This is just a short follow up on my previous post about the importance of a postpartum lying in period, and postpartum care in general. After we have our babies, we focus so much on how baby is doing, which we should. This beautiful video by Elizabeth Stopford entitled “The 10th Month” is an artistic and eloquent reminder of how important it is to also focus on how we are doing. Those first few weeks are amazing and beautiful, but they can also be difficult and frustrating. That is all ok. Just keep checking in with yourself to see how you are doing, and you’ll see that each day gets a little better. If you haven’t asked yourself in days, weeks, or months, “How am I doing?”, take the time to do so today, and regularly moving forward.
Some women need to be induced for medical reasons, or choose to be induced for other reasons. No matter what your birth circumstances, the most important factor in having a positive birth is feeling informed and empowered in all your decisions. This implies that you are first given the opportunity to make the decision for yourself, rather than having your care provider make it for you. If you know you would like to give birth in a hospital, and are planning to have or need an induction, it is important to educate yourself ahead of time so that you know what the procedure involves, and can give a TRULY informed consent. That way you will feel in charge of your birth experience, which will increase the likelihood of feeling good about your birth experience after the fact.
INDUCTION: Labor Induction is defined as a procedure used to stimulate uterine contractions during pregnancy before labor begins on its own. This means that someone is initiating the labor process rather than having the baby initiate it when ready. If you’re doctor recommends induction, it is important to weight the risks and benefits before agreeing. First of all, know that ACOG (the American Congress of Obstetricians and Gynecologists) does not support induction before 41 weeks without medical necessity.(Source ACOG) Ideally, induction will be recommended only in situations where the risks of continuing the pregnancy are greater than the risks of induction, and when your Bishop Score is favorable. If you don’t know what your bishop score is, you can calculate it with the information obtained from a cervical exam by using this calculator. It is basically a calculator that tells you how ready your body is to go into labor at that moment. A bishop score lower than 6 or lower has a low chance in ending in a successful vaginal delivery, while a bishop score of 8 or higher has a good chance. Here are some situations in which induction may be less risky than allowing the pregnancy to continue:
- You have a medical condition that is putting you or your baby at risk, such as Preeclampsia or Gestational Diabetes. Please note that both of these conditions can be managed, but they can also have life threatening complications for both mother and baby. If you’re doctor recommends induction, ask all the questions you may have about your current condition and its effects or possible effects on your and baby. This way you feel fully informed before deciding to move forward with your induction.
- The placenta has peeled away from the uterine wall, either completely or partially. This is called a placental abruption, and it can deprive the baby of oxygen and nutrients. In the mother, it can cause heavy bleeding and hemorrhage. In this case, the baby must be born. Depending on the severity of the abruption, either an induction or a cesarean section will be required.
- The placenta has begun to deteriorate. This naturally occurs as the pregnancy reaches term and goes beyond. Once you have reached full term (41 wks) your OB or midwife may choose to begin Biophysical Profile and Non Stress Tests to keep track of the health of baby. These tests will give your care provider the information necessary to know if your baby is doing well in utero, and if the placenta is still in tact. Signs of placental deterioration will show up on these tests, and if they are present, you and your care can then come up with a plan for induction or cesarean birth.
- Your baby has IUGR, or Intrauterine Growth Restriction. This means that baby is not growing at the expected pace. This is often a sign of a placental or umbilical cord problem, which means that baby is not getting enough nutrients. If you are past 34 weeks, induction will be recommended, however if you are not that far along, baby will need to be monitored further until he/she is old enough to be delivered.
- There is an infection in your uterus
- Your water has broken, but you are not having contractions, also known as premature rupture of membranes or PROM. when PROM occurs, it is safe to wait 48-72 hours without an increase risk of infection to the baby or mother (Source: Evidence Based Birth)
- You are approaching two weeks beyond your due date. Keep in mind that you are not considered full term according to current ACOG guidelines until you are 40 wks 6 days. Also, a newborn has the best chance of not suffering any complications postpartum if it is born between 39 and 41 weeks. (Source: Evidence Based Birth)
So now that we know why inductions are performed, lets talk about how they are performed. There are three steps involved in induction: 1.)ripening the cervix, 2.)rupturing the membranes, and 3.)stimulate contractions.
- RIPENING THE CERVIX: The cervix is naturally positioned at the back of the vagina. Throughout most of your pregancy, it is hard and closed, protecting the baby from external elements. When your baby is mature enough to be delivered, the body begins the process of ripening the cervix, which includes effacement & dilation. Effacement is measured in percentages, 0% being a cervix that is still hard and thick, and 100% a cervix that is completely softened and thinned. Dilation is measured in centimeters, and represents the opening of the cervix from 0 cm to 10 cm. Ripening the cervix can be done in many different ways:
- Foley Cathedar is a device that
- RUPTURE OF MEMBRANES: This is also known as breaking your water, or an amniotomy. It is not always done during an induction, but sometimes, this can trigger contractions to begin naturally due to the increased pressure on the cervix. The procedure involves your care provider inserting an amni-hook into cervix, and create a hole in the amniotic sac, thus allowing the amniotic fluid to escape and removing the cushion otherwise provided between the baby’s head and the cervix. There are, of course, risks involved in an amniotomy, as with any procedure, and it is important to know these risks in order to make an informed decision on whether or not to consent to this procedure. According to ACOG, an amniotomy should be performed when a mother’s cervix is dilated and effaced, and the baby’s head has moved down into the pelvis (Source: ACOG)
- MAKING CONTRACTIONS: At this point, your body is ready to begin responding to contractions (or as ready as it is going to be). Hopefully, you are given some time to see if the previous procedures trigger contractions. If you are not, or your body does not begin to contract naturally, then medically induced contractions are necessary. In a spontaneous birth, the body releases oxytocin, which triggers uterine contractions. In an induction, synthetic oxytocin, in the form of pitocin or syntocinon, will be used to trigger contractions. Ideally, you will be given a slow drip of pitocin to see if your body begins to react and produce oxytocin on its own. This will help keep contractions more manageable as well. This is because in natural labor, the contractions increase in intensity over a long period of time, which gives the body time to build up it’s own supply of natural endorphins to reduce the perception of pain. If the pitocin is increased slowly, the body is given a chance to respond with endorphins before the pain becomes too much to bear.
I hope this is helpful to any moms who are faced with the decision to consent to an induction or not. I’m listing some other great resources for you to look over as well. Feel free to comment with any questions. Thanks!
“…As a country, we are sending millions of women back to work every year incredibly, and kind of horrifically soon after they give birth. that’s a moral problem…(and) it’s an economic problem…”
~Jessica Shortall, author of Work. Pump. Repeat: The New Mom’s Survival Guide to Breastfeeding and Going Back to Work
I came across a TED talk by Jessica Shortall on the subject of paid family leave after baby. It was recorded late last year, and it speaks to the problem with our postpartum leave policies in the US. 40% of working women in the US are the sole or main source of income for their families. Unbelievably, 88% of working women in America have no access to paid maternity leave. That is a huge number. On top of that, nearly 50% of new mothers also don’t qualify for FMLA (unpaid) leave. Of the small amount of women who do qualify for unpaid leave, the majority of them can not afford to take that time out without major implications to their family’s financial well being.
As Doulas, we often speak to mothers about the importance to lay in with baby and bond, but as a country, we need to address how to make that possible for more mothers. Here is the link to the video:
When you find out you are pregnant, you’re often flooded with a list of ideas of things you need to prepare for. You want to start thinking about decorating the babies nursery. You want to get pregnancy books and read about the journey ahead of you. You want to look into childbirth classes to learn about how to have a great birth. But so often, expecting mothers neglect to look into the one person that can hold the key to that great birth she is hoping for: her care provider. So often, expectant mothers are already so familiar with their existing OB or Midwife that they assume that their good bedside manner for annual exams, pap smears, and birth control chats will easily transfer over to a good fit for labor and delivery. Unfortunately, if you have not labored previously with him or her, how can you really know how they will react to your birth plan? Will they be onboard with your vision? Are their office policies in line with your expectations of your birth. The pregnant mother – care provider relationship is one that we women often look at from a reverse perspective, especially as a first time mother. There is so much that we don’t know the first time we are expecting that we often assume that since the doctor knows so much more about pregnancy, labor and delivery than we do, that they have the right answer, but this may or may not be true.
It’s important to remember that we are the one’s hiring the doctor, and they provide a service for us. If we were hiring an architect to design our home, would we assume that the architect friend we know who is very kind to us will be a good fit to work with and to design something that is in line with our desires? Most likely not. We would interview him, along with several other designers in order to make sure we’ve selected the right person. We’d also look at his portfolio, and ask for recommendations. It is our responsibility as patients to do the same when it comes to the care provider we select to support us through pregnancy and at our child’s birth. OK, so an OBGYN or Midwife doesn’t have a portfolio that we can glance through, but there are ways to find out if they would be a good fit. First, ask other mothers in your community for recommendations of doctors who will support the type of birth you are hoping to have. If you are hoping to have a vaginal unmedicated birth, VBAC, waterbirth, etc, ask specifically for people who have successfully achieved this and find out who was their care provider. Mention your care provider and get feedback. Local mom’s groups and natural birth/parenting networks online or on social media are a great place to get open feedback like this. If you get negative feedback for your care provider, move on. Once you’ve decided on a provider who has good recommendations, make an appointment to have a consultation with them, and come prepared with questions. Here is a good comprehensive list you can start with:
- What prenatal tests do you require or recommend?
- What is your view on labor and delivery?
- Can I move around during labor?
- What positions can I labor in? Push in?
- Can I eat or drink during labor?
- How will the baby be monitored?
- How often will the baby be monitored?
- Can I labor in the water? Deliver in the water?
- Do I have to have an IV?
- What is your Cesarean Rate?
- What is your induction rate? At what gestational age do you typically induce, and for what reasons?
- What are your views on episiotomy?
- Do you allow delayed cord clamping and cutting?
- How long can i be skin to skin with my baby before he/she must be taken away for procedures? (ideally 1-2 hrs)
- How many deliveries are you performing in a month?
- What happens if two mothers are in delivering at the same time?
- have you ever missed a birth?
- Will you do a vaginal breech delivery or vaginal twin delivery?
- What do you do if a mother goes beyond her due date? beyond 41 wks? 42 wks?
- How many patients of yours hire a doula? How do you feel about working with doulas?
- What do you consider a high risk pregnancy
This list should give you a good idea of the doctor’s practices, and let you know if your birth plan will be respected. That way, you will go into your baby’s birth knowing that your care provider is supportive of your choices, and will give you every possible opportunity to have the birth you envisioned.
Is there anything you think I might have missed? leave me a reply below!
Many hospitals in Cincinnati now allow parents to delay baby’s first bath, and there are many reasons to do so. Did you delay your baby’s first bath. Here’s a great article on why perhaps you should consider it for your next baby.
For all the people who have asked me why I got a doula for my births, or if/why they should consider getting a doula, here is a great article about why doulas are worth the cost.
Birth can leave a mother with a euphoric high, especially when it is unmedicated. However, now a days, a natural unmedicated birth has become somewhat difficult to come by. This leaves a lot of mothers asking themselves what they should do to ensure a natural birth, or to put it more precisely, an unmedicated vaginal birth. First off, it’s important to keep in mind that birth is not something we can control. More often than not, we just have to ride the wave and go with the flow. That being said, there is no way to really ensure you will have a natural birth, but there are definitely somethings you can do to increase your chances of having the birth you are hoping for.
- Stay home as long as you can. The less time you spend in the hospital, especially in early labor, the less time you have for any interventions to occur. Not to mention that you want to be comfortable during early labor to allow your body to do its work, and I am certainly more comfortable in my own bed with the lights down than in a hospital room with beeping machines and bright lights. Keep in mind, that even if you know this and are trying to follow this advice, chances are you will still arrive at the hospital earlier in your labor that you thought you were, especially if it is your first birth. Just make sure you know the emotional signposts of labor so that you and your partner know what to look for to let you know it is time to go to the hospital. If you’re having a home birth, feel free to ignore this bullet 🙂
- Select a care provider who is supportive of your wishes. I can not emphasize this enough. No matter how well you plan and how much you educate your self, if your care provider ‘s policies are at odds with your wishes it will be difficult, if not impossible to convince them of your choices. This means that first off, you need to know what you want to happen during your labor and delivery, and more importantly, you need to know what you DON’T want to happen. For example, if you don’t want to have a cesarean (unless medically necessary), then make sure you know your providers cesarean rates. If they are high, or if he/she doesn’t know them, then they are not the best provider for you. As the patient, you need to educate yourself about the practice you have chosen, and if the reality isn’t looking good, it’s ok to cut your loses and find a provider whose culture reflects what you envision for your birth.Some red flags of an OBGYN office or provider who is not very supportive of natural birth are:
- High cesarean rate
- A doctor who will not allow you to go past your due date
- A doctor who wants you hooked up to continuous fetal monitoring, i.e. not able to move around or change positions.
- A practice or doctor with a high elective induction rate.
- Have a birth plan. In fact don’t just have one, have one that your provider has signed. This way, if the hospital staff question your birth plan, they will see your provider’s signature and clarify with him/her before denying you anything you have listed on there. Having a birth plan requires a lot of research on your part, but it also prepares you to understand all the interventions and options that exist, especially in a hospital setting. Knowing your options is essential to providing informed consent to any interventions that may end up being necessary. Writing a birth plan can be daunting, especially for a first time mom. A doula can be a huge help with this. Doulas have a wealth of knowledge and statistics on birth, interventions, and the choices you have. They can help you come into your birth confident and informed. Here is a sample birth plan if you’d like to take a look..
- Go into labor naturally. That is avoid induction unless it is truly medically necessary. It has been shown that women who are induced before their body is ready to go into labor are at a higher risk for Cesarean Section and babies are at higher risk for needing to spend time in the NICU. If your care provider recommends induction, make sure you are knowledgeable about the circumstances under which induction is necessary and those under which it is not. Situations in which induction is medically necssary are diabetes, pre-eclampsia, infection in the uterus, when baby is not growing properly in the uterus, when a placental abruption occurs, or premature rupture of membranes. If your caregiver gives reasons other than this, such as a “big baby”, you have the right to decline. Basically if mom and baby are doing well, let baby tell you when it’s time for him/her to come.
- Take a childbirth education class, preferably one that focuses on having an unmedicated vaginal birth. It is important that you are educated about the process of birth, whether you plan to give birth at home or in a hospital. Taking a childbirth class is a great way to begin this education. I would recommend taking a class that is more than just a few hours at the hospital. The short hospital birth classes generally just give you an idea of what the hospital’s policies are, and how they handle birth. This is not bad information to have, but it’s even more important to know about the process of birth, its stages and signposts, and how to manage pain during labor without analgesics if this is your goal. Some great options are Lamaze, Bradley Method, and Hypnobirthing. These courses will teach you techniques for managing labor as well as offer you lots of evidence based information about labor and common interventions. This leads to my next point.
- Educate yourself. If you are going to walk into a providers office with a well laid out birth plan that states the many things you would like to have, and would like to avoid during birth, you need to be armed with evidence based information as to why you do or do not want them. Know ACOG’s most recent guidelines. Visit Evidence Based Birth‘s website, and others that offer statistics and information in regards to birth and interventions. This information will prepare you to have an educated discussion with your care provider knowing that the facts are on your side. If you’re going to read books, and I recommend you do, choose books that support your vision of a normal unmedicated birth. Any book by Ina May Gaskin is wonderful (I particularly love Ina May’s Guide to Childbirth), as are many others.
- Be prepared with techniques for handle pain without analgesics (medications). If you’ve taken a Bradley Method or Hypnobirthing class, then you are already going into your labor with some great tools. Add to that some music or hypnosis playlists, aromatherapy, massage techniques, and access to shower/bath, and you will have a great toolkit for handling pain throughout labor. A doula can be a great help with this. Doulas will know how to massage, apply counter pressure, get you in a better position, and help you feel as comfortable as possible throughout labor.
- Hire a doula. Doula’s are trained to understand labor and birth, and they are trained to offer emotional and physical support to the laboring mother throughout labor and during the immediate postpartum period. A doula can also support your partner and help him be a greater asset to you. Also, a doula can be a huge asset well before you go into labor. Most doulas help with writing birth plans. They also offer education and evidence based information so that you can walk into each appointment with your care provider ready to ask the right questions so that you can be sure you and your care provider are on the same page when the big day comes.
Hopefully you found this list helpful. Feel free to comment below with any questions you might have.
I saw this article from midwifethinking.com posted by another local doula, and I found it very interesting. I had an anterior cervical lip during my labor with my second daughter. I didn’t realize until I did a little research after my delivery that it isn’t uncommon. As this article states, at some point in labor, most women will have an anterior cervical lip. Whether or not it is detected depends on whether or not a woman consents to a vaginal exam. As doulas, we can not perform vaginal exams to check dilation, so we have to watch for other cues of what stage of labor the mother is in. Also, it is becoming more and more common (at least where I live) for women to request to not have any vaginal exams during labor unless medically necessary. This means that the exact number of cms she is dilated is not information we will be privy to in a lot of labors we attend. It is important for us as doulas to understand what the anterior cervical lip is, and how the body works through it, so that we can then support the laboring woman to navigate this without fear or anxiety. Here is the article from Midwife Thinking below.
This post touches very close to home for me. Nearly three years ago I had my first baby, Norah. She was as stubborn then as she is today, sitting in a complete breech presentation that we didn’t discover until 39 weeks 3 days. After spending several days doing everything under the sun to attempt to turn her, we went into the hospital for an ultrasound knowing that if she had not turned, it would be followed by a scheduled cesarean section. She, in true Norah fashion, had stayed right where she was, curled up and cozy, still in a complete breech position. After coming to terms with the fact that my dream natural birth would now be a cesarean delivered, and after going through a somewhat rough first 48 hours of recovery, I was hit with another wave of disappointment. My baby was continuing to lose weight. I was given a couple of days to continue to try and breastfeed her and see if she started wetting diapers and gaining weight, but the pressure was on. As any breastfeeding mother knows, pressure and stress are not the most conducive to successful breastfeeding. On our 5th and final day in the hospital, as we were getting ready to leave, I was told that I had to supplement with formula before being discharged. We agreed, but I was crushed. Not only had I not been able to have the birth I had hoped for, but I had also not been able to breastfeed my baby, something I was told was easy and would just happen if i tried hard enough. The shame that I felt was overwhelming. And it didn’t stop there. When we saw our pediatrician, he was supportive of supplementing to keep Norah from continuing to lose weight, but also mentioned that I needed to try harder and see if we could eventually drop the supplement. At post surgical appointments with my OBGYN, I was told the same thing. Keep trying. When trying to talk to friends about our issues, I was told the same. Just keep it up and it will happen. Three weeks into her life, after too many sleepless nights of non stop nursing and screaming, and my milk still not coming in, I quit. I cried, and I quit. I felt like I was a failure, and I felt like there was no one whom I could talk to about it without being seen as a quitter and a failure.
Today, looking back, I know that I was also fighting an uphill battle with postpartum depression and anxiety. It left me wondering if there is anyway care providers can be supportive of breastfeeding without leaving formula feeding mothers feeling ashamed or judged. Now that I see my incredibly healthy and intelligent nearly 3 year old, I am at peace with our decision to formula feed, and I know that it was the only way we were both going to get through those early days of motherhood for me and life for her. She needed the nourishment, and I needed to let myself heal mentally from the trauma of her birth. The sleepless nights, and the stress of failed breastfeeding were not allowing me to do that. Today’s new ACOG guidelines on breastfeeding still strongly support breastfeeding as important and necessary, but hopefully, they will also allow for formula feeding moms to be open about their feeding decisions without fear of judgement from their care providers. Below is a forbes article on the new guildelines.
Doulas in the news! 😊
I just wanted to share this fantastic article on NPR about doula care and its implications on healthcare costs. I love seeing more and more stories like this, and I hope that eventually insurers will take note of this data, and these news stories will begin to break down the financial barriers that keep many women from receiving doula care.
Read the full story
Women With A Doula Are Less Likely To Have Preterm Birth : Shots – Health News : NPR http://www.npr.org/sections/health-shots/2016/01/15/463223250/doula-support-for-pregnant-women-could-improve-care-reduce-costs