Childbirth Choices Series Part V: It's Almost Time to Have a Baby!

This is the fifth in my Childbirth Choices Series, geared toward newly pregnant or planning-to-be pregnant couples with the goal of educating women and their partners about the many options they have when it comes to their prenatal and maternity care, including choosing a care provider, choosing where and how to give birth, and information about labor, delivery, and the immediate postpartum time. This is not meant to replace or substitute for a childbirth education class. Rather, it is intended to get women thinking about their options and making informed choices when it comes to their care throughout pregnancy and labor and delivery.

More articles in this series:
Part I: I've Just Found out I'm Pregnant; Now What?
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?

Part IV: What Will Happen at My Prenatal Appointments?
Part VI: Labor and Delivery

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It's finally here! You've finally reached the end of your pregnancy! You're 38, 39, 40 weeks (or even 41) weeks along. You're anxious to meet your baby. This section will address what's going on with your body at the end of pregnancy and some things to think about as you go into labor.

Nearing and Passing Your Due Date

As described in an earlier article, your "due date" is really just an estimate of when your baby will be born, based on your last menstrual period. A normal, full-term pregnancy can run anywhere from 38 to 43 weeks, and the 40-week estimate is just a convenient mid-point of that range from which to measure the pregnancy. Many factors, both natural and artificial, can influence when you give birth, and scientists and researchers have yet to determine the exact mechanism or sequence of events that tells your body to start the labor process.

By the end of the pregnancy, though, you're likely feeling very uncomfortable. You're big, ponderous, experiencing aches and pains, having difficulty sleeping at night, having heartburn, needing to pee frequently, noticing swelling in your fingers, hands, ankles, and feet; you're short of breath and possibly even feeling strong, if not painful, contractions of the uterus. You're ready for this pregnancy to be over and to start life with your new baby.

Remember that every day that your baby grows inside you is good for his lifelong health. Take things day by day, and remember that you will eventually have this baby!

What Your Body and Baby Are Doing

At the end of your pregnancy, your body and baby are getting ready for labor and delivery. From early in your pregnancy, you were experiencing mild contractions called Braxton Hicks contractions. These contractions help to "warm up" the uterus and strengthen the muscle to eventually push out that baby. As you near the end of your pregnancy, these contractions will increase in frequency and intensity but will generally not be painful.

You may also experience early labor, or prodromal labor, also called "false labor." These are regular contractions that may be mildly to noticeably painful that continue for several hours and then stop without building in frequency or intensity. Prodromal labor may begin several weeks before your estimated due date. Many women call their provider or even go to the hospital thinking they are in labor, only to find out that the cervix is not dilating or that an hour of rest makes the contractions stop. If you experience painful, regular contractions, try lying down and resting for a while, drinking water, or even going for a walk. If the contractions slow down or stop after a while, you were probably experiencing prodromal labor. If they continue to increase in intensity and frequency, there's a good chance you are in the early stages of active labor. It can be very hard to know for sure, even if you've been through childbirth before, so don't be embarrassed to call your provider to find out what you should do.

Your baby should "drop" into the pelvis in the late stages of your pregnancy. This may happen a few weeks before your are due, or it may happen just days or hours before labor begins. You'll notice that the weight of your uterus seems to be lower in your abdomen than it has been, and the shape of your belly may change. You may be able to breathe more easily, and your symptoms of heartburn and pressure in your chest may ease. You will feel more pressure in your pelvis, more urgency to pee, and possibly increased constipation or hemorrhoids.

Your baby is packing on weight at the end of your pregnancy, at a rate of about half a pound a week! Ideally, she is settling into a good position for delivery, with the narrowest part of her head, the occiput, pointing toward your cervix. You can help her along by being upright and active, walking, stretching, and moving your body in ways that feel good. Unless you are on bedrest for health reasons or are experiencing unusual symptoms that make physical activity particularly painful, the end of your pregnancy is not a time to convalesce (that comes after you give birth!).

Going Post-Dates

As you near your estimated due date, your provider may discuss with you how far "post-dates" or "overdue" he or she is comfortable allowing you to remain pregnant, and what to do if labor does not start spontaneously by a certain date. Remember that the average first pregnancy goes beyond 41 weeks, and that the "due date" really is only an estimate. Your provider may express concerns about the health of your placenta or the size of your baby and may request that you have a non-stress test (NST). We talked about NSTs in the previous article.

There are two main issues with a pregnancy continuing on into the 42nd week. You may raise these concerns with your provider, or she will likely bring them up with you if you do go past 40 weeks. The first concern is that your placenta may begin to age or calcify, which would be dangerous for your baby. The health of the placenta can be checked by ultrasound, but as long as your baby's heart rate is good and he is moving normally, you probably don't have a lot to worry about. The other concern is that the baby may "poop" in the womb, or release meconium. The problem with that is that he may aspirate the meconium into his throat or lungs before or during delivery. Meconium is very sticky and can cause breathing problems if inhaled.

Because of the risks associated with these possibilities, some providers are not comfortable with a pregnancy going much more than 10 days "overdue." She or he may offer an induction or ask that you schedule a c-section. Remember that there are many risks associated with an artificial induction of labor and with c-section that are not found in a normal, spontaneous labor. You may like the idea of knowing when your baby will be born, but you should also be aware of these risks.

The biggest risk of an artificial induction of labor is emergency c-section. If the induction of labor does not work, or if your cervix does not dilate fully, and especially if your waters are broken, it may be necessary to get the baby out some other way. Pitocin can cause the baby to go into distress, which would also typically require an emergency c-section. There is also the chance that your due date was incorrectly estimated or that your baby really did need those extra days or weeks to grow and that inducing labor means that he comes too early, leading to lifelong health problems due to his brain or lungs not being fully developed.

Your provider may also mention your baby's size as a reason for wanting to induce. The size of the baby rarely has any bearing on whether it is possible to give birth vaginally. Remember, too, that ultrasound estimates and measurements of your uterus are just guesses that can be off by up to 1.5 to 2 pounds. "Large baby" alone does not have to be a reason for early induction or scheduled c-section.

It is important to investigate the risks of interfering with the natural process of labor before making your decision. Don't be afraid to ask questions of your provider regarding his or her reason for wanting to induce or schedule a c-section and the risks to you and your baby both of waiting for labor to start spontaneously and of induction and c-section.

This article discusses what a c-section is and some of the risks associated with c-section.

Inducing Labor

Many women become impatient to give birth and will look for any trick to get their bodies to go into labor. Some of the "natural" (non-medical) ways you might attempt are:

• Sexual intercourse: Having sex releases the hormone oxytocin, which is the same hormone that stimulates uterine contractions. In addition, semen contains prostoglandins, which can help ripen the cervix. Do not have sexual intercourse if your water has broken or if your provider has asked you to refrain from sexual activity for any reason.
• Walking: Taking long walks is good for you throughout your pregnancy, and especially at the end. Walking helps the baby get into an optimal position for delivery - head down, with his face to your back - and settles him into the pelvis. The pressure of his head against your cervix as you walk may also help the cervix to begin ripening. If you can manage it, walking up stairs or steep hills can be very effective at moving labor along if you think you're in the early stages, and it's excellent exercise in any case. Otherwise, simply strolling along to music on your iPod or conversation with your partner is good for you. Make sure you stay hydrated, as dehydration can be dangerous for you and your baby during labor. Check with your provider if you are concerned about what level of physical activity is safe for you at these late stages of your pregnancy.
• Acupuncture/acupressure: Some women say that getting acupuncture or an acupressure massage helps stimulate pressure points that encourage labor. 
• Massage: Stress can inhibit labor, so anything you can do to help you relax is good. Specifically, prenatal massage can also help open up the pelvis and loosen your muscles, as well as relieving pregnancy-related body pains such as back pain.
• Nipple stimulation: As with sexual intercourse, stimulating your nipples releases oxytocin, which may trigger uterine contractions. You can self-stimulate, have your partner do it, or use a breast pump for 20 minutes at a time.
• Castor oil: Taking a teaspoon of castor oil triggers an "emptying" of your digestive tract (read: possibly painful cramping and diarrhea). It is thought that this may stimulate uterine contractions as well. It is often considered a "last resort" because this effect is uncomfortable and unpleasant.
• Various natural/herbal remedies: There are many herbal preparations that you take orally or insert into your vagina that may or may not help jump-start labor as well. Because herbal remedies are not regulated by the FDA, please make sure you are obtaining your preparations from a reputable source and that you are using them according to directions.
• Various foods and drinks: I've heard many tales of eating a particular food or drinking something specific that may help bring on labor. Who knows if any of this is true, but it probably doesn't hurt to eat something you like if it has that possibility attached, right?

If your body is not ready to go into labor, or your baby is not quite ready to be born, these methods may not work. However, if you are on the brink, or are in early labor, trying one or more of these options may help to speed things along or get things moving in the right direction. At the very least, it may help you psychologically to know that you are doing something relatively noninvasive to make labor start.

In the previous article, I talked about some of the ways your provider might attempt to get labor started without medications, such as stripping your membranes. 

If you are full term (at least 39 weeks, according to the newest recommendations from the American College of Obstetricians and Gynecologists), your provider may offer to have you come in to the hospital for a medical induction. An induction before your body is ready for labor, and especially if this is your first pregnancy, is risky, because your body may simply not respond well to the induction. Many labor inductions result in an emergency or unnecessary c-section that may have been avoided if labor was allowed to start spontaneously. However, if you must be induced for a medical reason (such as preeclampsia), or you elect to be induced because of severe discomfort, a medical induction is fairly straightforward.

Depending on your circumstances, whether there has been any cervical ripening or dilation, and the urgency of the induction, your induction may start with a drug to ripen your cervix, which is inserted into your vagina and left there for 12 to 24 hours. Sometimes this alone can start labor, if you are nearly ready. Alternatively, your provider may use a special device that physically opens the cervix over the course of about 12 hours. Once some cervical ripening has occurred, you will likely be started on a Pitocin IV. 

Pitocin is a synthetic version of the hormone oxytocin. Oxytocin is produced in the brain under several different circumstances, such as sex, breastfeeding, and labor. During childbirth, oxytocin specifically stimulates uterine contractions. Synthetic oxytocin - Pitocin - will also stimulate uterine contractions and is administered via IV. Pitocin-induced contractions may be more intense, stronger, and more painful than the contractions your body would naturally experience from the oxytocin your brain produces. 

Once labor begins, an induced labor will likely follow a similar, if accelerated, pattern to a spontaneous labor, if all is going well. We'll talk about labor and delivery in Part VI, so stay tuned!

Risks and Benefits of Induction

Let's talk briefly about the risks and benefits of having your labor medically induced.

Benefits:
There are occasions where it may be necessary or preferable to have your baby before labor starts spontaneously:

• In cases where the mother's life is at risk due to a pregnancy-related complication such as preeclampsia or PUPPPs, giving birth is often the best option, especially if you are near your due date. Giving birth usually resolves the issue almost immediately, so a medical induction or c-section may be preferable to continuing to risk the mother's health or life by allowing the pregnancy to progress.
• In cases where the mother is suffering from a pregnancy-related condition such as hyperemesis, induction at the first viable opportunity (37+ weeks) may be an option to relieve the mother's suffering. If you think you can stick it out for a few more days or another week or two, it is likely better for the baby to do so, assuming the condition is controlled and the mother's health is stable. However, you may discuss with your provider the earliest reasonable date for having the baby if you are unwilling to wait for spontaneous labor.
• There are certain conditions of pregnancy in which the health of the baby is actually more endangered by continuing the pregnancy than by inducing labor or doing a c-section. One example of this is cholestasis of pregnancy, in which the risk to the baby increases after 37 weeks.
• In cases of general extreme discomfort or gestational diabetes, early induction of labor may be preferable to allowing the pregnancy to continue because of pain or extreme weight gain for the mother or danger to her health. In less clear-cut cases, the risks and benefits must be weighed fully, and you should discuss with your provider the best set of options for you and your baby. Especially in cases of GD, your provider may wish to induce early due to "large baby." These types of inductions often fail and result in emergency c-section, and, as stated above, "large baby" is not, by itself, a good reason for early induction.
• Some women and their providers consider the convenience of knowing when the baby will be born to be a benefit of medical induction or scheduled c-section. If you have childcare or job issues, if your provider may be unavailable after a certain date, or if you or your partner need to figure out maternity/paternity leave or there are other schedule complications such as a military deployment or the need for a family member to arrive to help with the birth or other children, scheduling the childbirth may be an attractive option. In this case, when there are no actual health issues to consider, weighing the risks against the convenience of knowing the birth date is very important. Some providers will be more reluctant than others to encourage a scheduled c-section or induction under these circumstances, but it is ultimately your choice to make. You should consider the short- and long-term risks for you and your child of waiting versus artificial induction or scheduled c-section.

Risks:

While there may be risks to waiting for spontaneous labor, typically there are greater risks to an early induction (except in certain cases like some of those described above). There are risks both to mother and baby of using Pitocin to start labor and to giving birth before your body or baby are ready.

The list here is not comprehensive but will give you some things to consider as you weigh your options.

• Premature or late preterm delivery. Scheduling an induction for your due date or a few days before your due date may result in a baby who was not quite ready to be born. For example, if your estimated due date was off by even a week (you think you are 39 weeks but you're actually 38), and your pregnancy would have continued another week or two beyond that date (to 41 or 42 weeks), inducing labor at 39 weeks may result in a baby who is actually 3 weeks premature. This is called a late-preterm baby, and late-preterm babies may have lifelong health risks or short-term problems as a result of being born just a little too early. These problems may include learning disabilities, lung and breathing issues, susceptibility to illness, NICU stay, difficulty breastfeeding, developmental delays, and low birth weight.
• Postpartum hemorrhage. Pitocin use is associated with postpartum hemorrhage due to the hyperstimulation of the uterus.
• Fetal distress in labor. Pitocin contractions are intense and often faster and stronger than natural labor contractions. These intense contractions may compress the umbilical cord or cause other stress to the baby, causing a sharp increase or decrease in fetal heart rate, which may lead to an emergency situation requiring a c-section or other interventions.
• Increased need for pain medication in labor. Pitocin-induced contractions may be more painful and intense than natural labor contractions, which may sway a mother who is unsure about using medicinal pain relief options toward opting for them. The most common option is the epidural, which limits your movement during labor and may have other risks associated with it, including a drop in maternal blood pressure, lethargic baby, and slowed labor progress. We'll talk more about epidurals and other pain relief options in the next article.
• Increased risk of c-section. If an induction "fails," i.e., labor does not progress or the baby goes into distress, a c-section may be necessary. The risk of c-section is much higher in an induced labor than in a spontaneous one, often due to malpresentation (when the baby is not in an optimal position for delivery) or distress (due to the Pitocin).

The final article in this series will talk about labor itself, what to expect as you go into labor, and the decisions you may be faced with once in labor.

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More articles in this series:Part I: I've Just Found out I'm Pregnant; Now What?
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part VI: Labor and Delivery

Childbirth Choices Series Part I: I've Just Found Out I'm Pregnant; Now What?

This is the first in a series of posts that I plan to enhance into an online course along the same lines. The goal is to educate women before they become pregnant, or when they are newly pregnant, about the many options they have when it comes to their prenatal and maternity care, including choosing a care provider, choosing where and how to give birth, and information about labor, delivery, and the immediate postpartum time. This is not meant to replace or substitute for a childbirth education class. Rather, it is intended to get women thinking about their options and making informed choices when it comes to their care throughout pregnancy and labor and delivery.

More articles in this series:
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's Almost Time to Have a Baby!
Part VI: Labor and Delivery

Choosing a Care Provider

Once you've gotten a positive home pregnancy test or a blood test confirming that you are, indeed, pregnant, one of your first steps will be to choose a care provider (CP). By care provider, I mean the person or persons who will handle your prenatal care and help you deliver your baby.

I've described below the three main types of care providers available in most states to provide maternity care. Before you can choose a CP, you'll need to decide what you're looking for when it comes to your prenatal and maternity care. I suggest you talk to friends and family members who have given birth to find out about their experiences with their CPs and the birth(s) of their child(ren). You may find that attitudes vary widely, from those who prefer a medical approach to birth to those who want a more hands-off, back-to-nature style. If you're not sure what you want, it will pay off to do some research and talk to people who have made various choices, and, most importantly, discuss why they made those choices. Your options and decision will also depend on your location. For example, you may have a Baby-Friendly hospital nearby that provides excellent maternity care. Or, your local hospital may have a dismal maternity record, but there is a birthing center not far away that is very highly rated. I'll get into where you might want to give birth right after the discussion about CPs.

Obstetrician (OB)

An OB, or obstetrician, is the type of care provider most of us think about when it comes to pregnancy. An obstetrician is a medical doctor who specializes in maternity care, including prenatal care and delivering babies, either vaginally or via cesarean section, as well as postpartum care. Most OBs also handle general gynecological issues and regular GYN checkups. OBs typically work in an individual or group practice and deliver babies at a local hospital at which they have privileges.

Why Might I Choose an OB?

As mentioned, an OB is the most commonly selected option in the United States when it comes to maternity care. Many women will simply continue to see the same doctor they have been seeing for their regular GYN care. If you are comfortable with your current OB/GYN and feel that your needs and desires for your maternity care are being addressed, then sticking with a provider you already know can be a great option. An OB can oversee your pregnancy and delivery, and it may be comforting to you to have a medical doctor and surgeon with you at delivery and throughout your pregnancy.

Why Might I Not Want an OB?

Depending on what you're looking for in your prenatal and maternity care, you may find that OBs tend to be clinical and traditional when it comes to how they view birth. This is not a blanket statement about OBs, because I know of many OBs who believe strongly in the course of normal birth and are not so quick to offer interventions. However, often OBs think in medical terms and will take a clinical approach to your care, meaning that they will be more likely to recommend interventions, medications, and tests. For some women, this is comforting and familiar and will be attractive. For others, they may want to look for either a non-traditional OB or investigate another care provider, such as a Certified Nurse-Midwife.

Certified Nurse-Midwife (CNM)

Another option for maternity care is a nurse-midwife (CNM). A CNM is a registered nurse who has gone on for special training in prenatal and maternity care, as well as general gynecological care. A CNM is not a surgeon and cannot perform a cesarean section. She (or he) can deliver a baby vaginally as well as order the use of certain medications and tests during pregnancy and delivery, if indicated. CNMs may work privately or in group practices or may be affiliated with a particular hospital or birthing center. Some CNMs work independently or in a group offering home birth services.

Why Might I Choose a CNM?

Midwives tend to take an approach to pregnancy and birth that is less medically oriented. This means they will be more likely to view pregnancy, labor, and delivery as a natural process rather than as a medical issue that needs to be addressed. Women who are interested in having a "natural" (non-medicated) birth, or who are looking for a CP who will take a more holistic approach to their care, may find a CNM an attractive choice. Please note that a competent CNM can and will monitor you and your baby throughout your pregnancy and labor and will know if it is necessary to recommend emergency intervention by an OB.

Why Might I Not Want a CNM?

First of all, CNMs generally cannot take high-risk cases, so if you have a high-risk pregnancy, a CNM may not be able to take you on as a patient. It may also be the case that you cannot find a CNM who can deliver in the venue you've chosen. For example, you may want to deliver in a hospital, but the hospital you go to may not allow CNMs to oversee deliveries. Also, if you have any concerns about the need for medical or surgical interventions during your pregnancy or delivery, you may be more comfortable with an OB.


Licensed Midwife (LM)/Certified Professional Midwife (CPM)

A Licensed Midwife is a practitioner who specializes solely in maternity and women's health services and is licensed by a particular state's medical board. A Certified Professional Midwife (CPM) is a midwife who has been certified by the North American Registry of Midwives. Similar to a CNM, but not a registered nurse, a midwife can provide prenatal and maternity care, deliver babies, and order medications and tests, as needed. She cannot perform surgery. Not all states recognize or license midwives. In some states, out-of-hospital midwifery is illegal. You will need to find out what the options and laws are in your state if you wish to work with a midwife. Most LMs and CPMs work outside of the hospital setting, often offering home birth and home care services.

Why Might I Choose a Midwife?

A midwife will likely be similar to a CNM when it comes to practice and philosophy. Midwives typically work with low-risk women and babies in the normal course of pregnancy and childbirth. Their services are typically low-intervention and focus on pregnancy and birth as a normal process that may require assistance but not necessarily medical or surgical action.

Why Might I Not Choose a Midwife?

If you prefer to deliver in a hospital or a birth center affiliated with a hospital, you may not have the option of a midwife other than a CNM. A competent midwife will have the necessary equipment, medications, and knowledge to assist with birth, and she will also be able to determine if the mother and/or baby need to be transferred to a hospital for medical or surgical intervention if there is a problem. However, if you are more comfortable delivering in a hospital setting, or you feel strongly that an M.D. should attend your birth, for whatever reason, the option of a midwife may not be attractive to you. And, as stated above, midwifery is illegal in some states.


Do I Want a Group or Individual Practice?

You'll also need to decide if you want to see a CP who works privately or one who is part of a group practice. There are advantages and disadvantages to each.

With a CP in an individual practice, you'll be certain to see the same person at every prenatal appointment, and if you deliver your baby during your provider's working or on-call hours, you'll be certain that he or she will attend your birth. However, if your CP is not available at that time, you will be seen by whichever provider is on-call when you're ready to deliver. Some individual practitioners try to make it a point to be available to all of their patients. This is something you'll want to discuss with your provider at an early appointment.

With a group practice, there are several providers who work together. The advantage to this is that there is a good chance that one of the CPs from the practice will be available/on-call when you have your baby. If you choose a group practice, you'll probably want to schedule appointments with each provider in the group so that you can get to know each of them, so that whoever does end up delivering your baby won't be a stranger.

Choosing a Venue

As you can see, the choice of care provider and venue are closely intertwined. If you want a midwife and a hospital, you'll need to find a hospital that allows midwives to attend deliveries, and you'll need to find a midwife who has privileges at that hospital. If you want an OB and an unmedicated birth, you'll probably need to give birth in a hospital, but you'll want to choose an OB and hospital who will be supportive of your wishes. You will also need to check your state's laws concerning midwifery and home birth, and find out the availability of a birth center near you. You'll want to research your local hospitals to find one that fits best with your needs and desires. Some women will find that there doesn't appear to be a "perfect" or even a "good" option that fits with her ideals, and for those women, being armed with knowledge and research will be especially valuable.

Hospital

Over 98% of American women give birth in a hospital. Many women may not even be aware that there are options other than a hospital birth. Hospital birth is seen as the norm in the United States. Most hospitals have a Labor & Delivery unit where women come to labor and give birth, then stay for an average of two to four days (depending on the method of birth and if there were any complications) while they and their babies are cared for by doctors and nurses on the hospital staff.


Why Might I Choose a Hospital to Give Birth?

As mentioned, hospital birth is considered by most to be the "normal" and expected choice for women in the United States. Nearly all women deliver their babies in a hospital setting. In a hospital, you'll be certain to have access to an operating room, if necessary, medications and anesthesia, if you want them, and nurses and doctors for both mother and baby. A hospital will be prepared with personnel and equipment for dealing with most complications of birth and the neonatal period. In a hospital, you will have the reassurance that, should something (G-d forbid) go wrong, you're in a place that can help you.


What Hospital Should I Go To?

The temptation is typically to go to the nearest hospital to your home that has a Labor & Delivery unit. No one relishes the idea of a long car ride or cab ride while in labor just to get to the hospital, and there's always that fear of giving birth on the way if the hospital is far. However, when choosing a hospital, it's important to know a few details.

- Do they have a well-equipped NICU?

Since a major reason for choosing to give birth in a hospital is the comfort of being there "just in case," it's important to know that your baby will be well cared for if there are complications. If the hospital you choose does not have a NICU and you have need of one, then your baby will have to be transported to a different location for care, and you may be separated for several days. If you have the option, giving birth in a hospital with a respected NICU may be important to you.

- What is their rate of cesarean section compared to vaginal births?

If a hospital has a high cesarean rate (and you'll have to decide for yourself what "high" is), there is a higher chance that you may be pressured into a c-section that you didn't necessarily want or need. Over 32% of babies today are delivered via c-section, and most authorities and experts agree that this number is too high. A hospital with a lower c-section rate likely first turns to methods of managing your care during labor that will reduce your risk of c-section, while a hospital with a higher c-section rate likely jumps straight to surgery as an answer to problems or blips that may not actually be emergency situations. You can investigate a hospital's cesarean rate and learn more about c-sections by visiting http://www.cesareanrates.com/.

- What is their policy on rooming-in? Do they have a nursery in the Postpartum ward?

Research shows that rooming-in with your new baby - keeping your baby in the room with you at all times, rather than having him/her cared for in a nursery - facilitates breastfeeding and bonding and is healthier for mom and baby, assuming neither suffered major complications during labor and delivery (which the majority do not). Find out what your hospital's policy is on rooming-in. Some hospitals do not even have a nursery for healthy babies and require that the baby remain with the mother if there are no extenuating circumstances. Others will require that the baby is kept in the nursery at night and brought to the mother only for feedings. Some hospitals will offer each family a choice between using the nursery and rooming-in.

- What kind of breastfeeding support do they offer?

If you plan to start out breastfeeding - as the majority of new moms do - you'll want to know what kind of breastfeeding support your chosen hospital offers. Do they have a high rate of suggesting formula supplementation in otherwise healthy babies? Do they offer the use of a hospital-grade breast pump if needed? Are babies supplemented with bottles or formula without the parents' consent? Are there lactation consultants on staff who are available to new mothers on the postpartum ward? Are the maternity nurses trained in basic breastfeeding support? These are important questions, which you can ask on your hospital tour, ask of friends who have given birth there, and look for more information about online. Research shows that good breastfeeding support in the hospital fosters continued breastfeeding success after mom and baby go home.

- Are they Baby-Friendly?
"Baby-Friendly" is an official designation given by the Baby-Friendly Hospital Initiative (BFHI), an initiative of UNICEF to improve breastfeeding rates and increase exclusive breastfeeding duration. Only 6.7% of births in the United States currently occur in a Baby-Friendly designated hospital. There are 159 Baby-Friendly hospitals in the United States as of January 2013. You can find out if there is a Baby-Friendly hospital near you by visiting this site. A Baby-Friendly hospital will follow all of the 10 Steps to Successful Breastfeeding that evidence has shown to increase the rates and duration of successful exclusive breastfeeding. Some hospitals are working toward the Baby-Friendly designation and may follow some or all of the 10 steps even if they have not received the official title. You can ask if your chosen hospital follows any or all of these steps, as this can greatly affect your birth and postpartum experience at the hospital.

Why Might I Not Want to Give Birth in a Hospital?

There are many reasons why you personally may not want to give birth in a hospital. Reasons some women cite for not wanting to go to a hospital include fear of hospital-borne infection, fear of doctors, fear of hospitals due to previous trauma, or lack of a good hospital close to home. Some women, rather than an issue of a specific reason not to want to be in a hospital, simply want to give birth in another setting. Many women feel that hospitals are for sick people, and pregnancy and birth are not diseases that need to be treated. In a hospital, you are more likely to be offered interventions such as epidurals, Pitocin, and constant monitoring, and your risk of c-section is likely higher.

Home Birth

A home birth is just what it sounds like: giving birth at home (usually your home). Typically, you hire a midwife or team of midwives to attend you prenatally and at delivery. The midwife will advise you how to set up your home for the birth. When you are in labor, she (or they) will come to your home and monitor you as you labor, help you with techniques for pain management and positioning of the baby, and assist with the delivery. A midwife will have equipment to allow her to listen to your heartbeat and that of the baby, to check your blood pressure, to give you an IV of saline or medication if needed, and can make the call that transfer to a hospital is necessary if an emergency situation should arise.

Why Might I Choose a Home Birth?

I'll preface this by saying that home birth is not legal in every state, and many states have regulations about where your home has to be in relation to a hospital if you choose the home birth route. If you're thinking about a home birth, make sure it is an option where you live.
Although fewer than 1% of births in the United States occur at home, the number is rising quickly. Women who choose home birth give a few reasons for their decision. One is that they enjoy being in the comfort of their own home, feeling that being in a familiar environment helps them to relax and give birth in a peaceful state of mind. At home, you may feel you are more in control of your birth, able to make decisions about where in your house (bed, bathtub, special birthing tub, backyard) you feel most comfortable, what position to give birth in, and to avoid medications and interventions. Women who choose home birth also like that they can have their family around them (or not, as desired). Some like the idea of older siblings being present for the birth, for example. Also, if you give birth at home without complications, you don't have to suddenly pick up and go anywhere: you're already home!

Why Might I Not Choose a Home Birth?

There are many reasons you may not want a home birth. Many families are uncomfortable with the idea of not being in a hospital if an emergency should arise. Some are worried about the mess or feel that their home is just too small for comfort. Some desire an epidural or other medication options, which they would not have in a home birth situation. Also, if you have a high-risk pregnancy or birth, you are not a good candidate for home birth, as your risk of requiring emergency interventions is higher, and these cannot be provided at home by a midwife. Some women simply like being in the hospital, recovering on the postpartum floor, and having a couple of days to be waited on by nurses.

Birth Center

A happy medium if you're torn between a hospital birth and a home birth may be a birth center. Birth centers are typically free-standing facilities that strive for a home-like feel, employ midwives for prenatal and delivery care, and promote a non-intervention birth environment. Some birth centers are within hospitals or on hospital grounds, while others are independent.

Why Might I Choose a Birth Center?

If you are striving for a low-intervention or unmedicated birth but you don't want to or cannot give birth in your home, a birth center may be a good option for you. At a birth center, you will typically be attended by midwives who will help you manage the pain of labor, ensure the baby is in a good position, and assist with delivery. You and your baby will be monitored as needed. Many birth centers will offer the option of giving birth in a tub, in a bed, or in whatever position is comfortable for you. You generally will not stay long after your baby is born, just long enough to ensure that you both are healthy, perhaps eight hours or so after the birth, so if you don't want to be away from home for long, this may be another reason to select a birth center.

Why Might I Not Want to Give Birth in a Birth Center?

As with home birth, if you have a high-risk pregnancy, a birth center may not be able to take you on as a patient. Birth centers typically do not have emergency services such as a ready OR or a NICU. If you would like the option of epidurals and other medications, a birth center will generally not offer these, and you may want to consider a hospital instead. Also, if you want to stay longer after giving birth, a birth center will not have the facilities for you to spend several nights there like you would at a hospital.

Making Your Choice

The best way to get most of this information is word-of-mouth from friends and neighbors who have given birth in the last few years. You may also want to join an online community to get more perspectives, or attend a support group meeting such as La Leche League or ICAN where you can learn about options you may not have considered and hear from individual women about their own experiences and why they made the choices they did.

You will also probably have financial considerations when it comes to making your decision. Find out what your health insurance will cover, as you may be limited in your options of hospital and care provider. You'll want to find out what your out-of-pocket share will be. Some insurance companies will cover the services of a midwife and a birth center birth, although most will not cover a home birth - you'll need to find out if this is the case with your insurer. It is important to know that typically the fees for a home birth and the services of a midwife are considerably lower than a hospital birth with an OB, and if your out-of-pocket commitment with your insurance company is high, paying for a home birth in cash may not be much of a difference. You should also consider the importance of a healthy pregnancy and birth for yourself and your child.

Be aware that you may switch care providers and venues far into your pregnancy. If you have made a decision and are not happy with it, even if you're 30 weeks along already, it may be worth investigating other options so that you can be satisfied with your experience.

For the record, I've had three babies, all in a hospital setting. My first was with an OB in a well-respected hospital near my home. I got my referrals from neighbors and friends who had recently given birth at that hospital and were happy with their experience. I didn't know what my other options were, and the most important thing for me at the time was to be in a hospital close to home. Because I had complications and hemorrhaging with my first, and because my first was a c-section birth, my husband and I both felt that it was important that I give birth in a hospital in the future as well. With my second and third babies, I knew about the options of home birth or birthing centers, and I knew about the option of using a midwife rather than an OB. My health insurance HMO did not give me many options of care providers or birth locations, but the hospital where I gave birth to my second and third sons was excellent and had achieved Baby-Friendly status by the time my third was born. My care providers were mostly CNMs, and I appreciated their approach to pregnancy and birth. An OB delivered my second baby, and my third was delivered by a CNM. I was very pleased with both experiences.

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More articles in this series:
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's Almost Time to Have a Baby!
Part VI: Labor and Delivery

On That Episode of Downton Abbey (Spoilers)

If you've seen it, you know the one I'm talking about. If you haven't, stop reading NOW. I was grateful no one spoiled me for this one, and I'd hate to inadvertently spoil anyone else. This is Episode 5 of Season 3, which aired January 27, 2013 in the United States. (I'm trying to write enough that the preview of this post will not show any spoilers.)

This episode was fascinating to me, for obvious reasons. Birth in 1920 wasn't handled all that differently from today, except considerably fewer births took place in the hospital. I'm reminded of reading Cheaper by the Dozen when I was in sixth grade, which takes place around the same time. The mother decided to try having one of her babies at the hospital, though all her other babies were born at home. A few hours there, and she came traipsing back home, saying that a hospital was no place to have a baby. At the time, I had no idea that babies sometimes weren't born in hospitals, and I had no idea that there was such a thing as a "home birth."

It's funny to think that now, less than 100 years later, giving birth at home is the unusual way.  Times change.

And yet.

If you watch the episode from the point of view of birth advocacy or knowledge of birth, watching the two doctors argue over the best course of action was eerily similar to what happens today. Watching Lord and Lady Grantham disagree over which doctor to listen to, watching poor Tom's distress over his wife's potential fate, watching the sisters try to understand what was going on - well, those kinds of panicked discussions happen just as much today, when the doctor raises the question of fetal distress or other potential birth emergency that may necessitate a cesarean or other intervention.

Dr. Clarkson, the beloved village doctor, wanted to take her to the hospital for a cesarean. There was no way to know, of course, whether it might already have been too late. (And, of course, this is all fiction, so the writers could have taken this in whatever direction they wanted. But let's pretend Lady Sybil, Dr. Clarkson, and Sir Philip were real people, just for the sake of discussion.) There was no way to know whether the cesarean itself would be more risky than allowing labor to continue. They didn't have the option of Pitocin to move things along, or magnesium sulfate to prevent seizures, or fetal monitoring to see how the baby was doing. But they had seen toxemia (preeclampsia) before, and they had seen eclampsia before, and how painful it must be to see those seizures begin and know the patient is going to die and know there's nothing you can do. Eclampsia is still a major cause of maternal death, and it is still unknown what causes an otherwise healthy woman to have a spike in blood pressure, organ failure, and seizures leading to death. It is known that the only way to prevent it is to deliver the baby before the pre-eclampsia becomes eclampsia.

Dr. Clarkson's recommendation to attempt a cesarean section in hopes of saving Lady Sybil's life was not made lightly. He knew the only way to avoid eclampsia was to deliver the baby as quickly as possible. He also knew that a cesarean section was extremely dangerous, a last resort. Until the 1970s, c-sections were performed extremely rarely (4% or fewer of cases). It was known that the risk of infection to the mother was high for surgery performed in a public hospital. Obstetrician-to-the-nobility, Sir Philip, who Lord Grantham hired because he wanted his daughter to be in the best of hands, was aghast that Dr. Clarkson would even suggest such a thing. He felt the risks associated with a cesarean section were higher than the risk of eclampsia. It's possible professional pride prevented him from admitting that he, too, saw the signs of toxemia. It's also possible that he felt labor was progressing well enough that no intervention was required. When the baby was delivered healthy and Lady Sybil appeared to be fine, it looked as though Sir Philip had indeed been correct. Unfortunately, hours later, we learned that Dr. Clarkson's dire prediction was to be borne out.

A case like Lady Sybil's today would probably have been a no-brainer. She would have been taken in for an emergency c-section, and very likely both she and the baby would have been fine. By the end of pregnancy, a woman receiving regular prenatal care would be seeing her doctor or midwife weekly. Her blood pressure would be monitored, and if there was any suspicion that her blood pressure may be rising or that she may be at risk of preeclampsia, she would be told to watch for symptoms such as those described by Lady Sybil - sudden swelling of the ankles and hands, headache, disorientation, visual disturbances.

With both my first and second sons, my blood pressure rose toward the end of my pregnancy, and I was given weekly or even twice-weekly reminders to call my doctor immediately if I should experience any of these symptoms. As it happened, though I was not diagnosed with preeclampsia, my blood pressure was high enough, and stayed high enough, at my 37-week appointment with my second son, that the decision was made to deliver him to protect both of us. Fortunately, a Pitocin induction, in my case, worked perfectly, and my son was born healthy and full-term, and I was fine. My blood pressure came down immediately upon delivery and I experienced no further symptoms that would suggest preeclampsia.

As with any medical decision, decisions regarding birth and interventions during labor require a weighing of the risks and benefits of action or inaction. Sometimes the safest route really is to simply wait and see. Other times, an emergent situation changes the balance in favor of intervention, up to and including immediate surgery. As the helpless viewer of Downton Abbey, we could yell and scream at the TV to go do the cesarean, or that no, she'll be fine, or however we felt, but we couldn't affect the outcome. I could see they were leading up to something when Sybil complained to Mary about the swollen ankles and headache she was experiencing a few days before she went into labor. I was puzzled that Dr. Clarkson didn't mention anything about her blood pressure at that point, since they specifically showed him taking a measurement. I don't know enough about 1920's medicine to comment on his knowledge of the significance of blood pressure in pregnancy. In any case, as committed as I am to allowing labor to take its course in most cases, it became clear that we were supposed to root for Dr. Clarkson's proposal and to be angry at Lord Grantham for agreeing with Sir Philip.

In 2013, a c-section is a relatively safe option in a first-world hospital setting. However, as with any medical or surgical procedure, it carries risks, including infection and complications. The issue, as always, is whether those risks outweigh the benefits of performing the procedure. When the life of the mother or baby is clearly in immediate danger, the benefit of mother and child surviving is obviously greater than the risk of infection, for example. It is important to know what the risks are to both mother and baby of performing a c-section under various conditions and to consider whether the benefits truly make those risks worth taking.

Of course in Lady Sybil's case, the risks of c-section were considerably higher than they would be today in a modern hospital setting, so the decision was nowhere near as clear-cut.

There's a lot of discussion these days about encouraging doctors and hospitals to be more hands-off during birth, to allow nature to take its course, to trust in the birth process. The issue of eclampsia and other life-threatening complications of pregnancy are a stark reminder that modern medical practices during birth also save lives, and that there is definitely a time and place for these interventions. We can hope that, in the future, there will be a better balance between the use of interventions when necessary and relaxing and letting things progress normally when appropriate.

As a side note, I did spend quite a few minutes wondering who is feeding the baby?! when everyone was tending to Sybil and the baby was nowhere to be seen. I was glad when they mentioned that they'd found a nurse for her, though it seemed a throwaway line just to cover that detail. That was the main option for a family of means when the mother died in childbirth. Today, the idea of wet-nursing seems odd, but they didn't have the fancy formulas we do today. Though rudimentary formulas and other infant-feeding options did exist, including simply feeding sheep's or goat's or cow's milk directly, a wet-nurse, if the family could afford and find one, was a better option.