My Fourth Birth!

I started out my fourth pregnancy confident. I knew my body could grow and birth healthy babies in a healthy way. I knew the "rules" of pregnancy and childbirth, breastfeeding and infant care. I found myself quite laid back about the whole process.

Until I neared the end. I was due October 22 (also my oldest son's birthday!), and we had moved to a town that is usually very quiet and relaxed, except one weekend a year, the Pumpkin Festival, when something on the order of 200,000 people flock over the hill on the one-lane, one road to the coast to...look at big pumpkins and explore the street fair (at least, that was my impression of it). The traffic makes it nearly impossible to take the most direct route to the other side of the hills, where the hospital is. We could still get out if we needed to, but it could take a while (possibly over an hour). This year, the Pumpkin Festival was October 19 and 20, and there was a very good chance, based on my history, that I could go into labor that weekend and that my labor would be short enough to be a nail-biter on that long way around.

We had also arranged for my mother-in-law to fly in from Israel a few days before my due date, hoping she would arrive before the baby so she could stay with the other kids when we went to the hospital and then to help out after the birth.

At my 38-week visit with my OB, we both felt it was reasonably likely that I would have the baby quite soon. I was 3cm dilated already (not terribly unusual in someone who's been pregnant before) and experiencing strong (but not painful) contractions. Panicked, I spent the evening arranging with the neighbors to help with backup childcare in case baby decided to make his appearance.

But labor did not start. We got through another week, Pumpkin Festival weekend loomed, but at least it looked like my mother-in-law would be there in time after all. At my 39-week appointment that Wednesday, October 16, my OB and I decided to play it safe and try not to stir anything up. Thursday, my mother-in-law indeed arrived, and still I remained pregnant. Saturday, Pumkpin Festival day one, came, bright and sunny, and we went for a walk down to the main road to see the traffic, which was about as spectacular as promised. The walk turned into a leisurely day near the harbor, where we went to a pumpkin patch, had a panini, and enjoyed a sunny day without labor.

We found a pumpkin to match my belly.

Sunday was gray and cold, and still labor-less. If we could just make it through the day, it would be "safe," travel-wise, to have the baby. And boy was I ready. I'd been uncomfortable for weeks, with pain in my pelvis from the pressure of his head every time I stood up. I was big and ponderous. I was ready for this baby.

But I had a nagging fear that the baby was not positioned well. He was head down, but I worried that he was posterior (OP), meaning the back of his head (occiput) was toward my back, rather than the more ideal anterior position (OA), in which the back of the head is toward the mother's front. It is easier for the baby's head to make it under the pubic bone in the OA position, because the occiput is the smallest point on the head and helps to make way for the rest of the skull. As well, this position allows him to flex his neck and point his chin down to his chest to better fit under the pubic bone, rather than having to tilt his head awkwardly backward. OP babies are more likely to get "stuck," cause more damage as they come out, or even be unable to drop completely into the pelvis and require a c-section. Also, a baby in a less-than-ideal position can cause labor to stall or be slow to start. I was afraid the reason I was having so many contractions that weren't building into labor was because he was malpositioned.

So, naturally, I worried. I had worried for weeks about his position, and consulted the Spinning Babies website for ideas on getting him to turn. I half-heartedly tried one of the exercises (getting into an inclined, upside-down position for 30 seconds a day), and I spent time trying to open my pelvis by getting on my hands and knees and into a modified Child's Pose, hoping to give him the space he needed to turn.

Traffic wasn't bad Sunday morning, and we decided to see what all the fuss was about at this Festival, so we drove down to the town. We walked around for several hours, exploring. I was in a fair amount of pain by the time we started back to our car, underwhelmed and kind of cold.

N carves a pumpkin with S's supervision

Within a few hours of returning home from the Festival, my contractions, which had for weeks been strong but not painful, picked up in intensity, if not frequency. Every 10 to 20 minutes, sometimes with as long as 30 minutes in between, I would have a contraction I would label as painful, if not stop-me-in-my-tracks agony. Also, contractions that infrequent that did not build into more couldn't be called labor. We ate dinner. We put the kids to bed. I thought maybe, just maybe, this was the night. He had kindly waited until Sunday night, as requested. But would these contractions build into something more or fade away?

I discussed with my husband what we should do. I didn't feel an urgency to get to the hospital, but I wasn't sure whether we wanted to try to encourage labor along or get some sleep. Around 10:00, I said I'd like to take a walk and see whether that made a difference. If not, I would try to go to bed. If so, we could hop in the car.

We took a half-hour walk around the neighborhood with no appreciable effect on the contractions. They were still no closer than 10 minutes apart, and some of them were hardly painful. I never had to stop walking or talking to breathe through one. At 11:00, I called L&D at the hospital to ask what they thought. She said she couldn't give me advice over the phone and that we could come in if we wanted, but at 10 minutes apart, we were likely to be sent home. I explained that we were about 35 minutes away and couldn't be going back and forth. She suggested I wait an hour and see if there was any change, then call back if we were planning to come in so they could prepare a room and get ready for our arrival. I thought that was reasonable and said we would do that.

After another half-hour or so, I thought I may as well try to get some sleep. If I was having the baby soon, it might be nice not to have been up all night. I laid down in bed, but with every contraction (still about 10 minutes apart), I found I needed to get up on my hands and knees until it passed. And I certainly couldn't sleep through them. When I finally had two in the space of six minutes around 12:40 a.m., we said let's do it. I called to let the hospital know we were on our way, gathered some stuff to take with us, let my mother-in-law know we were leaving, and hit the road.

There was no traffic, and my contractions kindly picked up as we drove, to the point that I was concerned my water would break in the car. I figured I still had a few hours until delivery, judging from the spacing of the contractions and comparing to my third birth. Having contractions in the car is so much worse, too, because I didn't have the option to move around to find the most comfortable pose for riding out the pain. At home, I had been going on hands and knees with each contraction, and reclining in the front seat of the car was about the least comfortable position I could think of during each painful minute.

We got to the hospital a little after 1:00 a.m. and dashed through the ER to wander the maze of hallways until we found the birth center. The nurses were ready for us and got us into the room as I continued to contract frequently. I changed into a hospital gown, went over my birth preferences with the nurse, and had my cervix checked. I was 5cm, and it was about 1:30 in the morning. She had them call my doctor and started taking my medical history, getting an IV started just in case I needed fluids, Pitocin, or other meds. She attempted to get my blood pressure, but the contractions came faster and stronger, and every time she tried to get a read, I was in the middle of another one! My blood pressure was measuring a little high (really?!), which concerned her.

Are we having fun yet?

She continued to attempt to get my medical history, while I continued to have contractions reasonably close together. I had a chance to catch my breath in between, but after about half an hour, I found I was shivering and shaking and felt nauseous, all hallmarks of transition for me, but I didn't make the connection. After all I was 5cm only half an hour before, and I hadn't even gotten up to walk around, hadn't used the shower, hadn't done any of the things I'd intended to during my labor to help it along.

My "contraction face."

We noticed the baby's heart rate dropped slightly with each contraction but recovered just as quickly, so no one seemed concerned. I joked that he didn't like the contractions any more than I did.

My doctor arrived, got the story, and said she'd be back in a few minutes. I'd finally had enough of reclining in the bed and decided to at least go back to the more comfortable hands-and-knees position. Once there, I just stayed that way, my hands at the very top of the bed, my knees resting flat. They offered to raise the head of the bed so it was practically vertical. I found this to be perfect, dug my hands into the top of the cushion, and rode out each wave. My water broke with a pop, and I realized that my feet were in the danger zone. Ew. But I was locked into this position. I couldn't imagine trying to move again, even to turn around and squat like I'd planned.

At 2:13 a.m., about 45 minutes after first having my cervix checked, my doctor wanted to check again. It seemed everyone around me realized I was ready to deliver, even though I was certain there should be a few hours left of this labor. She checked me as I knelt, and, sure enough, I was complete. What?! "You can push whenever you want to," she declared. 

Let's do this!

With the next contraction, I bore down for all I was worth. I yelled until I was hoarse. I felt like nothing happened. My muscles were jelly, my stomach was weak, and still I pushed. I screamed "GET OUT!" I could feel his head against the pubic bone. I was so scared he was stuck. I had to push harder. I had to get him out. "GET OUT! GET OUT!" I shouted at him (I still feel bad that the first thing my new baby heard was me yelling at him). I'll go ahead and admit it, here, that I pooped, too. Pushing is pushing. They asked if I wanted to get the squat bar and turn around, but I was certain I couldn't move. My arms and legs were locked in place. I was delivering in that awkward position whether that's what I'd intended or not. I said, "If it's okay with you, it's okay with me," when the doctor asked if I was happy where I was. She said it was fine with her. I had the fleeting disappointment that I wouldn't be able to see him born - that was something I'd wanted this time around - but I knew I couldn't move. We were doing this, and we were doing this here and now. "GET OUT!" I screamed again, and then felt like I was out of power. "I can't do it," I said. "I can't." Three nurses, a doctor, and my husband assured me I could, that he was almost out. Another push, and I could feel his head straining against my perineum. I could feel the burn, the pressure, the stretch. "Let him stretch you. He's almost here," the doctor said. Then, "I see a face!" Another push, and he was through! I collapsed forward onto my arms, exhausted, but I still couldn't move, locked on my knees as I was.

Time of birth: 2:31 a.m. We'd been at the hospital for just over an hour.

I had wanted immediate skin-to-skin and delayed cord cutting, which they had said was fine. But he didn't cry right away and apparently was more purple than they liked. His cord was around his neck loosely, which they were able to unwrap, but they needed to take him to the warmer for stimulation to get him breathing. By the time I was able to turn myself over and recline against the bed, they had whisked him away, and the doctor was pulling gently on the cut cord to encourage the placenta to deliver. That, I got to see. The baby, I couldn't. My husband stood guard over him as he let out a lovely wail and pinked up nicely. They weighed him and measured him, then, finally, they brought him to me. He wasn't rooting, but he had a good suck reflex, and after a couple of tries and a bit of coaxing, we got him latched and sucking nicely. His Apgars came in at 9 and 9. A perfect baby boy, with a head of thin but noticeable black hair. Black?! We're a family of gingers!

Okay, okay, I'm crying. Where's my mommy?!

Because of my history of hemorrhage, they gave me Pitocin to help my uterus clamp down. They also massaged my belly - hard - OW - to encourage it to contract and to make sure there were no large clots or excessive bleeding. Once the bleeding slowed, my doctor was able to assess the damage. Surprisingly, and thankfully, I had but two skidmarks and a 1st-degree tear that needed just one stitch! SO much better than an episiotomy, and much easier than I'd hoped.

I asked the doctor if he'd been OP or OA, and she had to do some mental gymnastics, since I'd been facing backward. Since his face had been toward her, that meant he was indeed OA. I don't know if my prenatal attempts had encouraged him to turn or if he'd turned during labor, but I'm certain that listening to my body and finding the most comfortable - if incredibly awkward - position for laboring made everything go so smoothly.

This hospital's birth center was nice, because we didn't have to move rooms after delivery. The nurse sent me to pee while they converted the bed and cleaned up the room. This room would also serve as my postpartum room for recovery and care. They brought in a bassinet for the baby and put a mattress pad on the bed, changed the linens, and, voila!

The nurse said how she loved natural deliveries, because the babies were always so much more alert, and mom was ambulatory. I could barely walk with a midsection of jelly, but I also felt an incredible sense of accomplishment, and quite a bit of shock, at the speed and relative ease of the delivery.

My main wish for this birth had been that it would be drama-free. No side-of-the-road delivery, no unassisted bathtub birth, no complications or hemorrhaging or surgery or NICU admissions. Just get to the hospital and have the baby. Well, we took that one rather literally, didn't we?

Welcome, Baby Boy #4! 

Born 10/21/13 at 2:31 a.m.

8 lbs., 6oz.

20" long

14.5" head

I'll write about our hospital stay in another post. We had a bit of an interesting time after all, and I got to put my CLEC training to work...for myself!

Circus of the Epidurals

My husband and I are long-time fans of the British TV sitcom "Coupling," which ran for four seasons from 2000 to 2004. The fourth and final season followed one of the character's pregnancy and eventual delivery, and one episode, entitled "Circus of the Epidurals" discusses the character's desire for a natural childbirth, and her boyfriend's inability to understand why in the world she would want to forego drugs.

"There's pain, and there's pain relief," he says. "This is not a test anyone should fail!"

The episode is hilarious, and there's no question that it accurately reflects the basic tension between those who desire natural childbirth and those who can't understand why you'd want to "be a martyr" and refuse an epidural when it's right there and available to you. Why would you want to experience pain when you don't have to?

While I enjoy watching this and all of the other episodes of "Coupling," the amount of education I've had on this particular subject does make me want to throw things at the screen. First of all, the female character makes no effort to explain to any interested party why she wants a natural childbirth. (I'm avoiding names to try and limit the spoileriness, in case you decide to investigate the show - available streaming on Netflix!) The closest she comes is, "The pain of childbirth is part of being a woman," to which her boyfriend replies, "Yes! And it's the part we can fix!"

Now, since about the 1970s, there has been a movement toward "natural childbirth," as we well know. It became a trend to eschew any available methods of pain relief, including twilight sleep, Demerol, other narcotics, and epidural, in order to be fully present for the birth of your baby. Medical research has also demonstrated that the use of interventions such as epidurals may attach risks to the birth that otherwise would not exist. While, certainly, "Because I want to experience natural childbirth" is a perfectly valid reason for refusing pain relief, there are also scientifically sound arguments for avoiding or delaying interventions during birth and instead turning to "natural" methods of coping with the pain of labor and delivery.

The prevailing attitude of Western medicine is that our lives are substantially improved by removing pain and treating disease. And I have absolutely no argument with that stance in most cases. However, birth is not a disease, and the pain associated with childbirth is not necessarily an indication that something is wrong. Thus, while normally I'm all about feeling better, experiencing less pain, and reducing discomfort, the process of childbirth, when allowed to progress without intervention, without medication, without probes and monitors, and without interruption, has better outcomes than if we try to "treat" it.

I'm not saying we should never use pain relief, never do surgery, never use the available technology to assist in birth. No one is arguing that infant and maternal morbidity and mortality have not plummeted over the last century, largely due to improvements in medical technology and knowledge surrounding pregnancy and childbirth. However, there is still room for improvement, and mounting evidence suggests that likely over 90% of women will be able to give birth safely and successfully to healthy babies without any medical intervention at all. Allow her the space and time to labor, give her a clean and safe environment in which to birth her baby, have an experienced and well-trained birth attendant by her side, give her a supportive labor coach or two, and she will birth her baby in the most natural and ideal way possible, which will benefit her in her recovery and her baby in his development.

Studies have shown that the use of epidural, especially when in place for a long period of time (more than 10 hours), can interfere with a baby's ability to effectively breastfeed in the first day or two of life. Studies have shown that the use of epidural increases the "need" for Pitocin to augment labor, as the use of the epidural drugs and the fact that the woman is then required to remain on her back may slow labor contractions. Restricting a woman's movement during labor, forcing her to give birth lying on her back, and the use of sensation-dulling medications make it more difficult to push effectively and get the baby into an ideal birthing position. This increases the risk of c-section due to "failure to progress", "long labor", or "large baby." In addition, even if the baby is birthed vaginally, the risks of perineal tearing or episiotomy are increased, which may complicate the mother's recovery. The drugs in the baby's system may dull his sucking reflex and make him more lethargic, contributing to early breastfeeding difficulties. And, finally, the need to push IV fluids to maintain the mother's blood pressure when an epidural is administered may cause edema (swelling) in the mother's breasts within 12 to 24 hours of the birth, making it more difficult for her tiny new baby to latch and suck effectively at the breast, which can delay increased milk production and create a need for formula supplementation where none would otherwise have existed.

The point is, while many women desire a natural childbirth for non-medical reasons, many, many women have solid, evidenced-based reasons to eschew medical intervention and strive for a drug-free birth, for their safety and the health of their babies. Epidurals aren't going away, and many of the risks are manageable or can be mitigated by taking other steps such as allowing immediate skin-to-skin, encouraging rooming-in, and providing in-hospital breastfeeding support, but when women are made aware of these risks, they can make an educated decision as to how much risk they are willing to take on.

My personal desire to avoid the epidural is not a point of pride; it is not a hippier-than-thou exhibition; it is not out of an "I am woman; hear me roar" attitude. It is fear. Plain old fear that getting an epidural might cause a cascade of other interventions that would lead to an undesirable outcome for ME. It's important to note that what I find to be an undesirable outcome, other women may not. This is why women need to be informed, listened to, and included in the decisions made during their births.

So, thanks, "Coupling," for the laughs, but I'll stick to science, and not sitcoms, for birth education!

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.

***

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

What If We Could Have Honest Conversations about Birth with Our Care Providers?

Imagine if, at a regular prenatal appointment, your midwife or OB said to you, "Let's talk about your birth options." Imagine that she or he went on to ask you what you would like to know about giving birth, what you already know, and if you have any particular ideas or plan as for how you'd like to give birth. Imagine if, taking it a step farther, she or he then gave you information such as the following:

"If you would like to avoid a cesarean section, stay home as long as possible once you think you are in labor. The sooner you come into the hospital, the more likely your labor will be augmented with Pitocin, and the more likely you are to end up with a c-section."
"As long as your pregnancy is otherwise healthy and normal, we will not induce you without your express consent. Induction before the body and baby are ready to be born increases the chances of complications, negative outcomes, cesarean section, premature birth, and birth trauma."
"If you would like to discuss the possibility of a scheduled cesarean section, let me first tell you about the risks of doing so, both to you and to your baby. We can then discuss whether the benefits outweigh the risks."
"Unless medically indicated, we do not induce or deliver surgically any baby before, at minimum, 39 weeks' gestation."

And so on.

The point is, women are expected to do research for themselves in order to make informed decisions about childbirth. What's surprising, I suppose, is that more women don't inform themselves. (I didn't, with my first pregnancy.) If I were going in for just about any medical procedure, I would probably be scouring the internet for information about that procedure before agreeing to it. But childbirth? It's natural. The body knows what to do. The nurses and doctors know how it should go. Why do I need to research?

But it's this very problem, that many women (and their partners!) don't know that there's anything to know, that can be rectified by the care providers we trust to deliver our babies. Give us a fact sheet on various birth methods. Discuss risks and benefits. Give us strategies to cope with labor pain, to decide when to come in, to manage our labor process. Help us understand what Pitocin is and what it's for and how to refuse it if we don't think we need it. Talk about induction and scheduled c-section with us, realistically.

When I was pregnant with my second, I had a doctor tell me that babies delivered at 39 weeks via scheduled c-section, 99% of the time, don't have lung issues. She was busy trying to convince me to schedule a c-section, because I was still wavering on whether to attempt a VBAC. What she didn't bother to tell me is about all the risks associated with repeat cesarean sections, such as placenta accreta in future pregnancies, infection, "imposter babies" (those babies who appear to be full term but still aren't quite ready to face the world), etc. (See my post about c-sections for more information.) A second doctor, whom I saw later in the pregnancy, did tell me some of these things, and also told me I was a very good candidate for VBAC and that there wasn't any reason not to try. Obviously, he was right!

Let's move on to the hospital setting. Imagine showing up a little too early, say, at 3cm, and being told, "You should really just go home. It will be a while, and if you stay here, we may end up trying to speed things along, which will increase your chances of complications and possible c-section." Or, perhaps they would say, "Feel free to stick around, but it's still quite early and could be hours or even a day or more before your baby is ready to come. Would you like to speak with a member of our birth support team or a doula on duty to help you cope with these contractions without medication?" (Wouldn't it be amazing if hospitals employed staff doulas to provide labor support?!)

But what if a woman comes in and just wants her pregnancy over with, if she's swollen and in pain and past her due date and horribly uncomfortable and just can't be pregnant another day, and she has called her doctor and requested an induction? Shouldn't her doctor at least discuss the risks of induction? Shouldn't she know that her chances of complications and c-section are dramatically higher than if she waits to go into labor on her own? She shouldn't be "bullied" into waiting any more than she should be bullied into a procedure such as induction or c-section, but she should make the decision fully informed.

A woman isn't "wrong" or "bad" for choosing an elective induction or c-section. A doctor isn't "wrong" or "bad" for suggesting one, especially if a woman is really suffering in her last days of pregnancy. (And, of course, medically-indicated inductions and c-sections save lives.) My concern is that many women show up at the hospital in early labor, sure they'll be holding their baby in their arms in the next few hours, and, 18 hours later, they're under the operating room lights, scared out of their wits, undergoing an emergency c-section because the Pitocin caused fetal distress. Was she fully informed that this was a strong possibility when she decided to come into the hospital?

There's room for change, here. We can work from the bottom up, educating women one at a time about their birth options, which is, in part, what this blog is about. But we can also work from the top down. Hospitals, doctors, midwives, and other care providers throughout pregnancy can help to educate and inform their patients. Indeed, these care providers themselves may need to be more educated and informed about the latest research, evidenced-based care practices, and ways to improve maternal and neonatal mortality and morbidity. Working from all directions to improve birth outcomes - at the hospital administration level, at the care provider level, and with each individual laboring woman - will create a culture of birth that is more powerful, more open, and safer for all involved.

It's Time to Take Back Birth

The first time I was pregnant, I wish I had done more of my own research regarding childbirth.
The first time I was pregnant, I wish we had known more about labor coaching and support.
The first time I was pregnant, I wish I had known that there's more to baby's position besides "head down" or "head up."
The first time I was pregnant, I wish I had known it was okay to labor at home.
The first time I was pregnant, I wish I had known that being mobile during labor can mean the difference between vaginal birth and c-section.
The first time I was pregnant, I wish I had know more about the risks of c-section.
The first time I was pregnant, I wish I had known what I know now.

The second time I was pregnant, I decided to listen to people other than my care provider. I decided to hear what natural birth advocates were saying. I decided to find out for myself everything I could so that I would have a shot at a vaginal birth instead of a repeat c-section.

And what I've learned since then is shocking to me. Many obstetricians and Labor & Delivery nurses have never seen a birth without interventions. Many women have no idea the risks of an epidural. Many women have no idea the risks related to c-section, especially as they pertain to future pregnancies and births. And many women, and even some doctors, have no idea that inducing labor even a week or two before the due date can have lifelong consequences for baby and/or mother.

I want women to be informed. I want them to know the facts. I want doctors and midwives and other care providers to understand the difference evidence-based care can make. Women should be told all of their options at their prenatal appointments. They should be able to make a decision based on facts, statistics, and information. Their care providers should help them make these decisions based on best outcomes, risks and benefits, and the desires and goals of the parents-to-be.

That's why I'm so excited about the National Rally for Change taking place on Labor Day, September 3, 2012. Organized by ImprovingBirth.org, the Rally will bring together women, men, and children in dozens of cities all over the United States to demand evidenced-based maternity care.

Research shows that labor does not need to be rushed along with drugs, that epidurals can interfere with the natural progress of labor, that c-sections are not necessary 32% of the time (the current national c-section rate), that induction of labor is not medically indicated nearly as often as it happens, and that induction of labor leads to c-sections in well over half of cases. Research also shows that c-sections carry much higher risks than vaginal births, to both mother and baby.

C-sections, inductions, and fetal monitoring certainly have their place. Without them, we would see far more mothers and babies suffering injuries or death in childbirth. When we know the baby is in distress and we can quickly retrieve him from danger, we can give thanks for these life-saving interventions. When we know the mother may be in danger of life-threatening blood loss, stroke from toxemia, or damaging complication, the fact that we can identify risks and bring mother and baby through the birth safely is nothing short of miraculous, especially compared to the much higher mortality rates of the past. However, these types of cases are not the norm, and normal childbirth does not need to be treated like an emergency.

When we demand evidenced-based care from our maternity care providers, we are improving birth outcomes across the board. When we inform women of their choices in childbirth, we are creating a new culture of birth that moves away from fear into a place of empowerment.

When I was pregnant for the first time, I wish there had been a National Rally for Change. Thank you, ImprovingBirth.org!

To find a rally site near you, or to organize one for your city, visit ImprovingBirth.org.

The National Rally for Change - Improving Birth

Labor Day seems a fitting time for us to think critically about birth in this country. This Labor Day, September 3, 2012, women, men, and children will come together all around the country for ImprovingBirth.org's National Rally for Change. "The National Rally for Change is to encourage and insist that all maternal healthcare providers practice evidence-based care," to bring about a shift in the public perception of birth and the way care providers handle pregnancy and birth.

The statistics about birth in the United States show a disturbing number of unnecessary inductions and cesarean sections, unneeded interventions during the labor and delivery process, and a general fear of allowing nature to take its course. While modern medicine certainly has created an environment where it is theoretically safer than ever to give birth, the high rates of inductions and c-sections are disrupting the natural progress of pregnancy and labor and creating a culture of fear surrounding birth.

It's time to "take back birth!" When we demand evidenced-based care during pregnancy, labor, and delivery, we find that c-section and induction rates plummet and maternal and neonatal mortality and morbidity rates improve. Research is showing that our rates of cesarean section, induction, Pitocin augmentation, and other interventions during the birth process are far higher than necessary. Unnecessary or too-early inductions lead to c-section in a staggering percentage (67%) of cases, and c-sections carry a whole host of risks, such as premature birth to lifelong health problems such as asthma for the baby, and infection, infertility, and complications in future pregnancies for the mother.

It's not that c-section, induction, and other interventions don't have their place. Indeed, they are life-saving procedures when used properly. That's where the idea of "evidence-based care" comes in. Use interventions when necessary, based on solid medical research, not just because that's how it's done. 

The National Rally for Change and ImprovingBirth.org want women to be informed about their choices surrounding childbirth. Just as you are entitled to informed consent when it comes to any medical procedure, women have the right to make an informed choice about how they want to handle their births. We have a right not to be bullied by doctors and nurses into unnecessary inductions and c-sections. We have a right to labor in our own time and not on a hospital timetable. We have a right to know when procedures are necessary and when they are for the convenience or protection of the care provider. We have a right to know what a normal birth looks like, and we have a right to choose a normal birth. We have a right to give birth in a birth center or at home or in a hospital, with a midwife or a doctor, in the water or in a bed. We have a right to be mobile during labor, to eat and drink when we are hungry or thirsty, and to give birth in whatever position is most comfortable. We also have a right to choose a scheduled c-section or induction, to have an epidural administered, or to receive other pain relief via IV, as long as we make those choices knowing the risks and benefits. 

What is Evidenced-Based Materinty Care? "'Evidence-based maternity care' means that the care that is provided has been proven by reliable research to be beneficial to mothers and babies, reducing the incidences of complications, injury and death."

We need to raise awareness of the state of maternity care in this country and call for change. Please check out ImprovingBirth.org for information about rally sites in your area, how to become a rally coordinator in your city, and to find out other ways you can help. 

We hope to see you at The National Rally for Change, September 3, 2012!

Like Improving Birth on Facebook.

"Curing" Birth

I'm a huge fan of modern medicine. I'm grateful every day for antibiotics, life-saving surgeries, well-trained emergency room staff, ICU's, NICU's, and PICU's. I find it miraculous that conditions which used to kill us are now easily treated, cured, or managed by medications, surgeries, or simple monitoring and lifestyle changes. Where an illness like strep throat once might have been fatal or cause life-altering disabilities such as deafness and heart disease, now it requires a simple trip to the doctor, a throat culture, and antibiotics to knock it right out and get on with our lives. Appendicitis used to be 100% fatal, and now it can be taken care of with a simple laparoscopic surgery. We can fix or replace teeth so they look better than new. We can repair complicated broken bones with surgically placed pins and help them heal with custom-made splints. We can give people new hearts and lungs and livers and kidneys. We can remove brain tumors with an outpatient procedure using a gamma knife, with no need to even cut through the skull. Modern medicine is a great blessing that has lead to better quality of life, decades-longer life expectancy, and a healthier population.

The problem is that modern medicine is so good at finding and fixing problems that sometimes it seems we're actively looking for things to fix that may not actually need fixing. Or, we go way overboard trying to improve a situation that can be managed with less intervention. For example, often high blood pressure or diabetes can be managed by lifestyle and diet changes, without the need for medications, but we automatically jump to the "quick fix" of medications that may have unknown or unexpected side effects.

Nowhere is this phenomenon more obvious than in pregnancy, labor, and birth. Until about 100 years ago, birth did not take place in hospitals, attended by doctors, hooked up to monitors, using medications. Birth was the territory of women, specially trained midwives, with experienced mothers and grandmothers for support. Indeed, even today, in many other countries, obstetricians only come into the picture if there is a complication or emergency situation where the mother and/or baby need advanced care, made possible by modern medicine.

Statistically, the ability of a woman to safely have a vaginal birth is quite high, possibly over 90%. According to research, the optimal c-section rate (i.e., the total percentage of women who give birth via c-section) should be between 5% and 10% of all births. That is to say that in potentially 90% or more of cases, a woman will not need surgery to help her deliver her baby. Right now, in the United States, the c-section rate is around 32%, meaning that almost one in three women gives birth via c-section. Obviously, there is some disconnect between the optimal and the actual, and the question is, why? It is thought that the high rate of medical interventions during birth, including continuous fetal monitoring, epidurals, and Pitocin, do contribute to the high c-section rate. The bottom line is, in most births, a laboring woman given the proper support will eventually have her baby vaginally using nature's time-tested, age-old methods of contractions to open up the cervix and coax the baby down and pushing to encourage the baby through the birth canal and out into the open. It's primal. It's painful. It's hard work (hey, they don't call it "labor" for nothing!). It involves a lot of bodily fluids and parts of our bodies we don't normally have out in the open. But it's basic. It's biological. And it's a system that has worked to propagate the human race for a very, very long time. I mean, there are, like, seven billion of us. Obviously, we're doing something right.

I'm not saying, by the way, that emergencies don't happen. I'm not saying that interventions, drugs, and surgeries are never necessary. I'm not saying that modern medicine and obstetrical practices haven't saved numerous lives, both mothers' and babies'. I'm not saying that hospitals and doctors don't have a place in the labor and birth process. There's a reason that hospital birth is the norm in the United States and many other Western countries. We feel safe there. We know that if there is, G-d forbid, some kind of emergency, we're right there in a place that can tend to us. I know plenty of stories that end with, "If I hadn't given birth in a hospital, my baby would be dead," or, "If I hadn't been in the hospital already, I would have been infertile after my first birth," or, "Without the c-section, both me and my baby would have died." These stories are true, absolutely. Plenty of mothers and babies died in childbirth in years past from issues that we can now either prevent, treat, or handle because of modern medicine.

The trouble is that because we can make birth "easier" on women, sometimes it seems like we ought to. Obviously, if we have the choice between pain relief and pain in any kind of medical procedure, we typically opt for pain relief. I wouldn't want an appendectomy or tooth extraction without anesthetic! So if we know how to "take away" the pain of childbirth, it makes sense that we would want to. Pain is not typically seen as a good thing, and if we can make it go away, we'd like to do that. I'd rather take an Advil than suffer a headache; I don't know about you.

But birth is different. The pain of childbirth is not a "bad" pain. The pain doesn't mean something is wrong. The process of labor and delivery is part and parcel of bringing a healthy baby into this world. By jumping ahead and providing interventions that may or may not be necessary before finding out if those interventions might be causing problems, we have produced generations of people who were not born "naturally." It's only in the past few years that doctors and researchers are positively identifying real problems that are directly related to interventions during childbirth.

One of the biggest culprits is induction and/or c-section before 39 weeks, which has led to many, many beds in the NICU being taken by "late-term preemies," those born between 37 and 39 weeks, who were not quite ready to be born. Many of these inductions and c-sections were not done for medically indicated reasons but rather for convenience or because the mother was uncomfortable. Hospitals that have started banning non-medically-indicated inductions before 39 weeks are seeing a significant reduction in NICU admits, leaving those beds and resources available for babies who truly did need to come into the world before they were fully developed, in order to save their lives or the lives of their mothers. The use of Pitocin to start and/or "augment" labor is very common, and most women are not told about the risks both to herself and her baby that Pitocin may cause. The use of Pitocin is associated with fetal distress, postpartum hemorrhage, newborn jaundice, and possibly even neonatal brain damage. New studies show that at least half of induced labors lead to delivery by c-section - if the baby is not ready to be born, there is a high chance that induction simply won't work and a c-section will be the only way to get the baby out. Even when labor has started on its own, Pitocin is often used to "speed up" or "augment" the labor, and the risks of the use of Pitocin still apply in these cases.

The fewer interventions and less interference a woman has during labor, the more likely she is to give birth safely and vaginally. And, concurrently, researchers are finding that babies born vaginally tend to suffer fewer neonatal complications and lifelong health problems, such as asthma. Vaginal birth is safer than c-section, and spontaneous labor is more desirable than artificially-induced labor.

The root of the problem is that pregnancy and childbirth are viewed by the modern medical establishment as diseases that need to be treated or injuries that need to be fixed, rather than natural, biological processes that can continue on their own without interference. As more women advocate for their births to be supported rather than treated, the outcome is becoming more positive and healthier for mother and baby.

I'm not advising any woman on how and where she "should" give birth. This post isn't about what choices we as women should be making. Rather, it's about looking at how modern medicine sees birth and to address the changing tides of medical opinion toward better, safer births for all women. We as women need to know our options so that we can have useful, intelligent discussions with our care providers about how, when, and where we want to give birth, and, in return, our care providers need to be sensitive to the changing attitudes toward birth, back to letting nature take its course rather than trying to "improve" upon a system that works better without interference.

Just as we don't try to make our kids grow faster by administering human growth hormone willy nilly, just as we don't try to force our kids to walk before they're ready, or make their teeth start to fall out before the permanent teeth start coming in, just as we only turn to surgery for weight loss as a last resort after trying lifestyle changes, we can look at pregnancy and birth as normal processes that we need to wait out, rather than medical conditions that we need to treat.

Pain (and Pain Relief) in Labor

I love reading birth stories. They're incredibly cathartic, emotional, thrilling, even the "boring" birth stories. In fact, I wish everyone a "boring" birth story, because no excitement means no complications and no scary situations! So whenever a friend has a baby, I wait anxiously to read or hear her birth story, because I want to share the experience with her, to empathize, sympathize, commiserate, and celebrate with her. Reading other birth stories lets me understand my own births in a broader context, gives me insight into how other women perceive and experience birth, and demonstrates the attitudes of other practitioners and other facilities.

In reading a birth story the other day, I was amazed by how often she mentioned the pain, how she couldn't wait to go to the hospital and get the epidural, and how she mentioned the agony and doubling over and how excruciating it was. Now, I've given birth three times, and, yes, it hurts. A lot. No question. But she seemed so focused on the pain, so obsessed with getting the pain over with by getting her epidural.

I totally understand. I really do. Birth is intense, contractions sometimes feel like they're never going to end, and pain trumps reason. And when I had my first baby (as this was her first), I'm pretty sure I was quite focused on getting to the hospital and getting the pain over with.

I don't mean to belittle her experience. Indeed, some women experience pain more acutely. Some women have lower pain tolerance than others. And I'm sure that some women experience contractions as more painful or have more intense contractions than others. And reading her story, it sounds like her water had broken and was slowly leaking over the course of several days, and I well know that contractions without the bag of waters intact are far more powerful and intense than those that are cushioned by the amniotic sac.

All of that said, the reason I bring it up is this: I think that if you fear the pain of labor, or if you are focused on when you can have relief from that pain, the more painful you will perceive those early labor contractions to be. And if those early ones are "that bad," how much worse will the later ones be?

Again, labor is painful for most women. There's no getting around that. But there's a psychological element to pain, and I think that's where childbirth classes and preparing for labor and getting your head in the right place can really make a difference. There are many techniques out there for handling labor without medications. There's the well-known Bradley and Lamaze methods. There's Hypnobirthing. You can take classes or read books or listen to podcasts to learn about these methods. But even if you don't use a specific method (as I didn't), you can still prepare yourself emotionally and psychologically to expect and handle the contractions and associated pain.

Even with my first labor, I felt some obligation to delay the epidural for some time. I don't remember why, except that, even then, the limited knowledge I had was enough to know that getting the epidural too early can cause problems. As it was, I got it far too early, at only 4cm dilation. It probably would have been smart to be mobile longer in that birth, although there's no way to know if I would have been able to give birth vaginally to my large-headed, OP child. I do remember that I opted for the narcotic pain relief first, so that I could delay an epidural, even though I had been in active labor for quite a few hours by then and was very tired of it.

My self-education after that birth led me to consciously delay the epidural even longer with my second birth. I think knowing pain relief wasn't something I could have made me willing to work through the pain rather than resent it. Every contraction, after all, leads you closer to the prize. Every contraction is worth it.

I'm not saying that every woman should or wants to experience a drug-free, natural birth. By the end of my third birth, I didn't really want to, either! It happened that way almost by accident, because I had decided that I wouldn't have an epidural long enough that there wasn't time to get one. My mindset was such that this pain was something I just had to get through, and there would be a baby eventually as a reward. There's nothing wrong with getting an epidural. It doesn't make you weak or less of a woman or mother. It doesn't make your child's birth less meaningful or less enjoyable. Indeed, it might make it more enjoyable, given that you can relax a little and not be in so much pain!

I do want to stress that the longer you are mobile and not lying on your back, the more likely you will successfully give birth vaginally, so if you don't need the epidural, put it off a little longer. The reasons are basically that being upright will help move labor along, the pressure of the baby's head on the cervix will encourage it to open and efface, and being able to change positions can relieve pressure on the umbilical cord, increasing blood flow to the baby and reducing the risk of an emergency situation. To put it succinctly: Lying on your back is about the worst possible position for labor and delivery.

What it comes down to is, don't be afraid of the pain of labor. Don't dread it. Don't go in worried about how much worse it's going to get. Be aware that there will be pain, and learn about ways to relax in between contractions and get through each surge. Know that you have the option of an epidural if you want one, but don't think you have to rush to get it. It will be there when you're ready.

I can compare it to the aftermath of surgery when they give you pain meds and tell you not to take them more than every six hours. You sit there, watching the clock, waiting for the six-hour mark so you can pop another Percocet, because the previous dose wore off an hour ago. If you're sitting there watching the clock, just waiting until you can take another pill, those minutes will be excruciating. But, if you're distracted and doing other things, you might be aware that the pain is returning but not be focused on it until you glance at the clock and realize that it's been six hours. At least, that's how it is for me.

Everyone experiences pain differently, and, as I said, for some it is less tolerable than for others. But if there is a psychological aspect to pain, which there usually is, then you can reduce the pain by reducing the expectation of pain. And the most important thing to remember is, eventually, it will end no matter what you do! You will have your baby, and labor will end.

Your Birth, Your Choice

The birth of a child is a dramatic, life-changing event. I'm not just talking about the impact a new baby has on your life, but how the birth itself affects you. I think often a new mother's feelings about the birth itself are overlooked or minimized. A woman may be reluctant to admit that she was in any way emotionally harmed by the method in which her child came into the world or by the circumstances surrounding the birth. It's as if  coming out and saying that she is dissatisfied, angry, depressed, regretful, or unhappy about any aspect of her baby's birth is tantamount to saying she is not happy to be a mother, or not happy to have a new baby.

This isn't fair, and it isn't true. It does women a great disservice to tell them that their feelings don't matter. If such feelings must be buried, ignored, or hidden then they can't be dealt with. Not only that, but these feelings must be aired so that they can be separated from the feelings about the child. You can absolutely unconditionally love your child but not love the way he was born. You can be over-the-moon happy about motherhood but still be angry about not having the birth you expected or wanted.

Pregnancy and birth change a woman. There are, of course, the obvious physical changes. There are the crazy hormones. And there are actual changes in the brain that prepare a woman to care for, love, nurture, and protect her offspring. Pregnancy and birth change your body and your soul. Those changes may carry emotional consequences, some positive, but some also negative. It's no secret that some women are very uncomfortable in their postpartum bodies, that we spend years after giving birth hoping to return to our "prepregnancy size." For many of us, that simply never happens. Our post-pregnancy bodies have stretched and expanded in ways that cannot be undone through any amount of diet and exercise. This is especially true if there was any surgical involvement in the birth!

While postpartum diets, our "prepregnancy" wardrobe, our flabby tummies and floppy breasts, our widened hips and bigger feet are common topics of discussion among new mothers, the emotions we have attached to giving birth are less often brought to light. The result of this lack is that we are hesitant to bring up issues like "birth options," "alternatives," "unnecessary interventions," and so forth, especially after the fact. We feel we are stuck with what we get, unable to discuss our reactions to the unexpected c-section or the emergency induction we didn't want, because, "at least you have a healthy baby!"

Not everyone is affected by birth in the same way, of course. For some women, birth is a major spiritual event, connecting her back through the generations to all the women who came before, empowering her, grounded in thousands (millions?) of years of evolution and nature, filling her with all the magic of womanhood. For others, birth is simply the vehicle by which the baby goes from inside to outside, without any particular emphasis on spirituality or life-giving. Some don't know how they will feel until they've done it. Others have built up a great deal of expectation about what giving birth will be like.

All of these women have a right to be heard, and all of these women have valid feelings. There is no "right" way to feel about birth.

I have a friend who has two kids. Her older child was born via emergency c-section after a long, hard labor. When she was ready to give birth to her second, she decided on a scheduled repeat c-section. Describing this, she says there's no better way to give birth. You show up, get on the table, and an hour later, you have a baby! No labor, no pushing, no work. She usually punctuates her description by rubbing her hands together like brushing off dirt, as if to say, "All done! Quick and clean."

On the other hand, I have a friend who has one child, born via emergency c-section after a long, hard labor. I still haven't heard her entire birth story, because the experience caused her so much emotional trauma that she has trouble talking about it. She is healing, and she is more open about both what happened the first time and what she'd like the next time around than she was even a few months ago. She most definitely does not want a scheduled repeat c-section!

Then there's me. I had no idea that five years later, I would still be so affected by my first son's birth that I would be writing a blog about it! I, too, had a c-section (although not classified as "emergency") after a long, hard labor. For many months, I assumed future children would be born by c-section as well, not because I wanted it to be that way but because I thought I had no choice. I thought my uterus had been permanently damaged and that labor would put undue stress on my imperfect organ and cause me and my baby harm. It was only when I began to learn about VBAC, and that I might actually be a viable candidate for a vaginal birth in the future, that I began to process my feelings about the c-section and understand why I so badly wanted a vaginal birth.

At first, it was simply that my recovery from the c-section was very hard, and I saw friends who had had vaginal births having much easier and faster recoveries. That seemed to be the way to go. (That's what convinced my husband!) Then I started to learn about the risks of c-section and the benefits to both mother and baby of a vaginal birth. My attitude was still very clinical, but I was starting to acknowledge that there was an emotional aspect to my desire as well. But it wasn't until my second son was born vaginally that I fully recognized the power of getting the birth you want. As that baby slid easily out of my birth canal and was put on my chest, an incredible flood of joy and relief surged through me. This was my birth. I had done it. I was in control.

In a c-section, you have to give up control of the process and place your and your baby's bodies in the hands of others. In a natural birth, you are in control. You do the work. For me, that was very important, because I was able to put my trust in my own body instead of others' hands. I was able to get over the idea that my body was somehow imperfect. I could deliver a healthy baby on my own. I didn't need surgery to get him out. I am a mother. I am meant to be one. The revelation of motherhood didn't come with the first birth. It came with the second. (That's not to say I wasn't a mother to my first child before his brother was born, or that I don't love him and nurture him and care for him and protect him! It's just that I didn't feel like a mother, truly like a mother, until my second was born.)

When the time came to have my third baby, I knew without a doubt that I wanted a VBAC, and I was fairly certain I wanted to have the baby without any interventions, if I could. That is, I wanted no Pitocin and no epidural. I wanted to be in total control. I wanted to be able to ask for what I needed and refuse what I didn't need. And it turned out that the circumstances of his birth allowed me to have total control. I had no complications, and he was a full-term, healthy baby. I went into labor spontaneously and was able to fully dilate and push the baby out with no medication, although an episiotomy was helpful at the end. (This is in contrast to my second son's birth, for which I required an induction two weeks early due to pregnancy-induced hypertension. The intensity of the contractions caused by the Pitocin made it impossible for me not to have an epidural, although I was able to have the baby vaginally.)

Interestingly, despite having all of the power in this third birth, I didn't feel as powerful a sense of accomplishment as I had when my second was born. Partly, I felt I wasn't as strong as I could have been, because though I did end up having him without an epidural or other pain relief, I had broken down and asked for it repeatedly. My husband tells me over and over again that I'm being silly, that I was amazing and strong, but I think maybe I expected to feel more empowered, and instead I felt weaker than I wanted to be. I'm not at all disappointed. In fact, I'm thrilled to have been able to give birth in this manner, and my baby is as much a joy as anyone would expect. But, I think it's important to speak of feelings like these, just as it's necessary to express the anger, frustration, disappointment, or trauma of a birth that didn't go as hoped.

I bring up my third birth experience in order to make my final point. Going into this third pregnancy, labor, and delivery, I felt that I finally was fully informed. I knew what my choices were. I knew the possible consequences of any given option. I knew that sometimes an induction or c-section is unavoidable or absolutely necessary. And I felt that I would be able to make peace with however this birth happened, whether I got the natural birth I was planning or if I (G-d forbid) ended up needing an emergency c-section for whatever reason. I knew how to avoid unnecessary interventions that might lead to what would otherwise have been an unnecessary c-section. I knew what I didn't want (which I think was more important than knowing what I wanted). I'm sure that if the birth hadn't gone as "planned" (although I use that term loosely), I would have had some emotional consequences, especially if it ended up being traumatic as well as undesirable. But at least I would have known that I'd made all the "right" choices, that I'd known going in what my choices were and how various scenarios might pan out.

Thus, in conjunction with giving women the space to discuss birth trauma, to express any "negative" feelings that might be associated with their given birth scenarios, it is also important to discuss birth options. It is important to go into birth knowing what possible outcomes there are, depending on what choices are made. It is vital to understand when something is necessary and when it isn't. That's not to discount those times when we simply don't know what the right thing to do is, and we simply have to make a choice based on incomplete information, of course. But going in knowing that A may cause B, or that C is a direct result of A can help guide our decisions throughout the birthing process, and going in armed with information can at least alleviate the pain of thinking you've done something wrong if events don't play out as expected.

Five years after my own traumatic birth experience, I looked into the bathroom mirror and examined my recent postpartum belly. Under the little "shelf" of belly fat left over from being sewn up from the c-section is my external scar. I noticed, that day, that the scar was quite faded. It was no longer an angry red or purple. It no longer stands out brightly against my pale skin. It's there, but it's become a part of the landscape of my body. It no longer angers me. And I realized that along with the fading of the external scar came the fading of the internal ones, the emotional scars that I'd been left with because I thought I had made a series of bad choices that had led me to end up in a place I didn't want to be. Over the years, I have played out those couple of days of labor and delivery, trying to figure out "what went wrong." I shouldn't have gone to the hospital so soon. I should have walked around more. I shouldn't have gotten the epidural so early. I shouldn't have let them give me Pitocin. I should have been mobile so I could have pushed in a different position. It's easy to go over and over all the "bad" choices I made. For a while, I thought I might write out the "timeline" of the birth and go through and pinpoint each moment where I was led farther down the path to a c-section. But now, as I learn even more about the birth process, I have come to feel that a c-section may ultimately have been necessary no matter what choices I made to begin with. You see, the anger and guilt I felt didn't come from the fact that I had a c-section. It came from the impression that it was my fault I'd had a c-section. That I'd made the wrong choice when presented with an option. I no longer feel that way. I know I didn't have all the information going in. I now know that I couldn't have made good decisions based on what I knew at the time. And beyond that, now that I understand better how a normal birth should progress, I can see that it's entirely possible that my son was simply stuck, that there was no way he would ever have come through the birth canal no matter what I did, or that if I had tried to get him out that way, he or I might have been injured in the process. If that is the case, which I am more and more willing to believe, then thank G-d for the c-section, because I got a healthy baby and a healthy mom out of that decision.

My friend who had the scheduled c-section was describing the difference between the major surgery of a c-section and the major surgery of having her thyroid out. You see, "You get the door prize!" after the c-section. You get to take home your baby. Having your thyroid out isn't nearly as rewarding.

In the end, then, only you know how you feel about birth in general, about your birth experience(s), and about what you want to get out of having a baby. It's not anyone else's job to tell you how you "should" feel, or what choices you "should" make. I do believe, very strongly, that you need to know your options, you need to know the possible outcomes, you need to understand the process before you can make an informed choice. Because when you've made an informed choice, at least you aren't left with the "what ifs." I think it's the "what ifs" that are the most difficult to heal from.