Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

The Ol’ Bait and Switch, OR Finding Out Your OB Has Been Leading You On October 21, 2009

Submitted on 2009/10/20 at 3:24pm

Comment under: Urgent Message from ICAN! Please Spread the Word!!

Dear Nursing Birth,

 

I’m a day short of 35 weeks pregnant today and went in for an OB appointment this morning. My doctor said that if I don’t go into labor on my own in my 39th week that (depending on how much and if my cervix is dilated) she might put me on pitocin- although she did say that “they don’t induce labor for VBAC patients”. But that they won’t let me go to 40 weeks, and that by 40 weeks they will have to schedule another c-section for me. (I live in Cedar Falls, IA)

 

I am shocked and angry! First of all- since when is 40 weeks, too late? My OB says it’s not wise to go to beyond 40 weeks due to increased risk of uterine rupture. But this just sounds like B.S. to me!

 

And how does the doc get away with not telling me something important like this until NOW? Unbelievable!!  My doctor and I have already gone through my birth plan, line by line, because I want as few interventions as possible and no drugs, seeking a natural vaginal childbirth. I’ve taken 12 weeks of Bradley method birth classes to help my husband and I be better prepared this time.  I also have a fantastic, knowledgeable, and supportive doula. But I can’t believe what a fight it is to have a VBAC!

 

If I had known sooner that this was the doctor/hospital policy for VBAC, I probably would have gone somewhere else. Since it’s so late in the game now, I’m probably going to stick it out. I don’t have to do anything they say, I can always stay at home and come in when I’m ready, and that will be after I am already in deep labor on my own.

 

I was just wondering if perhaps this reflects a change in my hospital’s policy for managing VBAC? One of the other OB’s I met with at the hospital said that after a high maintenance VBAC patient a few months ago (who also insisted on a natural vaginal childbirth, and did it, but most of the hospital staff were very unhappy dealing with this patient…?) that the hospital is reviewing whether to allow VBAC at all. I’m probably not helping the situation by openly trying to avoid their planned interventions. I KNOW I’m required to have continuous electronic fetal monitoring… but I’ve also been told that my labor has to be pretty much “text book” regarding continuous dilation of my cervix, and of course no tolerance for fetal distress…or else!

 

I just wish all women would know this before their first c-section. If you thought recovering from a c-section was bad, wait till you try to have a VBAC and deal with the red tape and lack of support from the medical community. It’s just so frustrating to have to be prepared to battle, and yet relax at the same time! 

 

Have you heard of this kind of change in management of VBAC? That VBAC isn’t even allowed to go to 40 weeks?? Thanks for writing such an informative, educational blog and for being so supportive of natural childbirth! I have enjoyed your tips and insight from the hospital perspective (about writing birth plans, and managing your OB, and also the many ways hospital staff really will be supportive- even if you barf!).

 

Sincerely,

Kelly

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Dear Kelly,

WOW!  I am so sorry that this is happening to you.  You story deeply saddens, frustrates, and angers me because unfortunately YOU ARE NOT ALONE!  Women all over this country have to fight everyday for their VBACs.  Too many are unsuccessful.

First off I want you to know that your gut is absolutely right; 40 weeks is NOT too late and the research does NOT support your obstetrician’s claims.

Second, if that hospital is actually considering revising their entire VBAC “policy” in response to one mother who, as it sounds to me, shook the boat a little bit by demanding better care as well as exercising her right to informed refusal, they are absolutely outrageous and ridiculous!  I would be skeptical of that story if I hadn’t recently read this about the sign placed at the entrance of the Aspen’s Women Center in Provo, Utah.

Third, sounds to me like you did everything right!  You found what you thought was a VBAC supportive care provider, you researched your options and decided you wanted to stack as many cards in your favor as you could for a successful VBAC by planning a drug-free/intervention-free childbirth, you wrote up a birth planthat you painstakingly went through “line by line” with your physician early on in your pregnancy, you have sought out and taken childbirth preparation classes that are geared towards not only providing knowledge about how to have a successful natural childbirth but also help in preparing mentally and emotionally for such an important journey (and on top of that you took those classes with your husband!), and you even hired a doula.  (Yup!  Just as I suspected…you did everything you could!)  So what happened?!?!…

Unfortunately you are a victim of the ol’ bait and switch.

It happens to women everyday around this country.  And its existence is further proof that our maternity system is broken, in shambles really.  There are some obstetricians, family practice physicians, and yes, even midwives that have become really friggin’ good at this awful game.  Women write in to me all the time with similar frustrations and complaints as yours, Kelly.  And I always find myself helpless and speechless.  I don’t know how to help women avoid it and I struggle everyday in my own professional life with how to fight it and stop it!

The worst part of the ol’ bait and switch is the feeling of betrayal that most women report experiencing after they have been victimized they this outrageous action.  (I want to note that I used the terms “betrayal” and “victimized” on purpose.  I understand that they are very strong words but I feel they are the best to describe this very serious phenomenon).  So why does it happen?  Both from what I have personally experienced as a labor and delivery nurse as well as what I have read (for example: Born in the U.S.A by Marsden Wagner and Pushed by Jennifer Block) there is not one simple answer for why some healthcare providers use this “technique.”  But there is no doubt in my mind that money, greed, fear of litigation, fear of losing patients, competition, superciliousness, willful ignorance, impatience, convenience, blatant disregard for evidenced based medicine, favoritism for the “because we’ve always done it this way” model of practice as well as favoritism for the paternalistic provider-patient model of practice (that is, the care provider only presents information on risks and benefits of a procedure/test etc. that he or she thinks will lead the patient to make the “right” decision (i.e. the provider supported decision) regarding health care) all have something to do with it.  Providers who practice the ol’ bait and switch fall somewhere on the, what I like to call “Asshole to Apathy,” spectrum.   Some may be bigger assholes than others, but in the end, they all fall somewhere on that spectrum in my experience.

[PHEW!  Okay, WOW!  Now I’m all worked up!  Sorry, sorry!  I don’t know where that rant just came from!  But this kind of thing really burns by britches!]

So Kelly, you must be thinking, “Where does this leave me?”  The good news is that Kristen, a philosophical doula blogger friend of mine over at BirthingBeautifulIdeas is author of an amazing series she calls “VBAC Scare Tactics” which I think is a resource that you, and other moms in your situation, might find very helpful.  What you are describing sounds to me like VBAC scare tactics (#3): An early eviction date (aka “I’ll let you attempt a ‘trial of labor’ just as long as you go into labor before your due date.  After that, we’re scheduling a repeat cesarean.”)

In each post she identifies one particular scare tactic, supplies a list of questions that a mother can ask her care provider in response to this scare tactic, and then provides an analysis and/or summary of the research that either challenges or even debunks the scare tactic and its insinuations.  In the introduction to the series she writes,

 

“Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in this country have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.

 

Sometimes this opposition is blatant.  Sometimes this opposition becomes obvious only at the end of the third trimester. (Many VBAC-ing moms refer to this tactic as a “bait-and-switch” since it involves a supposedly VBAC-supportive care provider rescinding this support once the actual VBAC is imminent.)  Sometimes even a care provider’s “support” of VBAC is instead a conditional, half-hearted, or perhaps sneakily-disguised opposition to VBAC.  These “scare tactics” are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

 

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.”

Things I love about BirthingBeautifulIdeas’ VBAC scare tactic posts include:

#1    Her writing is organized and clear.  (You know how much I love organization and lists!)

#2    She respects research and understands the importance of evidenced based medicine. (In fact, the reason BirthingBeautifulIdeas is aware of much of the research she cites is because she actually used said research studies in weighing her own decision about whether to have an elective repeat cesarean section or instead prepare and plan for a VBAC.)

#3    She has personal experience with this subject.  (In fact she not only experienced a VBAC scare tactic and the “bait-and-switch” with her former OB, but also made the difficult decision to and successfully did transfer her care to a VBAC supportive care provider late in her pregnancy (at 37 weeks to be exact!) as well as experienced a subsequent and successful VBAC hospital water birth.  Check out her story “My very own VBAC waterbirth”.)

#4    She does not provide advice.  As she said herself, she is NOT anti-OB nor is she telling women to do anything.  Instead she provides tools that allow women to make their own decisions and stick up for their own decisions about the birth of their babies hoping that in doing so women come out of their birth experiences feeling positive and empowered, regardless of the outcome.

Kelly, please check out the post VBAC scare tactics (#3): An early eviction dateI was going to write to you about the research and such on the topic but BirthingBeautifulIdeas has already done such a fantastic job herself that it wouldn’t even be worth it to summarize her article.

While I’m at it, here’s the entire VBAC scare tactics series:

VBAC scare tactics (#1): VBAC = uterine rupture = dead baby (aka “Why would you want to risk a VBAC only to have a ruptured uterus and a dead baby?”)

VBAC scare tactics (#2): When bad outcomes in the past affect patient options in the future (aka “I’ve seen a bad VBAC outcome, and it was terrible.  You really don’t want to choose a VBAC over a repeat cesarean.”)

VBAC scare tactics (#3): An early eviction date (aka “I’ll let you attempt a ‘trial of labor’ just as long as you go into labor before your due date.  After that, we’re scheduling a repeat cesarean.”)

VBAC scare tactics (#4): No pre-labor dilatation = no VBAC (aka “Since you are 39 weeks pregnant and your cervix isn’t dilated or effaced, it looks like you probably won’t go into labor on your own ‘in time.’   We need to schedule a repeat cesarean and forgo a VBAC attempt.”)

VBAC scare tactics (#5): VBACs aren’t as safe as we thought they were (aka “You know, VBACs aren’t as safe as we thought they were.  They are much more dangerous to you and your baby.  A repeat cesarean is the safer route.”)

A VBAC scare tactic interlude (Thoughts and resources on transferring your care to a VBAC supportive care provider, inducing labor when you have a history of a cesarean and weighing the pros and cons of pain medications and interventions if you are planning a VBAC.)

 

VBAC scare tactics (#6): CPD or FTP = no VBAC (aka“Here in your chart, it says that your cesarean was for failure to progress (FTP).  Oh, and there’s also a note here about cephalopelvic disproportion (CPD).  You’re not really an ideal VBAC candidate since your cesarean wasn’t for fetal distress or breech presentation, so we need to schedule a repeat cesarean.”)

 

VBAC scare tactics (#7): Playing the epidural card (aka “An epidural can mask the signs of uterine rupture, so I do not permit my VBAC patients to have an epidural during their labors.” OR “In case of an emergency cesarean, I require all of my VBAC patients to have an epidural in place in early labor.  That way, we will not have to wait for the anesthesiologist to get the epidural in place if a uterine rupture occurs.”)

VBAC Scare Tactics (#8): The MD trump card (aka “Look, I’m the one who has earned the medical degree and I am telling you that you cannot attempt a VBAC.  Your only choice is a repeat cesarean.  Period.”)

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Kelly you wrote, “Since it’s so late in the game now, I’m probably going to stick it out. I don’t have to do anything they say, I can always stay at home and come in when I’m ready, and that will be after I am already in deep labor on my own.”  You are right.  You don’t have to do anything they say.  You have the right as a patient to both informed consent as well as informed refusal.  However I want to say a few things.  (Here comes my cyber pep-talk, meant of course to be 100% supportive of whatever you chose and not at all meant to give you advice.  But I don’t think many women get a chance to hear from anyone what I am about to tell you.  To get the full intent of this pep talk just picture me standing behind you vigorously rubbing your shoulders as I squirt water into your mouth from a sports bottle and wipe the sweat off your face.  So here it goes…)

You deserve the opportunity to have the unmedicated, intervention-free birth that you have planned for.  Your desires for said unmedicated, intervention-free VBAC are well supported by the research.  You deserve to be cared for by a birth attendant who shares your philosophy regarding (among other things) childbirth and VBAC.  You deserve to NOT have to worry about fighting anyone to be given a fair chance at having the birth you have been planning…not the hospital, not the nursing staff, not your obstetrician, NOT ANYONE.  You deserve it for THIS birth.

I know that it is scary to even think about transferring care to a new care provider so late in the game.  But I encourage you to at least think about it.  Even if you think that there are many limitations in your options regarding availability, insurance, distance, etc. etc, it is worth it to you to at least check it out.  I also encourage you to get in touch with your local ICAN chapter (unless, of course, you have already done that.)  Some of the members might be able to give you some suggestions on VBAC friendly care providers that they know actually attend VBACs!  Sometimes even if a VBAC friendly midwife or doctor is booked they will make an exception for a late transfer of care if a doula friend or former patient calls and asks for a favor.  (I’ve seen it happen before with my local ICAN chapter).  Also ICAN’s website has a variety of helpful articlesfor moms planning a VBAC against hospital or provider resistance.

I can tell by your story that you are a very strong woman and my gut tells me that you will indeed fight for your rights even if you stay with your current obstetrician.  You just shouldn’t have to do that and it saddens me that any your energy is going to be dedicated to defending yourself during your birth.  Even one tiny little bit of energy devoted to that is too much!  You deserve more!  You deserve better!  I think you said it perfectly when you wrote, “It’s just so frustrating to have to be prepared to battle, and yet relax at the same time!”

 

I couldn’t agree more!

So Kelly, I wish you the best of luck!  And like many of my readers, I really wish I was going to be your labor and delivery nurse!  CONGRATULATIONS on your pregnancy and on your upcoming birth!  I will keep you in my thoughts and I hope that you will one day come back and tell us how your birth went!  I hope that this post has helped you in some way.  Oh and please apologize to your friends and family for me since you probably will be wasting a lot more time in front of the computer now that I have provided so much reading material!  Haha!

Sincerely,

NursingBirth

 

Top Ten DOs for Writing Your Birth Plan: Tips from an L&D Nurse, PART 2 July 23, 2009

If you haven’t already, please check out PART 1 of this post:  Writing Your Birth Plan: Tips from an L&D Nurse.  Also, at the end of this post check out a birth plan written and sent to me by one of my blog’s readers who is due any day now!

  

#1    DO keep your birth plan short, simple, and easy to understand (1-2 pages max).

 

“Keep [your birth plan] short.  If you need to spell out a long list of points, you may not be with the right caregiver. If most of the things you want aren’t things your caregiver is used to doing (in which case you don’t need to put them in a birth plan!), you are unlikely to get them. For maximum effectiveness, keep your birth plan to a single page.”

Writing a Birth Plan by findadoula.com

 

#2    DO keep the language of your birth plan assertive and clear.

 

“Remember to keep your language assertive – polite but clearly stating what you want. Use phrases like “I am planning” and “I would like” rather than “if it is ok” or “I would prefer.

 

Be specific.  Avoid words and phrases such as “not unless necessary” or “keep to a minimum.” What one person thinks is “necessary” is not what another does. What one person defines as the minimum is not what the next person does. Instead, use numbers or specific situations, for example: “I am happy to have 20 minutes of electronic monitoring and if all is well then intermittent monitoring every hour for five minutes after that”  or  “I am happy to have a vaginal examination on arrival in hospital and after that every four hours or on my request.”

Writing a Birth Plan by findadoula.com

 

 

“Be sure to be assertive, but not aggressive when discussing your options. Do not allow your caregiver to brush off your decisions or suggest that this is unimportant. At the same time, don’t assume your caregiver [or nurses] will be hostile or uninterested in hearing what you have to say.”

How to write a Birth Plan by birthingnaturally.net

 

#3    DO use your birth plan as an impetus for doing your own personal research about your preferences for childbirth. 

 

One great place to start is at MothersAdvocate.com who, in partnership with Lamaze International and Lamaze’s Six Steps to A Healthy Birth, have created a website that offers FREE, evidenced-based, educational video clips and print materials to educate and inform childbearing families on how to have a safe and healthy birth for both you and your baby.  These extremely well reserached and produced materials are a MUST READ for all expecting moms!!!

 

The introduction handout for these video clips and print-outs entitled Introduction: Birth–As Safe and Healthy As It Can Be reads:

 

“While no one can promise you what kind of birth experience you will have, common sense tells us and research confirms that there are two tried-and-true ways to make birth as safe and healthy as possible:

 

• First, make choices that support and assist your natural ability to give birth.

 

• Second, avoid practices that work against your body’s natural ability, unless there is a good medical reason for them.

 

Lamaze International, the leading childbirth education and advocacy organization, has used recommendations from the World Health Organization to develop the Six Lamaze Healthy Birth Practices that support and assist a woman’s ability to give birth. Years of research have proven that each of these practices increases safety for mothers and babies.

 

The Six Lamaze Healthy Birth Practices are:

 1. Let labor begin on its own.

 

2. Walk, move around, and change positions throughout labor.

 

3. Bring a loved one, friend, or doula for continuous support.

 

4. Avoid interventions that are not medically necessary.

 

5. Avoid giving birth on your back, and follow your body’s urges to push.

 

6. Keep your baby with you—it’s best for you, your baby, and breastfeeding.”

 

The topics of the print materials include: 

Choosing a Care Provider,

Changing Your Care Provider,

If You Have Been Induced,

Maintaining Freedom of Movement,

Positions for Labor,

Finding a Doula,

Creating a Support Team,

Tips for Labor Support People

and even a Birth Planning Worksheet!!

 

 

“We cannot know the day or week labor will begin, how long it will last, exactly how it will feel, how we will react, or the health and sizes of our babies.  What we can do, however, is educate ourselves about the vast array of possibilities and learn which are more likely to occur. We can decide what is ideal and what we will strive for, what are the means to creating the most conducive environment for such a birth, and which people can best help us to attain those birth arrangements. Finally, we can prepare our own bodies and hearts for the process.”

Eyes-Open Childbirth: Writing a Meaningful Plan for a Gentle Birth

by Amy Scott

 

#4    DO include your fears, concerns, and helpful things for the nurse to know.

 

If appropriate, a birth plan can also include a few sentences regarding things you just want the nurse to know about and are important enough to make sure that every shift is aware of.  For example, I once had a patient who wrote the following in her birth plan:

 

“My husband is a type I diabetic and at times suffers from episodes of hypoglycemia where he does not have any warning signs or symptoms.  So if my husband starts to act inappropriate or seems ‘out of it’ or ‘drunk’ please offer him some juice!!  I am afraid that if I am in the throws of labor that I will not notice and this is something that I am very concerned about!”

 

Although this information wasn’t necessarily birth related, as a nurse taking care of this family I found this information EXTREMELY helpful to have in the birth plan!!  By putting it in her birth plan, this mother felt more at ease knowing that she did not have to waste any time worrying about forgetting to tell each new nurse that took care of her.  Having this in her birth plan also served as a reminder for me to pass along this important information when I was giving report to the next shift. 

 

#5    DO review your birth plan with your birth attendant and ask him/her to sign off that he/she read and understands it.

 

“Add a line at the bottom of your birth plan for your doctor or midwife, and other caregivers, to sign your plan under the statement ‘I have read this plan and understand it.’  When caregivers sign your plan, they are only acknowledging to you—on the record- that they have read and understood it.  They do not have to sign and say: ‘I agree.’  No matter what you tell them, they are always responsible for offering you their best judgment and skills as different circumstances arise, and then together you and your caregivers can agree on your care.  This benefits you.  Your birth plan will help you take responsibility for your decisions and ask to be fully informed.”

Creating Your Birth Plan, page 219

By Marsden Wagner & Stephanie Gunning

 

#6    DO make your birth plan personal (don’t just copy paste) and DO make sure that you understand and can elaborate on everything in the birth plan if asked.

 

In my humble opinion (regarding birth plans), there is nothing more frustrating for a nurse (and nothing more detrimental to a nurse’s overall attitude and view of birth plans) than to have a patient just copy and paste a general, “all-purpose” birth plan off the internet, check the boxes that “sound good”, and pass it in to a nurse with her name typed in at the top.  Why?  Because when a nurse (like myself) sits down to review the birth plan with the mother and her labor companions in order to start a dialogue about how the nursing staff can assist in adhering to the birth plan, it will most certainly become obvious to the nurse that the patient has done little to no research on any of her choices making it almost impossible to help the patient follow her birth plan when the birth attendant comes in and wants to do things differently.

 

Let me give you a few examples:

 

Example 1:  One time I had a patient who had the following statement on her birth plan:  “Regarding an episiotomy, I am hoping to protect the perineum. I am practicing ahead of time by squatting, doing Kegel exercises, and perineal massage.”  Now don’t get me wrong, this statement is great and it is one that I personally believe in and try to promote.  So while reviewing the patient’s birth plan with her and her husband I enthusiastically said the following, “Oh, I see here you have been doing perineal massage and Kegel exercises and wish to avoid an episiotomy.  That is great!  How many weeks have you been doing perineal massage for?”  The patient looked blankly at me and said, “What?  Oh I don’t even know what that is!  My sister just told me that I shouldn’t get an episiotomy so I checked that box.” 

 

Ladies, it is really hard for a nurse to advocate for you if you don’t even understand what you are asking for!

 

Example 2:  Almost all the birth plans I have seen make some statement about pain relief and pain medications.  Again, I think that this is a great thing, especially if the mother was inspired to research all of her pain relief options (both pharmacological and non-pharmacological) and make an informed pain relief plan during the writing of her birth plan.  One time I had a patient who had the following statement in her birth plan, “Regarding pain management, I have studied and understand the types of pain medications available. I will ask for them if I need them.”  Again, I was very enthusiastic when I read this and said to the mother, “I see here that you have done some research on pain management.  Wonderful!  Have you taken any childbirth preparation classes or read any books?”  The mother responded, “What do you mean?”  I replied, “Well you know, like any classes or books by Lamaze, Bradley, Birthing From Within, Hypnobabies, etc.”  The mother responded, “No.”  I then said, “Oh, did you do any research on the internet or talk to anyone?”  To which she replied, “No, not really.  I mean, it’s my first time so I don’t know what to expect.  My best friend just said she hated her epidural so I don’t really want one of those.  Unless , of course, I really need it.  We’re just going to wing it.” 

 

Ummmm, huh?!?!  Now again, don’t get me wrong.  I feel that I am very supportive of mothers that are preparing for a natural, or physiological, childbirth and I often write about the risks and benefits of common obstetrical interventions, including pain medication and epidurals.  But ladies, your nurse can’t be the only one who is advocating for your natural childbirth.  YOU have to be on board too and YOU have to understand your reasons for not wanting pain medication or epidural.  Because if you don’t even know why you don’t want an epidural then the next person who walks into that room who feels differently, be it a nurse or your birth attendant, guess what’s going to happen?!  You’re probably going to agree to anything said nurse/birth attendant tells you you should get, because you don’t know any alternatives.

 

I am not trying to say that taking a certain childbirth preparation class or reading certain books is required for a positive and empowering birth experience.  But some type of research and preparation on the part of the mother and her labor companions/partner is EXTREMEMLY IMPORTANT!!   

 

Now here’s one more example to give you the full perspective.

 

Example 3:  One time I was taking care of a patient who had the following statement in her birth plan: “My husband and I have been preparing for and planning a natural childbirth.  I am very interested in using the Jacuzzi tub for pain relief in labor and have been reading about other drug-free ways to cope with pain.  I am not interested in pain medication or an epidural as I had both with my last baby and had a poor experience with both.   I respectfully request that they not be offered to me.  I have done research and feel that the risks outweigh the benefits.”  When I asked her about it we embarked on a really informative discussion about her last delivery, in which she had persistent numbness in her right leg for 2 months after the epidural as well as a debilitating spinal headache that took required two blood patches and made it difficult for her to nurse or care for her baby during her hospital stay.  She also told me that she did not like the way the IV narcotics made her feel, as she was “seeing things” and generally “very out of it.”  After our conversation I felt confident in advocating for her with her doctor (who often insisted his patients get epidurals) because I knew that if I said anything to the doctor that she would, in a sense, back me up and likewise I would back her up!! 

 

It is so hard when a patient has something in her birth plan like “I don’t want an epidural”, and hence I argue with the doctor about how the patient does not want an epidural, but then when he goes into the room to ask the patient himself, the patient says “Oh well, whatever you think is best doctor!”  It really just makes the nurse look like she is trying to “push her own agenda” when in reality the nurse was just trying to follow the patient’s birth plan!! 

 

One more thing…I don’t want anyone to feel like I am implying that a woman has to “prove” anything to me when I ask questions about her birth plan.  That is NOT the case.  I just know from personal experience how important it is for a woman to understand and agree with everything she herself puts in her birth plan!  Remember, mothers, labor companions, and nurses work best when they are all on the same page and work as a team to facilitate a positive and empowering birth experience!!

 

#7    DO look at examples of great birth plans online to get some ideas.

 

The following is a list of some good places to start. Remember, while these websites provide a wealth of ideas, they should not be simply copied and pasted!  The best and most effective birth plans are personal, NOT just a list of things with check marks next to them!!

 

a)      BirthingNaturally.net

b)      Sample Birth Plans from BirthingNaturally.net

c)      ChoicesinChildbirth.com

d)      American Pregnancy Association

e)      BabyCenter.com

f)      MothersAdvocate.com

 

#8    DO run through scenarios in your mind about how labor could unfold and actually talk these scenarios out with your labor companions and doula (or perhaps even your childbirth educator or birth attendant too!) 

 

Think about all the different ways labor could unfold and how you might react if labor was faster or slower than expected; harder or easier than expected. What would you need for comfort, support and information in each of these variations?  Thinking about “worst case scenario” doesn’t mean it’s going to happen.  But if it does, or if any variation does, it will make you more at ease to know that your team has already talked about it and knows your wishes. 

 

“If you knew that something would go wrong or would pose a difficult challenge during a portion of the labor and birth, what would your ideal strategy and scenario for handling that problem be?  How would you want your midwife or doctor to speak with you?  How would you like your spouse or another support system to help?  What alternatives would you like to try, and in what order?  Again, in your mind’s eye permit yourself to have the best.  What would help you relax and be able to continue labor under difficult conditions?”

Creating Your Birth Plan, page 219

By Marsden Wagner & Stephanie Gunning

 

 

#9        DO try to treat researching and birth plan writing as a fun and exciting experience, not a chore! 

 

Enjoy this time!  Don’t be afraid to be creative and fanaticize!  There are so many amazing thing that you can discover and learn about while doing research for your upcoming birth.  It is never too early to start so don’t put it off till the last minute!

 

And finally…

 

#10    DO remember to bring your birth plan to the hospital!! 

 

It won’t do much help to the nursing staff if you forget it at home on your coffee table!  I encounter this very often at work and I always feel so badly because I know that there is usually a lot of work put into writing a birth plan.  It might be best to make sure that you place a copy of your birth plan in the bag you have packed to take with you to the hospital.  I have even had a few mothers put an extra copy in their car’s glove box so that they wouldn’t forget it!

 

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SAMPLE BIRTH PLAN

 

This birth plan was sent to me by a reader of NursingBirth who goes by the name “ContortingMom”.  Contortingmom’s guess date is 7/17/09 and she is still “cooking” with her first baby 🙂  I really like her birth plan for a variety of reasons.  #1 She was inspired to add some stuff to her birth plan after reading a couple posts of mine (which I think is pretty cool 🙂 and #2 I think it is a perfect example of a personalized birth plan!!  No check boxes here!  Thanks again to ContortingMom for allowing me to post her birth preferences for other moms to read and learn from!!

 

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Birth Preferences:

I understand that labor and birth are unpredictable and ultimately want the health and safety of both the baby and I to take precedence. In all non-emergency situations, all proposed procedures are to be discussed (benefits and risks) so I can direct the decision making with informed consent.    

Your help with these preferences is very much appreciated.

 

Labor:

• I intend to have as natural a labor as possible – including freedom of movement, intermittent monitoring, a saline lock instead of an on-going IV, and clear liquids as tolerated.

• Due to my GBS+ status, I request only very limited vaginal exams and do not want an amniotomy.

• Please accept my request that pain medication not be offered to me. For many reasons – personal and medical, I’m striving for an unmedicated labor and delivery. If I eventually want drugs or an epidural, I’ll be the first to ask for it and understand that options change as labor progresses.

• If augmentation is necessary, I would like to try non-pharmacological methods before resorting to meds. However, if my OB and I agree that pitocin is required, I request that the it be administered following the low dose protocol and increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each dose increase.

 

Birth:

• Please do not direct my pushing with counting or yelling. I will ask for help if needed.

• I strongly prefer a tear to an episiotomy and do not want a local anesthetic administered to the perineum.

• I plan to be as active during pushing & delivery as possible, including choosing productive positions. They will be probably anything except supine, lithotomy or “sitting squats” that put pressure on my tailbone. It’s been broken several times & currently inflamed. I also have restrictive pain from spinal injury & surgery, so please allow a position suited to my medical needs. I’ll make sure the OB has comfortable access.

• I would like to have the baby brought to my chest immediately for skin-to-skin contact & initial procedures – and to try nursing to see if it works to contract my uterus, delaying pitocin until we know.

 

If Cesarean Is Required:

• Please use double-layer sutures when repairing my uterus. If I have a second child, I hope to attempt a VBAC and understand this is a requirement for many doctors.

• As health permits, I would like to skin-to-skin contact with the baby, to stay together during repair and recovery, and to breastfeed during the initial recovery period.

• If my husband has to leave the operating room with the baby, I would like my doula to take his place.

 

Baby Care:

• We would like to spend as much time as possible with our baby after birth before being taken off for procedures and will be breastfeeding, so please refrain from giving bottles/pacifiers.

 

We Appreciate Your Support. Thank You!

 

Writing Your Birth Plan: Tips from an L&D Nurse, PART 1 July 22, 2009

There have been many a time that I have written about the option of writing a birth plan, especially if one is planning a hospital birth.  And some of my readers have questioned me further, asking things like “I don’t know how to write a birth plan!  How do I begin?” or “There are so many websites about writing a birth plan, how do I know which one is best?”

 

Indeed when you type “birth plan” into Google you get 22,600,000 hits.  Yowzers!!  No wonder why so many expecting moms write to me and tell me how overwhelmed they are!!   And as we all know, not all websites are created equal as some are more helpful (and more accurate) than others. 

 

So since I suggest writing a birth plan so often in my posts and comments I feel that it is only proper that I write a post specifically about birth plans.  I will try to help you navigate through the sea of websites and direct you to the ones that I feel are the most accurate, truthful, easy to understand, and helpful.  I would like to make a disclaimer though:

 

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Disclaimer:  This post is riddled with my own opinion as both a consumer of health care and an L&D nurse.  I feel that this post has something to offer to the world of birth planning articles because in all of my research I found very few birth plan guides written by L&D nurses.  I found them written by mothers, doulas, midwives, and even doctors…but very few, if any, written by L&D nurses.   This is very interesting to me because if you are planning a hospital birth the first person in the hospital that you present your birth plan to is the nurse.  Sure, your doctor or midwife might (wait, scratch that….SHOULD) go over it in the office with you and if you are hiring a doula, then she will most likely review it with you as well.  However when push comes to shove it is the L&D nurse who is your go-between and except for the actual “catching” part, it is going to be the L&D nurse who manages your care throughout your labor.  While I agree that there are probably many L&D nurses who feel differently than I do about how a birth plan should be written (if at all), I can say with confidence that there are surely just as many who do agree with my take on it.

 

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Since the vast majority of women are planning a hospital birth and I am in fact a hospital based L&D nurse, this post is geared almost entirely towards women planning a hospital birth.  Although a birth plan isn’t a bad idea for a home or birth center birth, it is often less crucial.  Why?  As Leah Terhune, a certified nurse-midwife with Midwives Care, Inc. in Cincinnati is quoted in the article Eyes-Open Childbirth: Writing a Meaningful Plan for a Gentle Birth by Amy Scott says:

 

“A birth plan is not a must for out-of-hospital births because there is more self-education done by the mother, and most people come into the situation with the same philosophy: childbirth as a natural process.  In a really good relationship with a midwife, it should be understood by the end of the pregnancy what the expectations are.”

 

 

My goals for this post are the following:

 

1)      To assist you in writing the best birth plan you can by pointing you in the direction of the best resources out there, that I have found, on birth plan writing,

2)      To review the true purpose of a birth plan and to help you write a birth plan for the right reasons, and

3)      To help you navigate through a bureaucratic hospital system often perforated with outdated dogma and run by unofficial “policies” and help you and your labor companions facilitate a positive and empowering birth experience for your whole family!

 

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What Exactly is a Birth Plan?

 

 

According to Penny Simkin, a physical therapist, doula, and author of The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions:

 

 

“The mother’s Birth Plan tells her caregiver and nurses in writing what options are important to her, what her priorities are, any specific concerns she has, and how she would like to be cared for.  The plan should reflect the mother’s awareness that medical needs could require a shift from her choices, and it should include her preferences in case labor stalls or there are problems with her or her baby.”

 

 

I like this definition of “birth plan” because no where in that definition does it state that a birth plan is the mother’s actual plan for her birth.  That is, it acknowledges what those of us who work with mothers in labor know to be absolutely true:  LABOR CANNOT BE PLANNED OR CONTROLLED.  (And likewise, when someone, including the mother, her labor coaches, or her birth attendant tries to control labor, it only spells trouble.)  Writer Lela Davidson quotes professional childbirth educator and doula, Kim Palena James in her article Create a Better Birth Plan: How to Write One and What It Can and Cannot Do For You:

 

 

“Too many parents create birth plans with the expectation that it will be the actual script of their baby’s birth. There is no way! Nature scripts how your child is born into this world: short, long, hard, easy, early, late, etc… The health care providers you choose, and the facility they practice in, will script how you and your labor are treated. The variations are vast. I wish every expectant parent spent less time writing birth plans and more time selectively choosing health care providers that align with their philosophy on health care, match their health status and their needs for bedside manner.”

 

 

In their article Writing a Birth Plan, findadoula.com writes:

 

“It is not possible to use a birth plan to “make” your caregivers agree to things they are not comfortable doing. For instance, if you don’t want an episiotomy but your doctor usually cuts them for most women, it is unlikely a birth plan will make your doctor change his practice.”

 

 

[For more information on choosing a care provider please check out my post: Must Read Blog: “It’s Your Birth Right!!”]

 

Also doula Kim Palena James warns that a birth plan CANNOT:

 

1. Change your health care provider’s style of practice, personality or protocols.

2. Script the nature of your labor.

3. Insure you have a satisfying labor. 

 

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What Types of Birth Plans are UNHELPFUL to Mothers and Nurses?

 

 

Remember how I said that you cannot control labor?  Well you also cannot control your birth attendant or the medical system.  This is why author, certified nurse midwife, and childbirth educator Pam England, CNM, MA warns mothers about “The Birth Plan Trap.”  In her book Birthing From Within she writes:

 

“Writing birth plans is becoming a ritual of modern pregnancy.  This practice began with the positive intention of encouraging parents to take a more active role in birth.  Writing a birth plan motivates parents to learn about their hospital’s routines (usually with the intention of avoiding them).  A birth plan also can be a tool to open dialogue with doctors.  Telling a doctor what you want (and seeing his/her reactions) allows insight into the doctor’s philosophy of practice and willingness to share decision-making.

 

While gaining information is advantageous, the subtle implications of writing a birth plan are more complex than many people realize.  If you look below the surface, you’ll see that birth plans are like a hidden reef on which your efforts towards deeper birth preparations may run aground.

 

In my classes I discourage mothers and fathers from writing a birth plan.  I’ve changed my mind on this issue for several reasons.  I now believe that the need to write a birth plan invariably comes from:

 

  • Anxiety and/or mistrust of the people who will be attending you;
  • A natural fear of the unknown.  Some women attempt to ease that fear, and enhance their sense of control by writing a detailed script of how the birth should happen;
  • Lack of confidence in self and/or birth-partner’s ability to express and assert what is needed in the moment.  (Birth plans may be intended to substitute for face-to-face negotiations with authority figures.) 

 

In writing a birth plan, a woman focuses on fending off outside forces which she fears will shape her birth.  This effort distracts her from trusting herself, her body, and her spirituality.  Rather than planning her own hard work and surrender, her energy is diverted towards controlling the anticipated actions of others.”

(Birthing From Within, pages 96-97)

 

 

Indeed I have met and cared for couples as an L&D nurse where it seemed like they spent the majority of their time preparing for the birth by writing a birth plan that was intended to “ward off the enemy.”  Pam England calls this “fear-based externally directed preparation” (i.e. “I don’t want this,” “I don’t want that”).  And when I work with couples like this I, in turn, spend the majority of my shift trying to convince the couple (and sometimes their doula) that I am actually on their side.   And don’t get me wrong…I completely understand where their fear comes from (they probably experienced or heard about situations like in my “Don’t Let This Happen To You: Injustice in Maternity Care Series”)!  And there are plenty of stories of unsupportive nurses and crazy on-call doctors to where I don’t blame the couple for feeling like they have to gear up to fight me for everything they want.  But all that fear and worry does NOT facilitate an empowering and positive birth experience and sadly, it sometimes becomes a self-fulfilling prophecy; indeed a mother must almost let go of “control” in labor and surrender to the power of her body and of birth.   

 

So we’ve just learned that birth plans intended to control birth or ward off the enemy are not helpful to anyone.  However unlike Pam England, I don’t take the same drastic stance as she does by recommending that couples do not write a birth plan.  Why?  Because when a birth plan is written for the right reasons and contains the right information, it can really be a helpful tool that nurses can use to help facilitate the birth experience that you desire.  So what types of birth plans are helpful to childbearing families and nurses?  What should be included in a birth plan? and, How should a birth plan be written?  Well, I’m glad you asked!!

 

What Types of Birth Plans Are USEFUL and HELPFUL to Mothers and Staff?

 

In her article Lela Davidson writes:

 

“A birth plan is most useful when you use it to:

 

1. Discuss options and choices with your health care provider. Understanding how your care provider thinks and what her normal practices are will help eliminate confusion, debate, and disappointment during labor and birth. You’ll also increase the level of trust between yourself and your care provider: She’ll understand your priorities and you’ll understand her limitations and preferences.

 

2. Communicate your personality and unique physical, emotional, and environmental needs to your labor and delivery nurse. Let her know what works best for you: A quiet environment? Whispered voices? Do you have a fear of needles? Are you worried about too many people in your room? What do you want to do for pain relief? What helps you relax? What does your partner need? What are his or her fears? Do you like to be touched? What did you learn in your childbirth classes that you’d like to try?”

 

Up for Tommorow:  Top Ten DOs for Writing Your Birth Plan

 

Coming Soon: Free Movie “Reducing Infant Mortality” July 1, 2009

 

Thanks to Maria at the Massachusetts Friends of Midwives Blog, I just stumbled across a a trailer for a new documentary that will be FREE to view on July 26, 2009.  The video is titled “Reducing Infant Mortality and Improving the Health of Babies” and is sponsored by the Santa Barbara Graduate Institute Center for Clinical Studies and Rearch. 

 

Watch the trailer here!

 

 

As stated on the website, “This free film will be a tool for everyone to use to draw attention to infant mortality and health issues as national health care policy is debated on Capitol Hill.”

 

The movie’s official website also reads:

The current US Health Care System is failing babies and families before, during and after birth. At this critical moment when the US government is re-envisioning our health care system, we are seizing the opportunity to make a 10-12 minute video not only to point out the flaws in the way we care for babies and families, but also to identify the keys to improved care. Our infant mortality ranking is 42nd on the world stage which means 41 countries have better statistics. This places us right in the middle of the following countries: Guam, Cuba, Croatia and Belarus, with over double the infant deaths compared to the top 10 countries of the world. (CIA World Factbook).

Our astronomically high African American infant mortality rate at 16 deaths per 1,000 is similar to countries such as Malaysia and the West Bank. Not only are babies dying needlessly, but the ones who survive this failing system are also often adversely affected by unnecessary procedures and separation from mother and family. Our intent with this video is to encourage policy makers to consider a health care system that holds prevention of these calamities as a high priority.  The midwifery model of care for healthy low-risk women is a simple solution which addresses many of these issues simultaneously.

We are advocating for a health care system in which it will be standard procedure for mothers and babies to thrive and not merely survive through birth and early life. The midwifery model of care will save our health care system millions of dollars each year.
 

To read about the credentials of the experts you see in the film’s trailer please visit  About the Film  and scroll to the bottom.

 

Spread the word!!

 

 

 

The Big Push For Midwives Campaign 2009 June 25, 2009

I believe that pregnancy and birth are normal, healthy processes and should not be treated as illness or disease and that women and babies have the inherent wisdom necessary for birth.

 

I believe that midwives can obtain quality education and experience in a variety of ways and programs, including certified nurse midwifery and direct-entry midwifery.

 

 I believe that women need access to professional midwives whose educational and credentialing process provides them with expertise in out-of-hospital birth as well as hospital-based and clinical care that extends beyond the childbearing cycle.

 

 I believe that empowering and safe births can and do take place in a variety of settings including birth centers, hospitals, and homes.

 

 I believe that every woman should have the opportunity to give birth as she wishes in an environment in which she feels nurtured and secure and her emotional well-being, privacy, and personal preferences are respected, whether that be in a hospital, birthing center, or at home and I believe that women in every part of the United States DESERVE THAT CHOICE!

 

  (Excerpts from my post My Philosophy: Birth, Breastfeeding, and Advocacy)

 

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Because of all of these things I support The Big Push For Midwives Campaign 2009 and I want to share with all of you a bit more about it!!

  

According to BigPushTube:

 

“The Big Push for Midwives Campaign builds state-level advocacy campaigns to license Certified Professional Midwives (CPMs) in all 50 states, D.C., and Puerto Rico, and educates national policymakers about out-of-hospital maternity care.

 

 [The Big Push for Midwives Campaign] works tirelessly to:

 

1) Educate state and national policymakers about the reduced costs and improved outcomes associated with out-of-hospital maternity care. $9.1 BILLION IN SAVINGS PER YEAR.

  

2) Support advocacy groups working for state licensure in the 24 states where out-of-hospital practice by CPMs is under threat of criminal prosecution.

 

3) Encourage mothers to tell their stories because only grassroots activists will be able to topple the money/power vested in keeping the status quo.

  

4) Advocate for CPM guaranteed reimbursement in National Health Reform, the Federal Employees Health Benefit Plan, Tricare, and Medicaid/Medicare.

  

5) Support freestanding birth centers seeking guaranteed Medicaid reimbursement, and midwives advocating for equitable Medicaid reimbursement rates.

 

The Big Push for Midwives Campaign empowers midwife advocates and moms groups as they promote increased access to out-of-hospital maternity care and the Certified Professional Midwives (CPMs) who are specially trained to provide it.

  

Our dedicated campaigners, or “Pushers” as they are affectionately known, help to educate the people in power (at the insurance companies, in the hospital associations, in the Statehouses, and on Capitol Hill) about the reduced costs and improved outcomes associated with using out-of-hospital maternity care and CPMs, who are specially trained to provide it, and works to widely share the stories of U.S. citizens who choose CPMs as their maternity care providers.” 

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I found this video on YouTube and I got all verklempt watching it!!  (Perhaps it was partly related to the beautiful song that was playing throughout the movie!  I’m such a sap!)  It’s only about 4 minutes long so if you have a chance please take a look!

 

 

 

 Our mothers and babies in this country DESERVE better care than what they are receiving!!  They DESERVE a midwifery model of care (whether that is provided by a certified nurse midwife, a certified professional midwife, a family practice physician, or an obstetrician).  They DESERVE to have CHOICES in childbirth that are proven to promote the best outcomes for both mothers and babies.  And they deserve these choices to be LEGAL!

 

Have you ever heard the term “lay midwife”?  Are you under the impression that a “lay midwife” doesn’t have any education and that all midwives who attend out of hospital births are “lay midwives?”  Do you want to know what the term “lay midwife” is really referring to?  Are you interested in learning what the real differences are between the different types of midwives?  Are you interested in learning more about how midwives train and what type of education they obtain?  If so please check out:  FAQ about Midwives and Midwifery by Citizens for Midwifery (CfM) and Midwifery Definitions by the Midwives Alliance of North America (MANA).

 

 Have any of you ever received care from a certified professional midwife?  I’d love to hear about it!

 

Preventing Maternal Deaths: An Interview with Ina May Gaskin June 23, 2009

Today an avid reader sent me a link to a few short interviews with the great Ina May Gaskin conducted by Mindful Mama Magazine about a very sad, but very real phenomenon: maternal deaths in the United States.  I felt that these interviews were so well done that I just had to share them with all of you.

 

Ina May Gaskin is a Certified Professional Midwife (CPM) and is the founder (along with her husband) and director of The Farm Midwifery Center in Tennessee.  She is the author of Spiritual Midwifery (1975) and Ina Mays Guide to Childbirth (2003), two incredible books that every woman who has ever had a child, is pregnant, or is thinking about becoming pregnant should read!!  

 

Spiritual Midwifery is THE book that changed my life, my outlook on the birth process, and my career goals.  Ina May’s Guide to Childbirth is similar in style to Spiritual Midwifery, but has a much broader appeal and a more modern style.  Ina May has been a home birth midwife for more than 35 years and is the founder of the Safe Motherhood Quilt Project, a national effort developed to draw public attention to the current maternal death rate, as well as to the gross underreporting of maternal deaths in the United States, and to honor those women who have died of pregnancy-related causes since 1982.
These interview clips are part of Rites of Passage, an exclusive video series and art/photo/ essay contest hosted by Mindful Mama Magazine that engages mothers across the country in a dialogue about childbirth and the transformation of new motherhood.  During the interview Gaskin speaks to the disturbing reality that 1) the United States lacks of a comprehensive, confidential system of ascertainment of maternal death designed to record and analyze every maternal death that occurs in the United States and 2) not all 50 states have questions on their death certificates that specifically ask about a woman’s pregnancy status (i.e. was she pregnant, postpartum, or within 1 year of delivering a baby) making our countries maternal mortality rates based solely on vital statistics data.  (And as an registered nurse who has had to fill out death certificates a time or two as a medical-surgical nurse I can attest to the truth of this!)  In reality the Center for Disease Control (CDC) estimates that our current maternal mortality rate is actually an underestimate and that our true maternal mortality rate could be as much as 3 TIMES HIGHER related to misclassification of the number of deaths that are truly happening. 

 

Please also see my post: Super Comment!: Maternal Death in the U.S., or TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth

 

So check out these videos and let me know what you think!!

 

PREVENTING LOSS PART 1

 

 

PREVENTING LOSS PART 2

 

 

WHY CESAREAN?

 

 

THE SAFE MOTHERHOOD QUILT PROJECT

 

 

Super Comment! Re: The Deal with Delayed Cord Cutting May 19, 2009

Many of you might not realize that I personally read every comment that is posted to my blog.  Why you ask?  Because I love reading what the people following my blog have to say!  I love when people engage in great discussions that have been stimulated by something I have written.  I love when women post comments seeking advice, information, or camaraderie and other readers respond!  And I love reading about other women’s birth experiences that they share via this forum.  Often, a reader will post a question to me under the comments section, a question so great that I take hours or days to research and write a response.  And I am such an information/research junkie that if I don’t know the answer, I’ve got to find out!!  Other times a reader will post a comment with some really great information or resources to share with other readers.  Unfortunately, many of these “super comments” often go unnoticed by readers who only read the posts and not each “comments” section.  So I have been inspired to create a new category for my blog entitled “Super Comments” to pay homage to all of the great super comments and questions that my readers post!

 

Today’s Super Comment is in response to May 17th’s post entitled The Deal with Delayed Cord Cutting or “Hey! Doctor! Leave that Cord Alone!”

 

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Dear Nursing Birth,

 

I have a student nurse question. In nursing school we were taught that clamping/cutting the cord stimulates respirations. This comes from our textbook, Maternity, Newborn, and Women’s Health Nursing by Susan Orshan, specifically this quote “…clamping of the umbilical cord affects chemoreceptors sensitive to changes in arterial oxygen and carbon dioxide content, contributing to the onset of respirations.” This sentiment was echoed by our faculty to the tone of *this is why cords are clamped and cut immediately after the birth*.

I guess my question is this: Is the above quote enough to justify swift cord-clamping? Or not?
Thanks so much for this post. I’m enjoying the research you’ve done!

 

Sincerely,

BCB

 

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Dear BCB,

 

That is a really great question!  What you (and I) both learned in nursing school is right on one hand, but wrong on another.  Let me explain a bit further.  I would like to first address the statement you found in your textbook.

 

Your textbook reads “…clamping of the umbilical cord affects chemoreceptors sensitive to changes in arterial oxygen and carbon dioxide content, contributing to the onset of respirations.”  This is true in the fact that clamping the umbilical does stimulate the baby to breathe…BUT the act of clamping the umbilical cord is NOT necessary for the baby to take his first breath!  Clamping of the umbilical cord in a way actually forces the baby to take his first breath!  In the textbook Respiratory Physiology author John B. West writes:

 

“The emergency of a baby into the outside world is perhaps the most cataclysmic event of his or her life.  The baby is suddenly bombarded with a variety of external stimuli.  In addition, the process of birth interferes with placental gas exchange, with resulting hypoxemia and hypercapnia.  Finally, the sensitivity of the chemoreceptors apparently increases dramatically at birth, although the mechanism is unknown.  As a consequence of all these changes, the baby makes the first gasp.  

 

The fetal lung is not collapsed but is inflated with liquid to about 40% of total lung capacity.  This fluid is continuously secreted by alveolar cells during fetal life and has a low pH.  Some of it is squeezed out as the infant moves through the birth canal, but the remainder has an important role in the subsequent inflation of the lung.  As air enters the lung, large surface tension forces have to be overcome.  Because the larger the radius of curvature, the lower the pressures, this pre-inflation reduces the pressures required.”  (page 152, chapter 9)

 

Also (and this is a bit technical so bear with me!) an excerpt from the article “Cord Closure: Can Hasty Clamping Injure the Newborn?” by George M. Morley, MB published in OBG Management in July 1998 tell us:

 

“Very early clamping results in less than physiologic blood volume. The normal, term child routinely survives, but clamping the cord of a compromised child before ventilation is riskier. Initial aeration of the lungs causes reflex dilatation of pulmonary arterioles and a massive increase in pulmonary blood flow. Placental transfusion normally supplies this volume. Clamping the cord before the infant’s first breath results in blood being sacrificed from other organs to establish pulmonary perfusion. Fatality may result if the child is already hypovolemic.”  (Thanks to gentlebirth.org for the reference!)

 

And to answer your second question…

 

Homebirth midwife from Mountain View, CA and author of the website http://www.gentlebirth.org/ Ronnie Falcao, LM MS writes in a post entitled “Some comments about ‘Anatomy of A Fetus: Circulation and Breathing’” :

 

“It is not air hunger that causes the newborn to take a first breath, and it is certainly not necessary for the cord to be cut in order for the baby to start breathing.  …I am quite certain that nature didn’t assume that a birth attendant would be standing nearby, scissors in hand.  In reality, babies start to breathe right away even if the cord is left untouched.  It is not air hunger that stimulates a baby to take its first breath.  It is likely the stimulation that comes from the shock of cold air and the sudden exposure to light and noise.  Even dim lights and low noises seem very startling to a baby who’s only used to life in the womb.

 

Both Williams Obstetrics  and Varney’s Nurse-Midwifery concur: ‘The phenomenon that occurs to stimulate the neonate to take the first breath is still unknown.  It is believed to be a combination of biochemical changes and a number of physical stimuli to which the neonate is subjected, such as cold, gravity, pain, light and noise, which cause excitation of the respiratory center.’

 

Beyond the question of what stimulates the baby to take a first breath, we can look further at the triggers for the changes in the foramen ovale and ductus arteriosus. The delicate process of rerouting the circulatory system depends on the intricate interplay of blood gas levels that occurs naturally as there is a gradual shift from reliance on umbilical cord oxygen to reliance on air breathed into the lungs.  Sudden severing of the umbilical cord is an unnecessary and dangerous meddling with this process. Some people refer to this as premature amputation of the placenta because the baby is still using oxygen carried through the cord from the placenta.”

 

As an L&D nurse, I have witnessed births where the birth attendant practiced early cord clamping and some where the birth attendant practiced delayed cord clamping.  And guess what!?  These normal, healthy, uncompromised babies took their first breath and started to cry whether the cord was clamped early or late!  (When I first personally witnessed a few of the delayed cord clamped babies breathing just fine I started to wonder if the impression that I was given in nursing school (i.e. that babies needed their cord to be clamped to take their first breath) was really totally true.  Both experience and research have shown me otherwise!  Pretty cool huh! 

 

 

Thanks for your great question!

 

Best,

NursingBirth