Your Birth People

Pregnant? Now what?

Whether you know it or not, your birth can be dramatically different depending on the caregiver you choose and place you decide to birth. Will you pick an OB or Certified Nurse Midwife and have you baby at the hospital? Or perhaps you would like to have your baby at home with a direct-entry midwife and a doula by your side.

I hope this post will help you understand the differences and debunk any myths you have about "unsafe" birth choices.

OBSTETRICIANS
OB's or OB/GYN's have completed medical school and four years of obstetric and gynecology residency. They have received specific instruction in gynecological surgery, women's health care, prenatal care, treatment for complicated pregnancies, vaginal delivery, and cesarean sections. The focus of an OB is to ensure you and your baby have come out healthy after the birth. They are not necessarily helping you to have a "birth experience". Many women choose an OB because of their high level of education and their ability to handle complications* should they arise.

*Please note that serious complications can occur due to procedures such as a medical induction, medications given during birth, and cesarean section, just to name a few.

FAMILY DOCTORS
Family doctors have also completed medical school where they learn to provide care for children, adults, and how to deliver babies. FD usually work with uncomplicated pregnancies and will consult and OB should a complication arise. Unless you live in a rural area or smaller town, you would most likely have access to an OB, but if not, a Family Doctor may be your only choice within a reasonable traveling distance.

CERTIFIED NURSE-MIDWIVES
CNM's are advanced-practice nurses who have two to three years of education in a nursing program. They have training in prenatal care, women's reproductive health, and childbirth. They care for women with uncomplicated pregnancies and will collaborate with an OB should a problem arise. Many CNM's are interested in helping women have a "birth experience" they desire. They work in hospitals or birthing centers.

CERTIFIED MIDWIVES
CM's have must pass the same national certifying exams as CNM's, but they are not nurses. They may have other medical training or a degree in a health-related field. They are for uncomplicated pregnancies and attend mostly hospital births. Only a few states recognize CM's. For more information about CM's in your state, contact your state health department.

DIRECT-ENTRY MIDWIVES
DEM's have midwifery training, but are not nurses. Their education varies and many of these midwives train with other established midwives who attend home births or work from a free standing birth center. They are familiar with the unique process of out-of-hospital births and are skilled to care for you and your baby during birth.

There are three kinds of Direct Entry Midwives:

• Licensed Midwife: attended a direct entry midwifery school and passed a state exam. Many licensed midwives will take payment from your health insurance provider. They care for uncomplicated pregnancies and attend out-of-hospital births. Many of them have a recognized relationship with a physician should a complication develop prenatally or during labor.
  
• Lay Midwife: trained by apprenticing with an experienced midwife. She attends home births and may or may not have a back up physician. She is not regulated or certified by the state, so you must do your own research into her skills and background.
• Certified Professional Midwife: is a licensed midwife and recognized nationally for her certification. She undergoes a lengthy process of establishing her experience and demonstrating her skills. She must keep her certification current by completing continuing education every three years.
  

REGISTERED NURSES
When you choose to birth at the hospital, you will be assigned a nurse for your labor. She may have one to three patients that she is monitoring at once depending on the staffing and number of patients that day. Nurses vary in their interests and experience. Some may be very supportive of natural birth and others may be more comfortable with medicating and high-tech monitoring.

DOULAS
A doula, or professional labor assistant, is trained to emotionally and physically support a laboring woman and her partner. Doulas know a variety of comfort measures such as massage, positioning for comfort, visualizations, and relaxation techniques. A doula can help you to have the "birth experience" you desire. She can also help you in understanding what may come during birth and give you the information you need to make informed choices about your birth.

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Of course, there are many other types of people that I recommend to have the ultimate pregnancy and birth you want such as: yoga instructors, childbirth educators, nutritionists, fitness instructors, chiropractors, lactation consultant, and acupuncturists.

Hoping you have a wonderful pregnancy, birth, and beyond!

A Conversation on Birth Choices

It's inevitable. You get a group of women together and childbirth will most likely come up. Especially if anyone of them is pregnant. It seems like this topic has come up a lot lately in discussions I have been a part of. There are so many different ideas out there on caregivers, childbirth classes, where to have your baby, breastfeeding, and the list goes on an on.

I must begin by saying that I have not had the experience of any of this yet, so I am the bystander on many of these conversations. Of course, as a doula, natural birth advocate, and breastfeeding supporter, I do often find myself wanting to advocate more than I should. I also know that natural childbirth advocates can often times get categorized as "radicals", not willing to hear any other side.

But, it makes me really think after these gatherings and such discussions with these women. I am glad to be a part of such a diverse group of friends who have different ideas and opinions. By now, you all know that I do, however, feel that it is important to be educated and informed on all aspects of childbirth if you are a mother (or father) or plan on becoming one soon.

I understand that when you are pregnant that you get all kinds of advice, solicited or not. But, if you say to me "I am not brave enough to have a natural birth" or "I need the epidural before I even go into labor", then you are going to get a few probing questions from me. I would ask you, "What makes you feel that way?" "Do you know you have a 1 in 2 chance of having a cesarean section if you birth in a hospital?" "Do you understand the repercussions of an induction?" Sometimes just talking it out with them helps bring the topic into a whole new light. Maybe they have heard horror stories about other births and feel the hospital and drugs are the safest route for them. Maybe they aren't fully educated on how the drugs may effect the mother and baby during and after birth. Maybe they want the process to be easier for their husband/support person so he/she doesn't have to "worry" about her as much or get too tired while she is in labor (a doula would help, but that is for another post).

Many people have gotten their view of childbirth from television and movies. You know, the shows that all depict childbirth as an "emergency situation". The media has truly misrepresented the intimate, calming, loving nature of birth. They have created birth to be a fearful, stressful situation that it does not have to be. Besides the media, I often wonder what really makes women feel fearful of childbirth. Is it the pain? Is it the "what if" factor? It is all the unknowns? Does she feel unprepared?

As women, we have the right to choose whatever kind of birth we want to have. It is, after all, our body and our birth. So, whether you choose to have a natural (unmedicated) birth or a medicated birth, please understand why you made that choice. That choice could affect you and your baby for the rest of your lives.

The Dreaded Cut

There are many reasons that I am thankful I have become a "birth junkie" before having children of my own. Many doulas happen upon this as their calling because they had a wonderful or not so wonderful previous birth experience. But, for me, I desire to educate, care for, and nourish pregnant and birthing mothers.

The "cut" is one of those things I dread to see and hear happen in births. It looks awful and sounds horrid when it is happening. Flesh being cut with scissors is almost the worst sound ever next to nails on a chalkboard!

If dads could really grasp what the "cut" is and all it entails, I believe he would demand for it not to happen at all costs. The first time I educated my husband about it, he was mortified and cringed in horror. I knew at that point that when the time came, he would fight for me if it comes to that.

When I discuss a birthing with my hospital clients and the "cut" comes up, I am sure to let them know that they need to discuss that with their caregiver and the nurses they have in the hospital. Many nurses will help adequately prepare the perineum for the birth. I also discuss the benefits of kegel exercises that help to prepare and strengthen the pelvic floor.

Many midwives pride themselves in having minimal perineal tearing in births. They will use hot compresses and perineal massage with oils. Midwives do not perform episiotomies and most believe that tearing, if that occurs, will heal better.

What is an episiotomy?
An episiotomy is a cut made in the back of the vagina to enlarge it for birth. With midline or median episiotomy, (the type usual in the U.S. and Canada), the cut is made from the back of the vaginal opening straight toward the anus. With mediolateral episiotomy (the usual type in most of the rest of the world), the cut is made off to one side. See photos below.




How does an episiotomy affect my pelvic floor?
In the past, most care providers believed that episiotomy would prevent serious tears extending into the anal muscle. Anal muscle injury is a concern as it can lead to leaking gas, a sense of urgency about elimination, or even leaking feces (bowel incontinence).

However, a large body of consistent research has shown that liberal or routine use of episiotomy promotes rather than prevents pelvic floor dysfunction. It offers no advantages over the spontaneous tissue tears that may occur during birth. Midline episiotomy (the type that is usual in the U.S. and Canada) increases risk for tears into or through the anal muscle. Nearly all anal muscle tears that occur during birth are extensions of midline episiotomies.

Mediolateral episiotomy (the cut is made diagonally off to one side) is usual in most other parts of the world. Although it doesn't seem to cause anal muscle tears, it doesn't prevent them either. Women with no episiotomy have similar low risk for anal muscle tears compared with women with mediolateral episiotomy. This type of incision, however, goes through muscle fibers and can involve a longer, more painful healing period, scarring, and sometimes a scar with uneven healing that pulls to one side.

What is a reasonable episiotomy rate?
While the percentage of women who give birth vaginally and have episiotomies has fallen steadily in recent decades in the U.S., it still has far to go. Currently, about 35 in 100 women with vaginal births have episiotomies. Episiotomy rates vary widely across caregivers and across birth settings; studies show that they could safely be much lower, 7 or fewer in every 100 vaginal births.

How can I avoid an episiotomy?
With 1 woman in 3 with a vaginal birth in the U.S. having an episiotomy and much higher rates in many other parts of the world, it is important to understand the practice style of those who might attend your birth. If possible, arrange to receive care from a caregiver (or group of caregivers) with a commitment to restricted use of this procedure. If this is not possible, make it quite clear that you do not want an episiotomy unless there is a medically urgent need to hurry the birth.

When might an episiotomy be recommended?
About the only reason most caregivers would agree that an episiotomy is appropriate is when the baby is close to being born and an urgent problem develops.

When examined in scientific studies, none of the reasons given for the common or routine use of episiotomy holds up, including:

• Woman is a first-time mother: Studies that attempt to restrict episiotomy do not find that having a first baby is in and of itself a reason for episiotomy.
• Caregiver believes a tear is about to occur: Performing an episiotomy for this reason has not been shown to have a protective effect.
• Woman is having a vacuum extraction or forceps delivery: Women are much less likely to have anal muscle injuries if they don't have a midline episiotomy with an assisted vaginal birth. (Mediolateral episiotomy neither prevents nor causes anal injury compared with no episiotomy.)
• Belief that episiotomy prevents pelvic floor weakness: Women are just as likely to have weak pelvic floors or urinary incontinence in the early months after childbirth with or without an episiotomy. Women with no episiotomy and no or only a tiny tear at birth (intact perineum) have the strongest pelvic floors while women with tears into the anal muscle have the weakest pelvic floors. Women with spontaneous tears do just as well as, or better than, women with episiotomies.
• Belief that episiotomy is easier to repair (to stitch closed) than a tear: No research supports this claim. Certainly the tear that occurs when a midline episiotomy extends into the anal muscle is more difficult to repair than more a small tear. With optimal care, many women will need no more than a few stitches or no stitches at all.
• Belief that episiotomy heals better: An episiotomy of either type is more likely to have delayed healing or to become infected in comparison with no episiotomy. A mediolateral episiotomy is more likely to scar and heal pulled to one side compared with the tears that may occur with no episiotomy.

Take the poll located on the right of the blog.

The 14th Birth

On Friday, June 5th I attended my 14th birth with a client from the adoption agency where I work. Here are some "belly notes" from that birth.

• At 23 years old, she desired to have a natural birth because her mother and grandmother did and she wanted to carry that on. In addition, she wanted to steer away from medications for the sake of the baby. It is rare when we have a client that truly understands and embraces the ability her body has to birth naturally and who also cares enough for the health of the baby that she intends to place for adoption.

• As an agency, we are working to accommodate the needs of every client, but unfortunately because 99% of them want medication, their 6 hour childbirth education class does not fully prepare them for having a natural birth.

• I am grateful for the two amazing nurses (two shifts) she had at the hospital that fully accommodated her efforts to have a natural birth and her 25+ hour labor, 12 hours of which we were at the hospital.

• I am thankful for the doctor on call who did not do a cesarean when she stalled at 8cm for a few hours. It makes me appreciate birthing in the middle of the night when there are not as many time restrictions and clock watching. Even the nurse admitted to that one!

• When she began to get tired and the pain got too much for her I got nervous. As much as I feel that I know how to help, this was a situation that I felt helpless. I had to dig deep into myself to really know what to do and say with her. After almost 20 hours in labor, she decided to have the help of medication.

• Although the agency does not have access to alternative childbirth classes, it has made me appreciate the births I have attended with clients who were adequately prepared. I believe that it is important for my clients to be well prepared and going forward I may request that my clients outside from the agency have Bradley, Hypnobabies, Hypnobirthing, or some other form of childbirth class that is geared toward natural birthing.

• I got to see the nurse actually birth the baby that early morning at 3:53am. The doctor was taking his time. But, because he did and the nurse was so careful, she did not tear or receive an episiotomy that she so desperately did not want to have.

• I was with her for 19 hours of her labor and birth. Although, not the longest birth I have ever attended, it was still tiring, but worth every minute of being sleep deprived. I never question why I do this because watching a new life come into this world makes me so happy.

The Mother-Friendly Childbirth Initiative

As the Tarrant County Birth Network is evolving, we are expecting that all members, practitioners, and those involved will adapt to the high standards of care that were put in place by The Coalition for Improving Maternity Services (or CIMS). Women and their families should expect no less than this standard of care as they conceive, carry, and birth their children.

CIMS has a mission to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.

CIMS has developed the Mother-Friendly Childbirth Initiative that is evidence based and is a collaborative effort of many individuals and more than 26 organizations focused on pregnancy, birth and breastfeeding during meetings spanning nearly three years in the 1990’s.

They incorporate many philosophies including: normalcy of the birthing process, empowerment, autonomy, do no harm, and responsibility.

I have included below the steps to Mother-Friendly Childbirth as found at the CIMS webstite.

Ten Steps of the Mother-Friendly Childbirth Initiative
For Mother-Friendly Hospitals, Birth Centers,* and Home Birth Services

To receive CIMS designation as “mother-friendly,” a hospital, birth center, or home birth service must carry out the above philosophical principles by fulfilling the Ten Steps of Mother-Friendly Care.

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

1. Offers all birthing mothers:
• Unrestricted access to the birth companions of her choice, including fathers, partners, children, family members, and friends;
• Unrestricted access to continuous emotional and physical support from a skilled woman—for example, a doula,* or labor-support professional;
• Access to professional midwifery care.
2. Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.
3. Provides culturally competent care—that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother’s ethnicity and religion.
4. Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on back with legs elevated) position.
5. Has clearly defined policies and procedures for:
• collaborating and consulting throughout the perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary;
• linking the mother and baby to appropriate community resources, including prenatal and post-discharge follow-up and breastfeeding support.
6. Does not routinely employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following:
• shaving;
• enemas;
• IVs (intravenous drip);
• withholding nourishment or water;
• early rupture of membranes*;
• electronic fetal monitoring;
other interventions are limited as follows:
• Has an induction* rate of 10% or less;†
• Has an episiotomy* rate of 20% or less, with a goal of 5% or less;
• Has a total cesarean rate of 10% or less in community hospitals, and 15% or less in tertiary care (high-risk) hospitals;
• Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.
7. Educates staff in non-drug methods of pain relief, and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.
8. Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.
9. Discourages non-religious circumcision of the newborn.
10. Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital Initiative” to promote successful breastfeeding:
1. Have a written breastfeeding policy that is routinely communicated to all health care staff;
2. Train all health care staff in skills necessary to implement this policy;
3. Inform all pregnant women about the benefits and management of breastfeeding;
4. Help mothers initiate breastfeeding within a half-hour of birth;
5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants;
6. Give newborn infants no food or drink other than breast milk unless medically indicated;
7. Practice rooming in: allow mothers and infants to remain together 24 hours a day;
8. Encourage breastfeeding on demand;
9. Give no artificial teat or pacifiers (also called dummies or soothers) to breastfeeding infants;
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospitals or clinics

† This criterion is presently under review.