Though most hospitals have “birth centers”, they are really nothing more than the labor and delivery floor where births take place. The only freestanding birth center in Colorado is the Mountain Midwifery Center.  MMC is owned and run by Tracy Ryan, CNM  along with 4 other main midwives along with supporting staff.

What is a birth center? From the MMC site: “A Birth Center is designed to be a “Maxi-Home” not a “Mini-Hospital.” Here we strive to allow women to labor and birth in a true home-like environment while providing one-on-one care that helps ensure superior mom and baby outcomes. The Birth Center is not just pretty birth rooms, it is an education-intensive program of care. From your first visit through the birth of your baby and beyond, the Birth Center is designed to facilitate healthy choices for families.”

Located about an hour from Colorado Springs in Englewood, the birth center is a fantastic location to birth.  Check it out!

There is an incredibly disturbing trend regarding “advanced maternal age” mothers being a hostile uterine environment for their babies. They are being subject to weekly Biophysical profiles or Fetal Non-stress tests tests that are normally reserved only for high-risk mothers and babies from as early as 32 weeks in pregnancy.  On top of the scans, these mothers are often pressured to agree to an early delivery of their babies by means of labor induction or cesarean even without other risk associations.  This is growing more and more prevalent especially for women over 35 who are first time mothers.

I have heard even from women that at their first OB appointment they are being told they will be induced at 39 weeks as a standard of practice and expectation for signing on with said provider.  The seed of fear and worry is being planted that their growing baby will die if the pregnancy goes to 40 weeks or longer.  What a way to start out a provider/mother relationship.  I would call that a red flag of immense proportion.

So what really is the big deal with “old” mothers?  This study ama morb and mort correlates various medical issues with “AMA” mothers though the biggest hot button is an elevated yet unknown cause of perinatal death.  This statement alone has caused a huge shift in the way these mothers are viewed regardless of  overall pregnancy health and abscence of any known risk associations. ACOG’s February 2009  “Management of Stillbirth” practice bulletin maintains there is a risk to older mothers with no explanation as to why there is a risk, what the percentage of  risk increase is or any prevention protocols.  Seems dodgy since the other groups noted in the bulletin have all the data included.

There are some serious problems with any practitioner taking this study and applying it across the board to “AMA” women.  The study even says so much, “It is important to note that the findings of this study may not be generalized to every advanced-maternal-age obstetric patient in the United States. Although the FASTER trial patient population was unselected, meaning that patients were not excluded based on any confounding factors such as race, parity, BMI, education, marital status, smoking, pre-existing medical conditions, previous adverse pregnancy outcomes, and use of assisted reproductive care, there may have been significant patient or provider self-selection.” So the population could have been skewed from the get go by provider or patient selection, along with the fact that it seems the only point of homogeneity is present in that most of the women were Caucasian.  Throw all these women in a pot and see what happens?  Next step is to make protocols and change practice style upon weak findings?

The study also shows an increased risk for cesarean by “AMA” mothers.  “As with prior literature, this study demonstrated that women aged 40 years and older are at increased risk for cesarean delivery. Older women may be at increased risk for abnormalities of the course of labor, perhaps secondary to the physiology of aging. It is possible that decreased myometrial efficiency occurs with aging. Nonetheless, maternal age alone may be a factor influencing physician decision making. It is uncertain whether the increased rates of cesarean delivery are due to a real increase in the prevalence of obstetric complications or whether there is a component of iatrogenic intervention secondary to both physician and patient attitudes toward pregnancy in this older patient population.” Very interesting. So “old” women are perceived as being unable or problematic so they have less successful vaginal birth outcomes. Now that is a self-fulfilling practice style with a huge dose of ageism thrown in.  I also wonder what the cesarean rate in this age grouping is going to be due to these protocols.

Let’s get to the perinatal and neonatal death risks.  The study says: “Studies regarding an increased risk for perinatal mortality in women of advanced maternal age have been controversial. In this study, the increased risk of perinatal mortality was not statistically significant for patients aged 35–39 years (adjOR 1.1). Age 40 years and older was associated with a statistically significant increased risk of perinatal loss (adjOR 2.2). There were only 119 stillbirths and 37 neonatal demises in total. As a result, we could not draw any meaningful conclusions about the etiology or timing of perinatal mortality in women of advancing maternal age. The reason that advanced-maternal-age patients may be at increased risk of perinatal mortality is unknown. The failure of uterine vasculature to adapt to the increased hemodynamic demands of pregnancy as women age is a proposed explanation. So in conclusion, we have no idea why this might occur and have no way of counseling “AMA” mothers to lower the risk especially those over 40. Another noteworthy thought is that this study had 79% under 34 year old women, 17% 35-39 year old women, and only 4% women over aged 40.  So with such a small grouping ALL women considered “AMA” are being put under very heavy handed protocols to delivery their babies in the 39th week of gestation.

In closing, I find it difficult to believe that anyone who reads this study would change practice style because of it and move pregnant patients who are otherwise maintaining a healthy pregnancy without risk associations to a high risk model of care. Amazingly the study itself says the same thing, “In summary, the majority of women of advanced maternal age deliver at term without maternal or perinatal adverse outcomes.” And, “The role of routine antenatal surveillance in women aged 40 years and older requires further investigation because these women seem to be at increased risk for perinatal mortality, including stillbirth. Although the likelihood of adverse outcomes increases along with maternal age, patients and obstetric care providers can be reassured that overall maternal and fetal outcomes are favorable in this patient population.”

Couldn’t have said it better myself.

Since the original posting – - – instead of women being told they must be induced in the 39th week they are now being “offered” non-medical, cesareans as a first course of action.  This sort of pressure is not evidence-based or even medically ethical in my opinion.

A couple of weeks ago I went on a quest to find out just what pushing was like for other women.  As an educator and doula it is probably one of the more challenging concepts to address.  Why?  Well some of the imagery can be quite vulgar.  “Push like you are pooping.” Do women REALLY want the image of pooping out their babies?! “The urge will overwhelm you and you cannot help it.” That also is not quite right some women never get the urge until the baby is very low and engages the nerves and some women will have the urge when baby is high and dilation isn’t complete (I did not say premature because I believe when the urge comes pushing “gruntily” with the peaks is alright as perhaps that will facilitate complete dilation and rotation of babe).  Some women feel great rectal pressure, some feel it in their abdominal muscles, and some don’t feel much at all going into it. Hey I do not believe we need to be fixed in this area.  I think whatever a woman’s body does is right for her body.

Below are many quotes that I frankly trolled for to edify women everywhere on the spectrum of what pushing is like. I could bore you to tears with the physiologic nature of the process but that isn’t what you really want to know now is it?! If you have questions on the new perineal massage, please refer to my previous entry http://prepforbirth.com/2009/08/25/new-episiotomy.html.

Quotes from real women

“My babies #1-4 practically fell out. #5 I was in what looked like early labor for 4 days. Midwife assistant came over, checked me, I was at 7 cm but ‘not in active labor’. I got into it quickly! Long story short I pushed, painfully, for 3.5 hours, baby had 11″ cord with a true knot. She needed to be pinked up but is almost 3 and is doing well.”

“When I was coached to push (w/ no 3..first natural birth) I was in agony. When I was left alone and did not push (w/ no 4), life was good.”

“I feel like if I can just get to the pushing phase, it will be a breeze from there.” (and it was. The whole “surrender/dilate” phase is much more challenging to me than the whole “take control/pushing” phase.)”

“Pushing was fantastic with my 2nd baby and awful with my 3rd! It was really surprising because after my 2nd birth I thought “Okay so pushing is the really fun and satisfying part! That’s when it gets EASY.” Then my third birth totally shocked me. Pushing was the most painful and difficult part of the birth. I had stayed so calm and collected… until then. Every pregnancy and birth is so different!”

“I love the way it feels to have a baby move through me and into my waiting hands.”

“I *loved* pushing. I didn’t do it for very long (two contractions), but it was so great to finally get there. I was told to purple push (not in those terms – the nurse told me to hold my breath), and intellectually I knew I shouldn’t, but I tried it and it really did feel like I was more productive that way. I felt like a warrior. It was awesome.”

“Before anyone hates me for only pushing through two contractions, you should know that I’d been in labor for three days – so it all comes out in the wash ”

“Pushing with my 2nd was horrible. 3+ hours of the worst pain I had experienced at that point in my life. Turns out her little fist was up by her cheek (um ouch) and her head did not mold much. My 3rd I did not push because she was precipitous and we were trying to get to the hospital. I felt like all the energy in the world was gathering and swirling at my fundus and then suddenly flowed through me carrying her with it. It was the best physical experience of my life.”

“I have heard some say that pushing feels good.. um, I personally have not experienced that and I have had clients remark the same … :p”

“Hmm…Definitely the best part of labor and delivery. For me though – never had any “urge” to push but still had baby out in 20 mins…I think I was feeling determined being a VBAC mom…still, would have been easier if I felt the need to and not just contractions. “

“Heard lots of clients say it feels good after hours of labor”

“Ahhh, I’m not so fond of the pushing. Did it for 2 1/2 hours with my daughter (LOA) and though it was only about 20 minutes with my boys, they were both OP. That was, shall we say, unpleasant. I cannot relate to those who’ve told me it was such a relief!”

“My labor was surprisingly short, only 6 hours and she’s my first baby so far. I woke up in active labor and at 4 cm and I wanted to push THE WHOLE TIME! It was horrible having the nurse say I couldn’t push yet when I wanted to so badly, but once I did get to push, oh my goodness, it felt incredible. So much control and power, it felt so good to finally work to end. 3 big pushes and there she was. ”

“Sheer, immeasurable power. Unbelievable!”

“Babies actually come out of your butt. Don’t let anyone tell you otherwise.” One of my clients recently said that. ”

“Birth is shockingly rectal” – Gretchen Humphries. She was totally right.”

“Pushing with my first felt like I was satisfying an urge, an uncontrollable urge. It felt almost desperate I couldn’t stop it. (kinda like having that rectal urge when you REALLY have to poop). Pushing with my second was no big deal, I followed my urges again and pushed 3x and out she came in her 10# glory. It was extremely satisfying and powerful I felt like I had just finished exercising. Amazing!”

“The ring of fire OH MY it is indeed! Though as soon as the burn started the whole are went numb almost like too hot or too cold numb and the power of the urge to push my son out was almost beyond description.  Pushing was never easy for me as I have an unusual pelvic shape.  But my last son WOW no molding and quite a large head to birth him was incredible really.  No tearing, just some abrasion.  Recovery was a snap.”

“I had at the point of delivery what was the best orgasm of my life!”

“Pushing was totally primal.  I had an incredible urge and it took over.”

Questions and Answers

1. I have had a previous episiotomy, do I need another one automatically? No you don’t.  Depending on how your scar has set and the position you push in the scar can re-open or it adhesions in the scar will need to be broken up.  I would suggest perineal massage prenatally if there are any adhesions to break them up and soften the area prior and to choose a pushing position that doesn’t put all the tension on that exact area.
2. Is is wrong to push when I am not fully dilated? Not necessarily.  Now I think grunty smaller pushes with those contractions can be effective to complete dilation if you are in transition.  Prior to that change the position you are laboring in to change where baby is placing pressure.  Knee chest can be very effective to abate very early pushing desire.
3. What if I poop during pushing? Some women will pass some stool and some won’t. You may here that when pushing the right way you may pass some.  Hey open bottom is vital to pushing, so hey it is a normal but not always occurence.  A fantastic nurse, MW or doc will not actually wipe it away but simply cover as to not cause constriction of the sphincter muscles which can disturb pushing progess. If it is possible to discard the stool without disrupting you, it will be done very quietly and discreetly.
   
4. I am very modest, do I have to have all my “glory” showing? Absolutely not.  You can maintain good modesty all the way up to delivery.  Even then you do not need to be fully exposed.  Truthfully a home birth or birth center birth with a midwife if likely going to help you have your modesty concerns respected and honored. Really no one needs to put hands in you during pushing, or needs to stretch anything, or needs to see everything either.  A midwife is trained to see by taking a quick peek or simply to know when she needs to have hands ready to receive baby and to offer external positive pressure if mom wants.

Check back later more Q and A to come as more questions are sent to me.

A birth plan is a tool to express your desires and needs for birth and initial postpartum, as well as, to make sure that you and your provider are on the same page.  Your birth plan should be brief (no more than one page) and only have the bullet point information that is specific to your care and desire or not usually done by your care provider or birth location.

Discuss with your care provider prior to labor and bring a copy with you to your birth location.  Remember it is not a legal document that your location of delivery or care provider must adhere to.

Here is a sample plan for an out of the home birth:

Birth Needs and Desires for: _______________________. Care Provider:____________________________________.

Estimated Due Date: ____________________________.

Labor

I am planning on a no to low-intervention natural birth.  I plan on being mobile, lightly snacking, drinking orally, and having ___________ present.   I understand that intermittent monitoring of me and my baby will be necessary.  I want to be fully consented for any procedure that may come up and fully participate in the medical care for myself and my baby.  I understand that there is pain management available to me, I will ask for it if I so desire.

• I plan on wearing my own clothing. I will ask for a gown if I change my mind.
• I would like a saline lock in lieu of an IV
• In the event of an induction and/or augmentation is medically necessitated-
  • Ripening – Foley Catheter instead of Cytotec (misoprostol)
  • Pitocin – A very slowly increased dosage
  • AROM – will only consent to if an internal fetal monitor is a must.
• Delayed cord clamping for at least 5 minutes (baby can receive oxygen or other helps while still attached to me).

Postpartum and Baby Care

• Request that my baby is on my belly or chest for assessments and warmth (even oxygen can be given on me)
• Delayed bathing
• Delaying vaccinations including eye ointment and vitamin k.
• Exclusive breastfeeding, no pacifiers, sugar water, or formula
• No separation from me unless absolutely medically necessary not just protocol.

Cesarean: In the event a cesarean becomes necessary and is not a true emergency requiring general anesthesia.  I would like to keep the spirit of my plan A to plan C so the delivery can be as family centered and intimate as possible.

• Only essential lighting
• Only essential conversation related to the surgery and delivery
• Lower sterile drape or have a mirror present so I may see my baby emerge
• Only one arm strapped down so I may touch my baby
• Pictures and video
• Aromatherapy as I desire for comfort, abate nausea and to mask surgical odors
• Baby to stay with me continuously in OR and recovery
• If baby must leave OR for treatment, my partner/spouse goes with baby and I would like my ____________ to stay with me so I am never alone.
• Breastfeed in OR and/or recovery
• Delayed immunizations
• Delayed washing and dressing of baby
• No separation from me except what is absolutely medically necessary

Today the cesarean rate is an alarming 31.8% (CDC 2007 preliminary data).  Only a maximum of 15%  of birthing women should be having cesarean deliveries in order to keep mortality (death) and morbidity (poor outcomes) to the healthiest levels according to the World Health Organization. With the staggering discrepancy in what should be and what is, you NEED to care about this topic.  You could have a questionable cesarean like so many others.

It is important that you the childbearing woman understand how to have the healthiest birth for you and your baby which is most often a no-to-low intervention vaginal birth.

When a cesarean occurs for a truly medical and/or life saving reason it is necessary and the benefits far outweigh the consequences for mom and baby.  The cesareans that occur for other than truly medical and/or life saving reasons are often not necessary or became necessary due to external influence that skewed the labor and delivery outcome (routine induction, epidural,  impatience by provider, mal-position of baby, staying in bed during labor, routine continuous monitoring, pushing in one position, lack of food and water during labor, routine augmentation of labor, lack of support, etc.)

Below is a list of ways to promote having a vaginal birth even if you have already had a baby this information needs to be known.

• Take the ICAN webinar on cesarean prevention.
• Interview before choosing your care provider – you are doing the hiring! Know his or her statistics.  If you do not get a clear answer, that is a RED flag.  You need individualized care. ou and your baby deserve no less.
• Interview both midwives and OB’s.
• Research your chosen birth location well.  There are other options outside of the hospital – home and birth center.
• Hire a doula who shares your philosophy and is comfortable with the type of birth you desire. Some searchable places for a doula are: www.cappa.net, www.dona.org, and www.alldoulas.com.
• Without medical reason standing in the way, labor at home into active labor if traveling to a hospital or birth center.  Well established labor upon arrival to the hospital or birth center decreases the opportunity for interventions, medications, and cesareans.
• Get educated! Take a childbirth class that promotes confidence, consumer awareness (knowing rights and responsibilities), and evidence-based practices. A “good patient” class is not what you want to take.  READ books that share positive stories and good information.  A few of the searchable sites are: www.cappa.net, www.independentchildbirth.com, www.lamaze.org, and www.ican-online.org.
• Turn off your TV – stop watching the dramatic birth shows.  They are not real.
• Use mobility in labor.
• Drink and snack in labor.
• Say NO to routine interventions – meaning interventions or medications without a true medical reason. These can include, IV with fluid running, artificial rupture of membranes, continuous monitoring, wearing of hospital gown, and vaginal exams.
• Say no the the epidural completely or at the earliest at 6 cm’s dilated.
• Push and deliver in positions other than the reclined or “C” position unless that feels good and baby is coming well that way.
• Only have those around you who will support what you need and desire in labor and birth. When you close your eyes who is there with you in your labor “cave”? Who doesn’t fit well there?
• Study yourself for what comforts, assures, and adds to your feeling of safety.
• Eat healthy and exercise during pregnancy.
• Read What Every Woman Needs to Know About Cesarean Section – http://www.childbirthconnection.org/article.asp?ck=10164
• For more information on Cesarean recovery and support, VBAC education and support, and Cesarean prevention go to www.ican-online.org.
• Bottom line – take your money and walk if you are not being listened to and treated as a partner in your care.

I am often asked what someone needs to take to the hospital or birth center.   I am going for items that may not be normally thought of along with some tried and true items. Wherever a mother is going to have her baby – it is her space, her labor cave as it were.  Now for a hospital or birth center birth painters tape could be a good idea for some items on the list as not to mark up the walls.

Appealing to the senses: Items that speak to sight, touch, sound, smell, and taste.  Try and figure out where the items fit!

• Pillow case that smells like you or your partner, really like your normal normal environment.  I eschew the thought of taking an actual pillow outside your home simply for the germs that are anywhere else you may deliver.
• Your own clothing:
  • For her: robe, a sports bra, bikini top, tank top – something that can get wet and not be ruined.  Two piece outfit, a Binsi or bathing suit cover skirt.  Sandals, slippers, socks or flip flops.
  • For him/labor partner: sweats, shorts, pajamas, hoodie, pullover, socks, underwear – items other than just a pair of jeans.  Swim trunks in case she wants you in the shower or labor tub with her. Nakedness outside of a homebirth is generally reserved for the laboring woman. Flip flops or other waterproof foot covers.
• A favorite blanket
• Essential oils or scented lotion.
• Pictures of other children, pets, favorite vacation, anything that is her happy place in thought, spirit and mind.
• Flashlight and/or night lights to give subtle low light illumination.
• Posters or phrases to put on the wall.
• Music – soft, slow, upbeat, fast – whatever is relaxing for the individual.
• Lip balm
• Mints and lollipops
• Toothbrushes and toothpaste
• Colored items that soothe and encourage.
• Affirmation cards or cd’s
• Scripture or encouraging religious texts
• Fresh herbs.
• A cooler with easy to digest foods  for her- smoothies, yogurt, ices, peanut butter sandiwches, protein bars…..
• A cooler with his favorite foods and drinks (again remember the toothbrush)
• Special symbolic or religious pieces
• Phone numbers of those who can encourage, pray, etc.
• Something to cover the clock with.
• your labor doula

Finally some of the inangibles that are not items:

• Quiet
• Peacefulness
• Courage
• Strength
• Patience
• Trust
• Faith
• Calm
• Connectedness
• Love
• Joy
• Excitement
• Patience (not a typo)
• Openness
• Willingness

Be blessed and to all those who are pregnant – I hope for you to gestate peacefully.

ACOG released a press release today regarding a new practice bulletin revising labor induction guidelines.  Though the practice bulletin is not available on the ACOG site, a detailed review is available by Medpage today.  I hope to soon have the full copy to share.

Some high points I found in the explanation and review of the revision:

• Misoprostol (Cytotec) should not be used to induce any woman with a previous uterine surgery or cesarean due to the increased risk of uterine rupture.
• The Foley catheter is a reasonable and effective alternative for cervical ripening and inducing labor (as stated in my blog earlier this week).
• The recommendation for fetal demise is for induction rather than cesarean unless unusual circumstances present as it is associated with maternal morbidity without fetal benefit.
• ACOG also states that the assessment of “gestational age and consideration of any potential risks to the mother or fetus are of paramount importance for appropriate evaluation and counseling before initiating cervical ripening or labor induction.”
• Admitting to this fact – At the same time, there have been a number of reports linking the induction of labor with increased risk of adverse events including uterine rupture and meconium-stained amniotic fluid.
• “A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn’t successful in producing a vaginal delivery,” notes Dr. Ramin. Although rare, there are potential complications with some methods of labor induction. (perhaps less inductions that are for lack of medical reason will be done if a physician must induction sit?)
• Post cervical ripening whether by medication or mechanical once the cervix is dilated, labor can be induced with oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation. (using an alternative like nipple stim interesting)

Some low points I found in the explanation and review in the revision:

• The new guidelines include seven recommendations based on “good and consistent scientific evidence” — considered the highest evidence level — including one that sanctions 25 mcg of misoprostol as “the initial dose for cervical ripening and labor induction.” The recommended frequency is “not more than every 3-6 hours.” (I want to see these studies)
• ACOG said that the data on the safety of high-dose misoprostol (50 mcg every six hours) were “limited or inconsistent,” making its recommendation on high-dose misoprostol an evidence level “B” recommendation. (again studies please)
• The practice of inducing labor has become more common. More than 22% of pregnant women undergo labor induction, ACOG says, and the overall rate doubled from 1999 to 2006. (once again – only 22% – this one I need to research)
• Rapid delivery or lack of access to good care at home as a potential reason to induce labor in rural areas.

More possible low points:

• Some examples in which labor induction is indicated include (but are not limited to) gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and postterm pregnancy.(need more information on how these are defined)
• Low- or high-dose oxytocin regimens are appropriate for women in whom induction of labor is indicated. (Pit to distress with high doses?)

So even ACOG says that induction needs to be taken seriously as there are risks and consequences associated.  Definitely I am in agreement with that. It IS a very big deal and the risks to not having your baby immediately must outweigh the benefits of baby staying put a little longer.

Normal, natural birth is spoken of all the time in the birth world.  It is discussed on many levels from the evidence of being overwhelmingly the safest and healthiest way to birth, to the emotional aspects of privacy, safety and support,  to following the money trail of interventive birth versus natural birth and so much more in between.

I ponder and sometimes struggle with what to share with expecting families and  how to share it.  Why the struggle?  This normal, natural birth viewpoint is counter-cultural.  I, along with many peers believe in the inherent design of women and babies to work as intended.  There is lack of belief in routine intervention, non-evidence based protocols or practice style that is created around pregnancy and birth being a tragedy in waiting.

Even in trepidation, the truths must be shared and not hidden simply because most of what is seen and heard in our culture is the opposite (think as an example of the media and the dramatic voice over person on those birthing shows).  The longer I am in this field and calling of work, I believe that protecting women from the truth for whatever reason is harmful.  I participated in a Henci Goer session several years ago at a conference that set this ideal permanently within me.  She asked many questions for the participants to answer.  One question was regarding telling options to expecting families even if they are not available locally – should you or shouldn’t you?  I stood for quite a time in front of the large paper on the wall while holding the marker in my hand.  There were many NO’s on the paper in front of me and it took some courage for me to write a commanding YES! next to their responses. I had bucked the trend.  Not easy, not a bit. When all the sheets were gathered and Henci peered at them to discuss all of the responses, she overwhelmingly said we have an ethical obligation to tell it all.  Phew I was not wrong in my group of peers, but sadly most of them said no probably out of the same fear as I had in answering the questions.  That moment gave me great strength and clarity not because Henci said so, rather because I stood in my conviction and faced the fear of being apart from others in the truth.

Why is it of the utmost importance to share all?  Because no one else goes home or remains home with that baby.  The care provider, staff, doula, educator….they all go home to their own lives.  Each expecting family must be able to live with the decisions made during pregnancy, labor, and birth.  Natural birth has many benefits but it isn’t consequence or risk free, so that too must be spoken of.  Each woman must decide what she needs and can best live with as a mother, wife, partner, even as a woman in her community who will go out and share her experiences with others.

I will often tell expecting families who contact me about childbirth education classes that they will receive much more than the anatomy, physiology, comfort measures, etc. from my course.  That very likely it will challenge to the core their beliefs and value systems surrounding what they know in their own birth culture of family, friends and personal history.

I love this work.  I hope someday to be replaced by the community based education women ought get back to. If not, I along with many others will be here to keep the conversation and education moving forward.

Today pregnant women need to be consumers and self-advocates. Many childbirth classes are teaching strategies to better these skills. This is not by chance, but rather by the often one-size-fits all packaging and management from pregnancy onset to labor through immediate postpartum in the care provider offices and hospitals of today.

Many routine tests are done prenatally. Though prenatal care and these tests can help further healthy outcomes for moms and babies, too often women can be funnelled into a cycle of unnecessary fear, stress and choice limitation while in reality still healthy and maintaining normal pregnancy.

Below is a listing of common prenatal tests and practices for you to question (what is it for, what does it improve upon, what can it lead to in other tests or interventions, is it for low-risk moms and babies, what will I do with the information), research and decide on are:

• pregnancy test by urine dip or blood work
• ultrasound to date the pregnancy
• blood pressure reading each visit
• weight measure each visit
• urine test – check for protein in the urine
• fundal height measurement as pregnancy furthers
• gestational diabetes testing
• triple screen testing (AFP)
• just because ultrasounds
• ultrasound for fetal size
• routine ultrasound for fluid level as “due date” approaches
• biophysical profile(s) as “due date” approaches or passes
• membrane sweeping

It is vitally important that you are equipped and aware of your care provider’s philosophy and usual practices.

What are you willing to do? What are you willing to bypass? How responsible for your pregnancy and birth are you willing to assume? At the end of the day you are ultimately the one who has to live with the choices you or your provider make.

Be a driver – you are more likely to arrive at the destination you desire.