Christina has been a semi-regular guest poster over the years here at KOTH, and I love her posts for several reasons, but the main one is that she is nothing if not well-researched and thorough. Her meaty posts show off her passion for digging deep into hard, controversial issues, and then using that information to empower women to make their own educated decisions. — Stephanie
Guest Post by Christina Szrama
As a new doula, I’ve spent the past year learning a lot through trial and error. I’ve seen many beautiful births—every one of them a true miracle. I’ve watched some birth teams affirm and build up a mom, while others absolutely undermine her confidence and disempower her, even as they add to her suffering.
I’ve realized just how many things you need to have settled with your care provider beforehand as opposed to mentioning it in a birth plan and trusting that it will be honored mid-delivery. Pushing is not a time to argue about pushing position. The doctor who seemed reluctant to “allow” a VBAC “trial of labor” may decide that your baby’s heart rate shows that he “might be distressed,” and you may be whisked away to C-section before you know what’s happening.
In labor, where two lives are involved, we more than ever want to be able to trust our care provider. Having to question or second-guess your doctor or midwife’s medical advice is far from ideal, and, in the worst case, could be life-threatening. Your care provider must be your #1 advocate in your mind, NOT an obstacle to be overcome.
Initiating an active role in preparing for labor and birth
As women, we want to take an active role in our health care and our baby’s health care, so how can we best ensure that our voices are heard, our concerns addressed and our research truly honored? By having good (sometimes long) discussions with our care providers well before the last trimester of pregnancy.
We may find our care provider enthusiastically familiar with anything we mention, or excited to try something new to him but evidence-supported. We may find her taking up our cause with confidence and enthusiasm. Or… unwilling to budge on issues we deem non-negotiable.
In that case, the three last months of our pregnancy should leave us enough time to find a new care provider. (And YES, that is OK!) Or you may reach a compromise you can both agree to.
For example, with my daughter I would have preferred to deliver without any IV whatsoever, and while my midwife agreed this would be fine, she knew it would cause needless consternation at the hospital, so I decided I was OK with the saline lock. I never needed it attached to anything, but it avoided a lot of hassle in my long, drawn-out posterior baby birth!
Image by jewelrylvr
10 questions to ask before your third trimester
In my experience, here are 10 discussions you will want to initiate well before your due date, especially if you desire to have the best chance at an uncomplicated, normal birth:
1. What is your personal C-section rate? Your practice’s? Your hospital’s?
You may well have already asked this as you picked your care provider in the first place. This matters because you don’t want to expect to “beat the odds.” Doctors and midwives are just like anybody else; they tend to do what they always do.
This also gives you insight into how they view labor: if they view labor as a natural, healthy, generally safe part of a natural, healthy, generally safe time in a woman’s life (pregnancy), they will not be in the habit of intervening. However, if they view labor and delivery as a hazard from which many women need to be “saved,” they will intervene regularly and invasively.
The maximum rate of C-sections considered acceptably safe by the World Health Organization (the WHO) is 10-15%. If your care provider’s personal rate is higher than this, switching is probably a good idea. If her practice average is higher, it may also be wise to transfer, since you may well deliver when he/she is not “on-call,” and you don’t want your doctor’s call schedule to be a factor in when you want to give birth.
Lastly, if your hospital has a high C-section rate, you may want to find another option, since that is an indication that “hospital policy” tends to create births that end in C-section.
2. What do you consider to be “post-dates”?
This is another glimpse into a care giver’s perception of birth. A care giver who recognizes that each woman and child can be different and yet still perfectly healthy will likely believe that most babies come on their own when they’re ready. The clinical definition for “post-dates” or “overdue” is 40 weeks from conception, or 42 weeks gestation. Women can safely carry babies far longer than that, with the longest recorded pregnancy lasting 53 weeks 6 days (yes, that is just over a full year!)– mom and baby were both fine.
However, it’s become common in our culture to assign babies a “due date” exactly 40 weeks from a mom’s last menstrual period (LMP), and treat the woman as ill and her baby’s life as threatened every minute over that date. Many care providers commonly induce labor on due dates, and still more will induce by “41 weeks.”
Know that the average first-time Caucasian mother will naturally carry her baby 41 weeks and 1 day, which makes inducing at 41 weeks a bit ridiculous. Second-time moms average 40 weeks 3 days. (I tell all my clients to add a week to their “due date” and get that in their heads instead!) I am not sure of the averages for expectant mamas of differing ethnicities, however, rates DO seem to vary by family, so asking your mom, aunts, grandmas and cousins for their gestation length can be helpful.
Also, not every woman has a 28-day menstrual cycle, and far fewer ovulate exactly on day 14 of their cycle. If your care provider bases “due dates” on known or estimated conception dates rather than LMP, that is another positive sign. If your doctor or midwife operates on a “wait and see” basis, monitoring babies regularly after 40 weeks instead of inducing, this is a very good sign.
Some care providers are constrained by hospital or license to only handle pregnancies lasting up to 42 weeks. (However, even in such a case care providers are required to give patients 30 days to find a new provider after giving a notice of termination of care, which provides ample time for most babies to come.)
3. How do you conduct inductions, and what percentage of your patients do you induce?
This question naturally follows the previous. If a care provider believes pregnancies have to end by a certain date, then they will probably conduct more inductions. Care providers who focus on wellness and nutrition and listen closely to their patients will also often be able to help you avoid situations requiring induction (for example, pre-eclampsia, diabetes, high blood pressure).
However, even the most conservative care provider will likely have a few patients for whom induction is a medical necessity for one reason or another. In those cases, what methods are usually used? While you wouldn’t be able to determine how exactly a potential induction would go (it will vary based on what you and your baby need), a discussion of what a care provider usually does is very eye-opening. Care providers vary widely in which of the following they combine or use:
- Prostaglandins (prostaglandin E2, brand name Cervadil) are often used to soften or “ripen” the cervix, but dosages and administration protocols vary. They don’t seem to change C-section rates, but they do increase the likelihood of uterine over-stimulation;
- Misoprostol (prostaglandin E1, brand name Cytotec) suppositories are at times suggested to begin the process because it is cheap, however, it is not FDA-approved for such usage (in fact its insert warns of grave adverse effects); once inserted it can’t be stopped or countered, and it has terrible risks, including death for mom and/or baby;
- The Foley catheter (a balloon inserted into the cervix) is mechanical rather than chemical, and as such avoids many pitfalls. It seems to be the preferable method of induction, reducing uterine hyper-stimulation without raising infection rates or discomfort levels.
- Synthetic oxytocin (Pitocin), is the most common inducing agent, often used after the other three methods or on its own. It causes uterine contractions and has a lot of risk, often causing labor that is harder on baby and mom than natural labor. Some say it interferes with the natural synthesis of oxytocin; however, much of its risk depends on the dosage and schedule of Pitocin. Traditional usage calls for the dosage to be increased every 20 minutes. Inductions where Pitocin is administered in smaller doses over longer periods of time, aiming to imitate natural labor more closely, tend to have fewer complications.
- Artificial rupture of membranes (AROM, ARM, amniotomy or “having your water broken”) is also often a part of (or the beginning of) an induction. This article outlines the function of this bag of waters, and the risks of breaking it. A drawback is that once your water’s broken, there is generally “no going back.”
- Nipple stimulation (either manually or with a pump). Studies do indicate its effectiveness. You also can use it to help avert postpartum hemorrhage – a good fact to know if you ever are in a precipitous birth situation!
- Alternative methods such as herbal tinctures (often blue and black cohosh), evening primrose oil (a natural prostaglandin), castor oil cocktails, acupressure and acupuncture. These generally are used by midwives instead of doctors. Most formulas have been around for centuries and while they may lack randomized controlled studies, they have years of experience behind them. Generally speaking, natural substances such as those in herbs are more easily assimilated by the body without as many side effects or risks as manmade substances. (I have personally experienced the success of blue & black cohosh tinctures taken orally.)
4. How do your patients get nourishment during labor?
Are you going to be asked to get an IV and content yourself with ice chips (or maybe a popsicle if you’re lucky), or will you be encouraged to eat and drink as you feel the need? Many women find an IV pole quite limiting, and those who opt for a saline lock (or “Hep-Lock “– an IV needle inserted but not hooked up to anything– so it’s there in an emergency) often find that painful and restricting since it can’t get wet. (Mine didn’t actually bother me, but I’ve had clients who all but ripped theirs out!) Besides these considerations there are the risks attendant to the IV fluid itself, including fluid overload and an appearance of excess weight loss in the infant (related to decreased breast feeding).
If birth is a normal event, why would a woman need to be restricted in following her body’s cues of hunger or thirst? “Nothing by mouth” (NPO) is standard pre-op procedure. But birth is not a surgery just waiting to happen. Many hospitals are behind the times with their official NPO policy (which dates back to days of opaque general anesthesia masks); if yours is, this may affect how long you wait before going to the hospital (and also the color of your Gatorade should you choose to “sneak” some…). Many care providers will also have their own policies that may contradict the official hospital dictum; I’ve been in many a birth where nurses turned a blind eye to moms chowing down and drinking whatever they liked due to the care provider’s personal policy.
5. How are babies monitored during labor?
While many care providers expect continuous external fetal monitoring (EFM), achieved by wearing a belly band hooked up to a monitor, these tend to give many false alarms without improving outcomes for mom or baby. In fact, they tend to increase unnecessary interventions.
While some units are mobile, many confine moms to or around beds, which has its own set of drawbacks. Evidence points to “intermittent auscultation,” (listening to baby’s heartbeat for 1 minute every 15-30 minutes while feeling mom’s contraction with your hand) being best for both babies and moms. This is not the same as intermittent external fetal monitoring. This mom’s story provides excellent tips for how to ensure you get this care.
6. What does labor generally “look like” in your practice?
If your care provider will come to your house, when will they come? Will they stay the whole time? Who else will be there? If you will meet them somewhere, what is the protocol for that (many birthing centers aren’t staffed around the clock, so you’ll need to call first after certain hours)? If your care provider delivers at a hospital, how will they be notified? Are they ever not “on call”? What is the hospital’s admission process? (Side note: In my experience, it doesn’t matter how much paperwork you fill out before hand, you will STILL be asked what feels like 100 questions during admission, unless you arrive pushing.)
Once you’re situated, will you be encouraged to move around as you feel the urge, or will you be expected (forced?) to stay in a bed? How often will you be “checked”? Will benchmarks be time-limited (for example, C-section 24 hours after water breaking, or pitocin augmentation if you haven’t dilated to 4 cm in ___hrs)?
Interestingly, ACOG has just extended all of its “normal time limits” regarding labor. Again, your care provider’s normative practice reveals how they view labor; either as “a condition” needing to be “managed,” or a natural process that looks different from one individual to another, but generally sorts itself out.
7. What types of pain management will I have access to?
Many women assume that labor will be painful, and certainly most hospitals reinforce this image. I’ve intercepted several anesthesia teams coming to “evaluate mom’s pain level” before the she even made it out of triage!
While I’m the first to admit that for most women, labor IS hard, uncomfortable work- and at certain points even VERY painful- this doesn’t define labor by any means. Even if we describe labor as “intense” or “hard,” women will want to have their labor eased.
What means will be available to you? Are your only options to “grit your teeth and she-woman it out” or numb all sensation from the waist down (with an epidural)? Or does your care provider encourage bringing a doula, maintaining a calm, positive environment, using position changes and rhythmic movement to manage contractions?
Will you have access to water in the form of tub, shower, or deep pool? Does your provider use a TENS machine, saline water injections, acupressure or acupuncture? Is he or she familiar with hypnobirthing?
Will even simple measures such as a heated rice sock be permitted? (I know one of our local hospitals claims they are a burn risk and some of the nurses won’t “allow” them.) What about other drugs besides an epidural (IV opiates, narcotics, laughing gas)?
How familiar will the support staff (assistants, residents, nurses) be with these things? If you will be doing something rather unfamiliar for your hospital, you will want to make sure that your care provider is 100 percent on board, as well as your entire birth team (husband, mom, doula, etc.).
8. Let’s talk second stage labor, aka pushing. How familiar are you with non-supine (“non-prone”) pushing positions? How familiar are you with self-directed pushing?
I think this is the conversation women tend to forget to have… and then really regret skipping!
At two births in a row, at two separate hospitals, I heard two OBs say nearly the exact same words: “well, you can try to push in any position you want, but in my experience, the lithomy position (flat on your back) leaves the most room for the baby.” I bit my tongue and resisted asking these doctors when they last looked at a model of a human pelvis. Further conversation with the same doctors revealed that they’d only ever assisted women delivering on their backs, so their ability to compare it to another position was rather inhibited!
Needless to say, most doctors do not regularly see women pushing any way but with their feet up in stirrups with a spotlight giving them (the doctor) a prime seat , however plenty of evidence (and common sense) point to many other positions being more effective. Ask your doctor how familiar she or he is with alternative pushing positions. If the answer is “not really done it,” then give him or her some literature on the topic. Keep up the conversation until you are certain that she or he will support you on this issue during birth.
While you’re on the pushing topic, broach the subject of self-directed pushing. Many nurses are still trained to count (loudly) to ten, instructing moms to hold their breaths, close their mouths and bear down for the full ten count, breathe in, then repeat twice more with each pushing contraction, and many care providers will let nurses “do their thing.” Known as “purple pushing,” this approach has many problems, including limiting oxygen to the baby, not allowing the baby to stretch the perineum slowly (leading to more perineal trauma), tiring Mom, and generally creating a stressful atmosphere. Since this is the norm, discussions with your care provider need to include when directed pushing might be imposed.
In my experience, far too many women are “allowed to try it their way” for a grand total of one or two pushes immediately upon reaching 10 cm dilation, are told “nope, not working,” and then are rushed on to “the normal way.” Expect the first few pushes to be practice pushes, especially for a first-time mom who has never done this before. Also, so long as baby and mom are fine, there is no need to rush second stage labor. One of my favorite sayings for the pushing phase is, “Don’t just do something, stand there!”
Interestingly, “laboring down” is becoming common for moms with epidurals; essentially moms are encouraged to rest when they get to 10 cm instead of being “pushed” to push, as they formerly were. The logic is that the uterus needs time to contract down around the baby once the baby has moved down into the birth canal, to allow it to push effectively. Contractions have been focused until now on dilating the cervix. Now contractions aim to push baby down and out. Once the uterus is tight around baby again, the “fetal ejection” or “spontaneous birth reflex” will engage: that feeling that you are pushing and no one could stop you even if you wanted them to!
Moms without epidurals can use this new trend to accommodate what’s often called a “rest and be thankful” phase: there is no need to immediately begin pushing if you don’t feel an urge to do so; it may work well for you to just rest and wait until the urge becomes unstoppable and your body begins pushing on its own!
(In retrospect, there have been several births where it would have been better for me to not immediately alert the nurses that the mom was “feeling a little pushy.” The moms had a long way to go yet! Rather, it would have served everyone better for mom to be allowed to just be for a while. If your hospital tends to needlessly rush second stage, this is a strategy that might serve you as well.)
One note on shoulder dystocia (baby’s body getting “stuck” after its head is born): women with a history of big babies or previous shoulder dystocia may want to ask their care provider how they typically handle them. The Gaskin maneuver (having mom flip over onto hands and knees if she’s on her back) is non-invasive and extremely effective.
The summary for second stage labor could be: God has made our bodies well. If we let them do what they tell us they need to do, we will be well served!
9. What is your policy regarding cord clamping?
Delayed cord clamping (DCC) is receiving a lot of good press lately, which means most care providers are willing to accommodate birth plans that include it. However, many care providers mistakenly assume that an intact cord will drain the baby of blood unless baby is kept lower than the placenta. This means some moms have to choose between immediate skin-to-skin and delayed cord clamping. (Sadly, I was at one birth where the doctor flat-out refused to delay cord clamping despite having previously agreed to it in her birth plan because mom was already reaching to hold her baby.) Make sure this isn’t a misperception your care provider has.
In every study measuring benefits of DCC, location of baby has NOT been a factor. Specifically bring up the topic of DCC with immediate skin-to-skin. (This article is a wonderful resource on common questions and misperceptions of cord-clamping.)
As far as how long to delay clamping, even just waiting 30 seconds has benefit. One minute allows 75 percent of the baby’s blood to transfer; waiting 2-3 minutes allows 90 percent. Ten minutes is a great (though arbitrary) number; it also forces everyone to slow down and let mom and baby just be. And there is no drawback to letting the cord remain unclamped until the placenta is delivered.
(In my experience, if your care provider is unfamiliar with DCC, a set time (such as 5 minutes) is more helpful than a vague “until the cord stops pulsing.” It also may be helpful to specify that you mean 5 minutes to clamping, not cutting.)
10. What is your policy during 3rd stage labor?
If you don’t have this conversation prior to birth, you will certainly never have it. ”Third stage” refers to the contractions following the baby’s birth that expel the now-empty placenta and begin returning your uterus to its pre-stretched size and shape.
Once that baby is in your arms, you will not be thinking about anything else! Here again, the norm for most hospitals is “active management.” This involves traction (gentle pulling) on the cord to pull the placenta out more quickly and IV pitocin (synthetic oxytocin) or other uterotonic to encourage harder contractions to avoid hemorrhage (some use Cytotec).
The “physiological approach” will tend to let the woman’s body detach the placenta at its own pace (which can lower the risk of hemorrhage), encourage protective maternal hormones to flow through keeping mom and baby together, and allow the natural oxytocin triggered by baby suckling cause contractions.
Many proponents of active management point to studies that suggest it lowers postpartum blood loss (not hemorrhage, just amounts within normal ranges); however opponents argue that too little blood loss can be as problematic as too much. Women in clinical trials with active management were more likely to return to the hospital for abnormal bleeding after discharge in addition to having higher blood pressure, more severe afterpains, and increased vomiting. Their babies were also more likely to have lower birth weights. Lastly, some midwives use herbs and prenatal nutrition first instead of drugs to avoid hemorrhage.
Here again, your practitioner’s view of birth – as a healthy, intricate process that generally functions flawlessly, or a hazardous ordeal which is just waiting to go catastrophically wrong – will affect how they handle the third stage of labor.
For any mom who would like to do further research on any of these topics, I heartily recommend Henci Goer’s work, Optimal Care in Childbirth. It is quite comprehensive and technical, well-referenced and covers every aspect of maternity care. It might just be the perfect thank you gift for your care provider, too!
Other Posts About Preparing for Birth
For moms that have already had a baby, what do you wish you had asked or known before third trimester?
**I am a doula, but not a doctor. This is based on my own research and how I use it in my own practice. If you have any medical conditions or concerns, please see your doctor.**