atmosphere–and labor and delivery units are rarely, if ever, inherently calm and peaceful–it can be difficult to achieve any sort of intimacy, especially during a birth!

And finally, the general support that a doula offers to a woman’s partner can help to make a couple’s experience more intimate and personal.  For when a partner is reassured about the “normalcy” of birth, and when s/he gets some idea of what s/he can do to help a woman who is laboring, then it becomes much easier for the couple to feel closer to one another during labor.

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With a doula present during your labor, your partner doesn’t have to worry about remembering everything s/he learned during your childbirth education class.

Here’s one of my favorite analogies: imagine asking someone to watch a couple games of football on television and then go out the next day and coach the Superbowl.

(Or for those not sports-inclined, imagine asking someone to watch a couple episodes of Bob Ross on PBS and then go out the next day and paint like Monet.)

That’s almost exactly what we ask of dads and other partners when we ask them to attend a childbirth education class and then offer labor support like a pro!

This is not to say that childbirth education classes are worthless.  Far from it.  A good childbirth education class is an enormously helpful, if not essential, component of birth preparation.  But it can be difficult for a person to watch his or her partner in labor–to know that the baby is really, truly on the way–and simultaneously remember everything that s/he learned in class!

A doula can take away some of that responsibility.  She can remind birth partners about what they learned in a childbirth education class when necessary, and then step back so that the partner can demonstrate what s/he has learned.

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Doula support has multiple (and unique) benefits for both moms and babies.

I couldn’t say it any better than this (from DONA International):

Numerous clinical studies have found that a doula’s presence at birth

• tends to result in shorter labors with fewer complications
• reduces negative feelings about one’s childbirth experience
• reduces the need for pitocin (a labor-inducing drug), forceps or vacuum extraction and cesareans
• reduces the mother’s request for pain medication and/or epidurals

Research shows parents who receive support can:

• Feel more secure and cared for
• Are more successful in adapting to new family dynamics
• Have greater success with breastfeeding
• Have greater self-confidence
• Have less postpartum depression
• Have lower incidence of abuse

In a word, doula support is truly invaluable for a woman and her partner!

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Doulas support is intended to “fill in the gaps” of your labor support team–not to replace anyone who is present at your birth.

Doulas don’t replace dads, partners, or even nurses, midwives, or doctors–they work alongside them.

Rare is the instance in which a nurse, midwife, or doctor can offer continuous support to a woman throughout her labor.

Rare is the case in which a nurse, midwife, or doctor can offer even temporary support to a laboring woman exactly when she finds that she wants or needs it.

Doulas can help to fill in these gaps.

What’s more, doulas can fill in knowledge gaps (reminding a couple of the risks and benefits of any recommended interventions), emotional support gaps (reassuring a couple of the “normalcy” of the intensity of birth), and physical support gaps (demonstrating comfort measures such as position changes or massage techniques) that may exist among a woman’s other chosen birth partners.

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So please don’t assume that a doula isn’t for you even if you have the world’s greatest husband/spouse/boyfriend/girlfriend/birth partner extraordinaire!  You might just find that having the right doula present during your labor might offer you and your birth partner just the sort of support that you want and need as you bring your baby into the world.

This post is a part of my “Doulas are for All Types of Women” series honoring International Doula Month.  I’m also giving away a copy of The Birth Partner by Penny Simkin for International Doula Month.  Please see my original post in this series to find out how you can win!