There is much awareness and conversation of what the routine interventions are that can occur during the labor and birth process within the hospital environment.  These interventions can include induction, augmentation with Pitocin, epidural, or cesarean. In all my professional and personal roles, I am privy to a great amount of pregnancy and birth stories. Within these experiences there are many “silent” yet obvious interventions that are hidden in plain sight under the guise of protocol, practice and societal expectation.

My current list of hidden in plain sight interventions in no particular order that can make a difference on how a woman labors and ultimately delivers her baby is below.

• The uniform -Asking and expecting the mother to give up her clothes for the hospital gown.
• Who’s on first? – If care provider is part of a large practice or on-call group a woman may have never met or have any knowledge of the person who’s practice style and philosophy is helping to guide and steer her labor and delivery. On-call CP may or may not adhere to the birth plan the laboring woman worked out with her own CP.
• On a short leash – Continuous monitoring even if she is not high risk, medicated, or being induced/augmented.
• The big drag around – Requiring IV running with absence of medical need.
• Staying put – Asking or requiring the laboring woman to stay in bed for ease of staff without medical need.
• Ice chips and Jello – Disallowing snacks and sometimes even actual water even though labor is hard work.
• The marketing tool – Disallowing the laboring woman to get into the touted tubs or showers since it isn’t convenient for staff and she will not want to get out.
• One is enough – Limiting the amount or type of support persons a woman is allowed to have with her.
• I know more than you – Treating the laboring woman as if she knows nothing or shouldn’t know anything.
• If you don’t… – Instead of giving informed consent and refusal, telling only what bad could, maybe happen.
• Attitude and atmosphere – Negative, non-listening, lacking compassion, leaving the door open, ignoring requests, and the like when a woman is laboring.
• Only if you ask – Though some wonderful practices are in place, they are only offered if a laboring woman or postpartum mother ask/insist on it.
• Bait and switch – The official tour of labor and delivery and the reality of labor and delivery don’t fit together.
• New with bells and whistles – The pretty with all the fancy bells and whistles like wi-fi, flat screen tv’s, etc. have to be paid for somehow. Because of this investigate the intervention rates there.
• Routine vaginal exams – By and large VE’s are very subjective and can vary greatly between one person to the next on how they score a VE. This variation can deeply affect the course of a woman’s labor and delivery.  Women birthing in the hospital really only “need” a VE upon entrance for assessment of where she is in labor, if she desires an epidural/IV narcotics, if she is having a very prolonged labor, or if she feels pushy.
• Pushing the epidural – When a woman is moving, moaning, making noise or just doing her thing in labor and it causes the staff discomfort or worry.  It could even be that anesthesiologist is going in to surgery and it can only happen now.

Simply because a societal norm is birthing at the hospital, as well as, what routinely goes on there, doesn’t mean the hidden in plain sight interventions are wise or harmless.

My goal here is to give pause and broader thinking to what intervention means for labor and delivery as another tool in planning and preparing for childbirth with eyes wide open.

ACOG recently updated guidelines for fetal monitoring in labor.  They call it a refinement.  Very interesting.

Directly from the press release “Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,” says George A. Macones, MD, who headed the development of the ACOG document. “Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.” That is an increase in use by 89% with what benefit to mothers and babies? More cesarean?  More interventions and managed labors? Perinatal mortality hasn’t decreased.  Shocking really.   So for the needs and most likely benefit of the truly high-risk moms and babies all women have been subjected to more and more electronic monitoring in labor resulting in more morbidity for mothers and babies.

Apparently a big issue is that there are huge discrepancies in interpretation when assessing the FHT strips by physicians. There was a group of 4 physicians who initially assessed 50 FHT tracings and only agreed 22% of the time. Then two months later the same 4 physicians were asked to re-assess the same 50 tracings and their own evaluations varied nearly 1 in 5.   I have heard this over and over anecdotally from labor and delivery nurses through the years.  That no one can agree.  That the variance is so great.  Better to treat just in case whether by interventions or a cesarean.  I have been told that even a 40 hour course on FHT assessment leaves one without any clear advancement of skill or knowledge. The training actually left one individual less inclined to trust assessment.  So how does this comfort the expecting woman? Knowing that the machine that rules so much of labor and delivery in combination with the human element is so fallible.  Now that is non-reassuring in real life application.

So what can be done?  Unless there is a real high-risk situation that needs to be addressed, ask for intermittent auscultation with a handheld doppler or even better with a fetascope.  When a nurse, midwife or doctor actually listens personally to a baby with a fetascope there is no machine interpreting sound. It is with their own ear and skill assessing your baby.

The other thing to remember is keeping away from routine use of  induction, narcotic use, and epidural use in labor can greatly improve the opportunity to remain low-risk and healthy.  Thus not requiring continuous fetal monitoring.

I only touched on a few aspects of the new guidelines.  For a more complete breakdown of the refined guidelines, the NY Times did a nice piece.

There are many reasons why a woman chooses to birth in the hospital. Women have the right to choose where and with whom she will birth regardless of what another would choose.

Women need the tools to navigate the hospital setting. She and her baby ARE unique. They are human beings. Laboring women are often placed under one-size-fits-all standing orders and protocols. Because of this, pregnant women need to be very careful regarding the books read, the types of birthing shows viewed, the care provider chosen and the childbirth class taken prior to entering the hospital to birth.

Here are some tips for a truly healthier and safer experience:

• Take the hospital tour – ask lots of questions – induction rate, induction medications and/or procedures routinely used, average cesarean rate for first time moms, VBAC rate, pitocin use rate, epidural rate, use of non-medical pain relief, natural childbirth rate, IV use versus saline lock, percentage of moms who utilize doulas, is pain management highly suggested to every laboring mom, monitoring norms, availability of tub or shower for labor, standard protocol on eating and drinking in labor, use of non-supine pushing positions, mobility in labor, are the labor and delivery nurses open to anything goes in labor, what is protocol on immediate postpartum baby care, is there a lactation staff available….
• Read the pre-admit paperwork. If you are not sure what it says, ask a paralegal or lawyer to look at it. Be certain that you agree with what you are signing.
• Do not sign epidural or cesarean consent form at pre-registration. You want to be fully consented during true decision making time. Be sure though to be familiar with benefits, risks and consequences of everything ahead of time.
• Take a non-hospital childbirth class or independently run class within the hospital.
• Only agree to induction for a true medical reason – (suspected big baby, pre-pre-eclampsia, being tired of pregnancy, care provider going on vacation, relative will be in town, being past your “due date”, just because you can – are not medical reasons)
• When induction is necessary – choose a foley catheter to ripen the cervix over misoprostol (cytotec, miso, or the little pill) and if labor establishes upon cervical ripening – decline pitocin or ask to keep it very low over a longer period of time.
  Keep your “water” (amniotic sac) intact until it breaks on its own. This can keep infection probability much lower, lessen risk of cord prolapse, and lessen the discomfort of contractions among many other things.
• As long as a mom and baby are low-risk – wait until well into active labor to arrive at the hospital – contractions 3 minutes apart and lasting a minute or more. Shortening the time in the labor and delivery room usually keeps interventions and medications to a minimum.
  Any birth and immediate postpartum preferences need to be discussed PRIOR to labor with your care provider. A concise birth preference plan can be given to the nurse upon arrival.
• In the event a cesarean is necessary (hopefully not created by interventions and medications in labor), discuss with your care provider prior to labor what you would like to have occur (partner in OR, no separation of baby from mom, pictures taken, etc. – for a complete list, please email me).
• Make postpartum baby care decisions prior to arriving at the hospital. You do not need to have a pediatrician or family practitioner picked out ahead, as the floor doctor will oversee your baby’s care. If you are unsure of what you want, it is always acceptable to delay any immunization, vitamin K injection, eye ointment, etc. until you have the opportunity to investigate further. As a parent you have the right to say yes or no to anything.

The key thing to remember is that as a consumer, you are paying your care provider for a service, for the hospital staff to attend you respectfully, and for the use of the room you are renting. You do have rights. Protocols and practices are not laws. You can say yes or no to anything or everything.

As a woman you are making parenting decisions throughout labor, delivery and early postpartum that should be respected, honored and can have lasting consequences. There is no do-over.

Remember to be a driver – not a passenger!

So let’s chat about childbirth education. Of the reported 30% of expecting parents who attend childbirth classes the majority go to the hospital where the birth is planned instead of seeking out independent options. I want to challenge you to think about how strange that is. Does it make sense that the information presented will REALLY be balanced, unbiased and evidence-based? Many protocols and practices used during labor and delivery in the hospital are designed as a one size fits all, no suited to each individual mom and baby. More importantly, they are not designed to suit the usual low-risk mom and baby (the majority of moms and babies are normal and low-risk), but can actually make a mom and baby appear or become high-risk. Some refer to hospital classes as “good patient preparation” classes because of lack of inclusive information. I will admit, that all hospitals do not offer education in this manner, however, in my experience and research many sadly do.

If a car salesman tried to sell you a car and actually insisted you purchase the specific color, make and model he/she decides for you, would you buy it? You would hopefully say no thank you and leave. How dare some one make such a huge decision for you. How long do you research a piece of electronics or a computer, even a cell phone plane before deciding? Even the pair of shoes you are wearing. Did you have to try on several before finding the right pair?

So why not think outside the big box, one size fits all class? Every mom, baby and partner deserve to know the wisdom of birth, understand what is normal and how to stay that way, when the abnormal happens what to do and be a skilled consumer.

There is no re-do here. This time is too important to leave to chance and inadequate education.

This is at the essence of why I teach my own childbirth classes at a location outside the hospital. I am able to freely give full spectrum information without restriction, bias or without the fear of losing my position.

Your birth matters to both you and your baby, to your future fertility, to your confidence as a mother

Below is a list of options available to families all across the US and variations in other countries as well (if if any class types have been overlooked, please let me know and I will add it).

• Independent – philosophy based (CAPPA, Lamaze post-2000, ICEA, CBI, ALACE, Birth Works, Birthing From Within)
• Independent – method based (Bradley, HypnoBirthing, Hypnobabies
• Self education

There are many other great ways to find a class that suits you.

• Ask around in your community
• Attend birth circles, Birth Network, La Leche League and/or ICAN meetings
• Seek out local doula groups and information nights
• Check out sites like Independent Childbirth

Here’s to finding the perfect fit and gestating in peace.

Desirre

Picture this: An expectant mother is preparing for the birth of her baby. She chooses the care provider her friend, co-worker or family member recommended, she is reading the most popular books on pregnancy and birth (she doesn’t know there are any others to choose from – everyone is reading these), she cannot help herself as she watches hour upon hour of those baby and birth shows on t.v., people tell her their birth stories and to just get the epidural (after watching those birth shows and hearing THOSE stories she is beginning to think it might just be a good idea). Right now, she is pretty sure she doesn’t want to be induced (she heard it hurts more, but knowing when the baby will come is appealing) or have a cesarean but other than that she is leaving it up to her care provider.

Now she starts her childbirth class. This class is based on normal birth and evidence-based practices. Hm those books she was given are SO different than what the instructor says during class. The instructor doesn’t even recommend those books but a host of other books and websites. She begins to wonder what her care provider really thinks and believes about birth. Also, what birth philosophy and practices her chosen birth location has.

I have written a list on choosing a care provider and birth location that is right for you. This is too important to make decisions without extra thoughtfulness and investigation. The key to this information is remembering you are the one purchasing a service. Essentially you are hiring a catcher with medical expertise and renting a room to birth your baby (if you are going to the hospital or birth center).

Choosing the place of birth for your baby – It is incredibly important that you understand where you fit best prior to choosing where to birth your baby. Take hospital and/or birth center tour, call and talk to L&D floor, get facts on home birth by talking to home birth midwives, other moms who have had home births, online and in books.

• Does the location offer what is most important to you (tubs, birth balls, wearing own clothing, intermittent monitoring, etc.)?
• What are standard protocols that are followed?
• Does location routinely use methods that turn a low risk mom and baby into high risk patients?
• Are waterbirths available?
• Are birthing stools or non-reclined pushing and delivery positions encouraged?
• What is the no/low intervention rate?
• What is the epidural rate?
• What is the cesarean rate? Does the hospital support VBAC’s?
• Are mom and baby friendly practices used? (no routine interventions, no separation of mom and baby, breastfeeding is the norm, movement in labor is utilized, etc.)

Points to Ponder afterward –

• Will I be able to have the type of birth I truly desire?
• What location will I ultimately feel most comfortable in?
• What location is ultimately safest for my specific needs (I am currently low-risk or high risk)?
• Is insurance or lack of it the reason I am choosing the location?
• Do I have realistic expectations for the location?
• Am I willing to take responsibility for my birth in the location?
• Is staff open to working with a doula?
• Is staff willing to work with natural childbirth practices?
• Are there any compelling reasons to choose one location over another?

Choosing your care provider – Use this as a template for the interview process or to be certain you are of the same philosophy and belief system.

• What is his/her birth philosophy?
• What is philosophy of pregnancy?
• Has provider seen normal labor and birth? How often?
• What percentage of patients have medicalized births?
• How is the “due date” approached? When is “overdue”?
• Will you answer questions over the phone?
• How much time will you spend with me during each appointment?
• What if I hire a doula? Are there restrictions on the doula I may hire? If yes, why?
• Do I need a childbirth class? Breastfeeding class?
  o Are there restrictions on the type of childbirth or breastfeeding class? If so, what and why?
• What routine tests are utilized during pregnancy? What if I decline these tests?
• What are routine intervention rates? (IV, AROM, continuous monitoring, etc.) Cesarean rate? VBAC rate?
• Induction rate? What induction methods are used?
• Is natural, normal labor and birth supported?
• What positions is care provider comfortable catching in? Birth stool? Hand/Knees? Squatting? Standing?
• If I choose an epidural, when can I get it or when is it too late?
• How often is episiotomy used?
• When would forceps/vacuum be used? Which method is CP comfortable with?
• What about a birth plan? Will desires be put into my file at the hospital so the nurse and/or back-up will know what has been agreed to?
• Are there any protocols that are non-negotiable?
• What if I choose to decline something after careful consideration?
• Is an on call rotation utilized or does CP attend all own patients? If there are partners or an on call rotation, do EACH of the others share in the same birth philosophy and approach to birth?

Points to ponder afterward–

• Did you feel immediately comfortable at the interview?
• Were or are questions specifically answered or is the answer “only when necessary” without additional information unless pressed?
• Was or is care provider willing to answer questions in detail without being annoyed?
• If already with a CP, do you feel comfortable and heard at each appointment?
• Is choosing your care provider based on your insurance or lack of insurance?
• What are you willing to do in order to have the birth you really desire? Birth location?
• How much responsibility are you willing to take for the health care decisions for you and your baby?

Yes you DO want to avoid a cesarean whenever possible. Cesarean is MAJOR surgery. It is not just another way to give birth. Both women and babies are well designed to give birth often never needing intervention of any type.

Cesarean can be a life-saving technique and used well for some serious medical conditions, including but may not be limited to placenta previa, HELLP syndrome, uterine rupture, placental abruption, cord prolapse, some breech presentations, true fetal distress, vasa previa and high order multiples.

Approximately 50-67% or more of all cesarean surgeries performed in the U.S. are likely unnecessary or become “necessary” from iatrogenic influences (non-medical inductions, AROM, pitocin augmentation, epidural or spinal anesthesia, “fetal distress”, suspected big baby, lack of mobility, continuous fetal monitoring, pushing positions and/or technique).

Here are some tips to help you avoid a cesarean and have a positive vaginal birth.

• Get educated: Book to start with – The Thinking Woman’s Guide To A Better Birth by Henci Goer, Ina May’s Guide to Childbirth by Ina May Gaskin, The Official Lamaze Guide. Giving Birth with Confidence by Lothian and DeVries. Seek out websites that use evidence-based information and normal birth practice information. TURN off the t.v. from the dramatic birthing shows unless you watch with a discerning eye to figure out what could be done differently and why. Seek out local resources such as La Leche League, Birth Network, Birth Circles and/or a local ICAN chapter to learn from other women. Take a childbirth class that is not a good patient preparation class. Take an independent evidence-based class that gives you tried and true techniques along with the communication skills to use your consumer voice. Study and learn about your rights as a pregnant woman, informed consent/refusal and all the usual interventions and medications (induction, augmentation, AROM, epidural, monitoring, etc.).
• Interview Several Care Providers: You want to find out what the raw data is for inductions, interventions, epidurals, episiotomy, cesareans, VBAC’s and so on. It is important to get at the core philosophy of the care provider. Email me at desirre@birthingtouch.com to receive my handout on this.
• Interview several and hire a Doula: You want a doula who will fit into your philosophy of birth and labor/delivery needs. One size does not fit all.
• Use normal birth practices: Stay home as long as possible in labor (if having an away from home birth), choose a care provider who supports and believes in you, use a variety of natural coping techniques, opt out of routine induction, opt out of continuous monitoring unless high risk, opt out of routine augmentation, opt out of routine epidural or narcotic use, opt out of routine pushing position, limit vaginal exams, use mobility, TRUST yourself, LISTEN to your body and baby, accept responsibility for your decisions, BE confident that you are designed for this task.

I hope this has given you a jumping point to go out and birth!

Happy Thanksgiving.

Desirre

http://www.cdc.gov/nchs/data/hestat/prelimbirths05_tables.pdf#1

http://www.ican-online.org/

http://www.lamaze.org/Default.aspx?tabid=171

http://www.birthingtouch.com/

http://www.childbirthconnection.org/

http://www.hencigoer.com/

These days political correctness seems to rule the world (at least the United States). We have become so easily offended that we often miss the truth and follow parcels of truth weighted down by vast untruth for someone else to gain from in some way, not for the health and safety of our bodies or our children.

Language matters. Language can affect how we perceive our bodies, our designed in capabilities and our baby. Language has the ability to strengthen confidence or smash it to pieces in one single moment.

Below is a list that is purposed to make you the reader stop and think. Take the almost ho-hum usual and shed new light on it.

Take a scroll down this inaugural blog and tell me what you think?

cesarean = “controlled” uterine rupture (read in Pushed)
planned epidural = planned paralysis
OB = high risk surgical specialist
Family Practitioner/Midwife = low risk normal birth expert
cesarean rate = epidemic
rising induction and cesarean rates = daylight obstetrics (read in Pushed)
induction = forced birth (Ruth Trode)
ACOG = trade union
Formula=stagnant (Ruth Trode)
Breastmilk=life (Ruth Trode)
Failure to progress = failure to wait (Henci Goer?)
Episiotomy = surgical cut
FEAR = a False Education Appearing to be Real (heard from many places)
AROM (artificial rupture of membranes) = artificial readiness of mother
unneccesary cesarean = unnecesarean (heard from many places and Joni)
CPD = care provider distrust

Please email me at desirre@birthingtouch.com if you have a word change up you would like to see on an updated post in the future. For more information on me, go to http://www.birthingtouch.com/.

Thank you to the women of www.independentchildbirth.com for working on this list with me.

Be BOLD, find the truth and spread it!

Until next time,

Desirre