Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

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


#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



“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


#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 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!!



b)      Sample Birth Plans from


d)      American Pregnancy Association




#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!





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!!



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.



• 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.



• 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!


“Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions July 9, 2009

Yesterday in my post entitled “Pit to Distress: A Disturbing Reality” I wrote about a troubling way of administering the drug pitocin to augment or induce labor that some birth attendants are practicing in our country’s maternity wards.  Called “pit to distress”, the intention is to order a nurse (either verbal or written) to continue to turn up (or “crank” as is the current L&D slang) the pitocin in order to induce hyperstimulation/tachysystole of the uterus so that a women is experiencing more than 5 contractions in a 10 minute period.  This action, sooner or later, will cause fetal distress as research has shown that a baby needs AT LEAST a 1 minute break in between contractions where the uterus is AT REST in order for the baby to continue to receive adequate oxygenated blood flow from the placenta and not have to dip into his reserve. 


Inspiration for my post came from two posts on the subject written by Keyboard Revolutionary and The Unnecesarean.  Since yesterday I have received many comments regarding this upsetting trend and one comment in particular has inspired me to address the topic again:





July 8, 2009


Dear NursingBirth,


I really enjoy your blog and I learn a lot from all your posts. I am wondering if there is a way (as the patient) to know if something like this is happening and refuse it? Is the patient always told how much pitocin she is getting and can she say at a certain point that she doesn’t want it any higher if she is making progress?









Dear Zoey,


This is a GREAT question.  I love hearing from women who desire to learn more about their choices in childbirth and become more proactive in the care they are receiving.  KUDOS to you for doing both!!  I have thought a lot about this and I have come up with a list that I hope you find helpful.  Please pass it along to all of your friends, both expecting and not, so that we can both work to inspire more women to do as you do….that is, DO their research and DEMAND better care!!!







#1  Interview different birth attendants/practices before or during early pregnancy and CHOOSE a birth attendant that practices in a way that aligns with your personal childbirth/postpartum philosophy, is appropriate for your health status, and (optimally) who practices a midwifery model of care!


I wish I could scream this from the roof tops!  Sometimes I feel like a broken record I say this so often but I say it so often because it is SO important!!  The bottom line here ladies is that if you think you can pick any care provider you want and then just write a birth plan that clearly states your philosophy and preferences and just get what you want…..THINK AGAIN!  Birth attendants are creatures of HABIT more than anything else.  If they cut an episiotomy on the majority of their patients then what makes you think that if you ask, they won’t cut one on you?  In fact, not only will they cut one on you but they will come up with some bogus reason why it was necessary.  Likewise, if your birth attendant induces most of their patients, what makes you think that he won’t start pressuring you to set up an induction date once you hit 37 weeks! 


Think of it this way, if the birth attendant has a high elective induction rate, they probably feel more comfortable managing pitocin induced or augmented labors as opposed to spontaneous labors and hence, they will probably try to do everything in their power [including persuasion (e.g. the “convenience” card and the “aren’t you sick of being pregnant” card) as well as scare tactics (e.g. the “big baby” card, the “I might not be there to deliver you if you don’t” card, or my favorite the “if you don’t your baby might be stillborn/dead baby” card)] to convince you that your labor needs to be induced or augmented with pitocin.  Why?  It probably is a mix between how they were taught (i.e. medical model of maternity care), what they are used to (a self fulfilling prophecy), and a desire to be the one in “control.” 


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.”  (Emphasis mine)


So PLEASE for the LOVE of all mothers and babies, PLEASE do your homework! 


Of course there is always the chance that you do interview a particular birth attendant and they act one way in the office with you and then, WHAM!, are a completely different person when you step foot on L&D.  I see it happen ALL THE TIME where I work.  Just because a doctor gives you his home phone number and is sweeter than sugar in the office, doesn’t mean he won’t section you just to get to the company Christmas party!  (This actually happened to a patient I took care of!  NO lie!)  So what can you do about that! 


Jill from Keyboard Revolutionary recently blogged about this:


“Ya know, sometimes I feel bad for the good physicians out there. I know they exist. We all do. We’ve all shaken our fists in righteous indignation at the rants of Marsden Wagner. We’ve listened intently to the poetic, thickly accented declarations of Michel Odent. We’ve swooned over the tender ministrations of “Dr. Wonderful,” a.k.a Dr. Robert M. Biter. God bless those diamonds in the rough, particularly in the obstetrical field. It must be twice as hard to shine when the lumps of coal around you are so horrifically ugly.


I was pondering just now in the shower how so many of us think we’ve got a real gem of an OB (or any other doctor, really) until show time, and suddenly we’re hit with the ol’ bait-and-switch. Sometimes there are warning flags along the way, sometimes not. Sometimes the flags don’t pop up until it’s too late. It sucks that for many women, we don’t realize what a crock we’ve been fed until we’ve already digested it. How do you know whether you’ve got a bad egg or your own Dr. Wonderful?”


This leads me to my second point…



#2  Ask the RIGHT QUESTIONS and the RIGHT PEOPLE when researching potential birth attendants.


Two of my favorite posts from Nicole at It’s Your Birth Right! are her posts about choosing the right birth attendant entitled Choose Wisely I and Choose Wisely II.  She writes:


“The decision about WHO is going to be your birth attendant should NOT be left to chance.  Where you deliver, how you choose to labor, what you chose to do while pregnant and in labor, while these things are definitely important, without the proper WHO, the plan will have difficulty coming together.


I get questions, all the time from friends, friends of friends and even strangers.  They want my thoughts about pregnancy, labor and childbirth. I have spent HOURS talking with women providing answers and information they should be able to get from their prenatal provider/birth attendant.  I think to myself at the end of those conversations, “Why isn’t she able to get this information from her?  If  he doesn’t make her feel special, does not answer her questions, and doesn’t agree with her philosophy on childbirth and labor, why on earth is she allowing him to be her birth attendant?!”


When I pose this question to the women themselves, the answers unfortunately never include “Because I did my research and I found him to be the best match for me and my desired childbirth experience.”  Most of the answers I receive fall into [one of] four categories, none of which are good enough reasons alone to choose a prenatal care provider/birth attendant.   They are: “She delivered my sister/girlfriend”, “She is my gynecologist,” “He is the best/most popular person in area,” and “Her office is so close and convenient to my office/house.”


Now I am not trying to say that you shouldn’t trust your sister, sister-in-law, or best friend’s opinion about her personal birth attendant but if you are going to ask such a person for advice please remember that she probably has only had limited experience with that birth attendant as compared to, say, an L&D nurse or doula, and it is important to ask her exactly why she loves her birth attendant so much.  Does she love him because he trusts in birth and strived to facilitate a positive and empowering birth experience for her or does she love him because he was the only OB in the area that would agree to induce her at 38 weeks because she was sick of being pregnant?  There is a difference!!


If you have done some research and found a birth attendant that you think you really like, I would recommend tapping into some community resources to get the “inside scoop” about your birth attendant.  Here are some ideas:


1)      Contact your local grassroots birth advocacy group like International Cesarean Awareness Network (ICAN) or BirthNetwork National and try to attend a meeting.  The women that attend these meetings are often in tune with the birth culture in their community and can be GREAT resources for which birth attendants are true and which are really wolves in sheep’s clothing!  Also, don’t count out ICAN as a resource even if you have never had a cesarean.  We have a quite a few moms currently in my local ICAN group that are first timers and decided to start attending because they said they were learning so much about birth in general from our meetings!


2) Sign up for a childbirth preparation class that is NOT funded/run by a hospital and ask the instructor for her opinion on different birth attendants.  It is the only way to guarantee that your instructor is not held back from speaking her true feelings since hospital based childbirth instructors are working for the interest and promotion of their hospital by the very nature of their job.  Independent childbirth instructors like Lamaze, Hypnobabies, Birthing From Within, Bradley etc. etc. can be GREAT resources as to which birth attendants follow which philosophies because often times their clients come back and tell them about their experiences.


2)      Consider consulting or hiring a doula.  A doula is a great resource as to the true nature of a birth attendant because she is someone who is actually in the labor and delivery room with her clients and has as close to an “insider’s view” as you can get without actually working for the hospital.  If you hire a doula to be with you during your labor, they will also advocate for you, your needs, and your birth plan as well as provide essential labor support that (unfortunately) even the most well intentioned nurse might not have the time to do. 



#3  Do NOT agree to an induction of labor unless there is a legitimate obstetrical, maternal, or fetal reason for delivering the baby before natural spontaneous labor begins!!  PLEASE Do NOT agree to an unnecessary elective induction of labor. 


This might seem like a no brainier ladies but so many get sucked in!  They don’t call it “the seduction of induction” for nothing! 


Bottom line is if you want to protect yourself from such an asinine, unnecessary, and dangerous intervention as “Pit to Distress” then DON’T agree to be induced unless there is a very important medical reason!




In the Lamaze Institute for Normal Birth’s MUST READ patient education bulletin entitled Care Practice #1: Labor Begins on Its Own, author Debby Amis, RN, BSN,CD(DONA), LCCE, FACCE, and editor Amy M. Romano, MSN, CNM write:


“There is growing evidence that induction of labor is not risk-free. In 2007, Goer, Leslie, and Romano reviewed the entire body of literature on the risks of induction in healthy women with normal pregnancies and found that when labor was induced, the following problems may be more common:

  • vacuum or forceps-assisted vaginal birth;
  • cesarean surgery;
  • problems during labor such as fever, fetal heart rate changes, and shoulder dystocia;
  • babies born with low birth weight;
  • admission to the NICU;
  • jaundice;
  • increased length of hospital stay.”


Okay, enough said!



#4  If you have to be induced or augmented with pitocin for a true medical or obstetrical reason, be honest with your nurse about how you are feeling and have one of your labor companions keep track of how often your contractions are coming.


And this does NOT mean for your labor companion to “monitor watch”!!  It’s not a TV for goodness’ sake!


Research has shown that due to the risks of pitocin, continuous electronic fetal monitoring (CEFM) is a safety requirement for anyone being induced or augmented with it.  However, remember CEFM is a machine and machines have limitations.  The tocodynamometer or “toco” is “pressure transducer that is applied to the fundus of the uterus by means of a belt, which is connected to a machine that records the duration of the contractions and the interval between them on graph paper.”  However, depending on your body type, how “fluffy” your abdomen is, your position, and your gestational age, the toco might not be recording your contractions appropriately.  You might be having contractions every minute but the machine is not registering them.  This is why I always remind women that they have to tell me how they are feeling. 


If you are being augmented or induced with pitocin your nurse SHOULD:


1)      Be palpating (feeling) your fundus (top of your uterus above the belly button) before, during, and after contractions periodically throughout your labor to judge how strong they are (mild, moderate, or strong).  Palpation before and after contractions also assures the nurse that your uterus is actually coming to rest (is soft) between contractions, which assures that the baby (and mom!) are getting a break!  Remember, unless you have an IUPC (intrauterine pressure catheter) in, the toco can only tell the nurse how far apart and how long the contractions are NOT how strong they are!  That’s right!  Unless you have an IUPC in, the height of the contractions on the monitors is ABSOLUTELY MEANINGLESS!  So therefore the only way for the nurse to know how strong the contractions are is to TOUCH your belly and ASK you!


2) Ask you about your pain level (for example to “rate” your pain on a scale of 0 to 5 or 0 to 10) regularly during your labor unless you have specifically asked her not to ask you about your pain.


3) Give you periodic updates on your progress and the progress of the pitocin.


[Note: I can only speak for myself here but what I do when I have a patient on pitocin is first and foremost to explain the process of titrating the pitocin and what the desired outcome is (and according to our hospital’s policy the desired outcome is moderate to strong contractions that are coming every 2-3 minutes, or 3-5 in a 10 minute period), as well as keep her informed throughout the process when I am increasing or decreasing the pitocin and for what reason.  For example, I might say “It looks to me like you are contracting every 4 minutes.  What is your pain level?  Do you feel like you are getting an adequate break?  Would you like to change position?  I would like to increase to pitocin to achieve a more regular pattern.  What do you think?” or “It looks like the baby continues to have variable decelerations in his heart rate despite all of the position changes we have tried.  I am going to give you a small IV fluid bolus and turn the pitocin down some to see if it helps to resolve the decels.  The baby’s variability is still very reassuring and she is still having accelerations so she is doing well.  I just would like to keep her that way!”  Your nurse should be keeping you “in the loop” so to speak and if she is not, it is your right to ask questions!]


It is also important to remember that that running pitocin is much more of an art than a science.  Therefore you might think she is being “mean” if she is increasing your pitocin since you are only contracting every 6 minutes but remember, running the pitocin lower than is needed to cause cervical change isn’t going to help you either.  No nurse wants her patient to end up in the OR for “failure to progress” because she didn’t turn the pitocin up enough.  There is a happy medium somewhere that most nurses are trying to find.  So please, know that sometimes, even if you really feel like those “every 6 minute” contractions are strong enough already, it is important for the nurse to titrate the medication to achieve an effective labor pattern that promotes a vaginal delivery with a healthy baby. 


If your nurse is NOT doing these things then it is your right to ask questions!!!  However, please remember for your own sake that when asking questions, one attracts more flies with honey than vinegar.  Don’t start yelling at her or demanding a new nurse.  Give her a chance and ask questions first!  She might just be so busy that day that she is in the zone.  Most nurses are happy to teach when asked!



#5  Learn about and practice non-pharmacological methods of pain relief as part of your childbirth preparation and consider not getting or postponing an epidural until all other methods of non-pharmacological pain relief have been exhausted. 


Okay, I know that this one is a bit controversial but please here me out first. 


It is the truth that pitocin contractions, especially when the pitocin is being abused, are typically stronger and longer than spontaneous labor contractions.  Also, being that you have to be on continuous monitoring can also limit your movement and hence, one of your most effective and instinctual coping methods for the pain.  For this reason, many people feel that it is crazy for a woman to go though a pitocin labor without an epidural.  And when “Pit to Distress” is in play, it is truly unbearable to both experience and to witness.  However, if pitocin is administered compassionately and appropriately it is important to know that an epidural is NOT an absolute necessity.  I have seen many women do it without an epidural and many who have done it with an epidural.  So if you have to be induced with pitocin and you desire an “unmedicated” birth, your hands aren’t completely tied.  You CAN do it.  However, I have said time and time again, I would rather a woman have a vaginal delivery with an epidural than a cesarean section without.   That being said, the pitocin and epidural partnership has a dark side too. 


While an epidural can help the woman relax and allow the pitocin to work more effectively, most birth attendants that practice “Pit to Distress” persuade and even bully their patients into getting an epidural specifically so the nurse can “crank the pit” without the woman objecting.  But I would like to remind you that even if you can’t feel those contractions, your baby IS feeling them.  Also, epidurals themselves CAN and DO cause fetal distress and anyone who tells you that epidurals pose no risk to the baby is being dishonest!  At my work, we nickname this the “ten by ten”.  That is, almost without fail, many women who get an epidural are is likely to experience a whopping fetal heart rate deceleration lasting approximatly ten minutes about ten minutes after she is put back to bed, which of course throws everyone into a tizzy. 


All of a sudden mom finds herself with her face planted into the bed, her ass in the air, a mask of oxygen on her face, an anesthesiologist pushing adrenaline into her IV to increase her blood pressure and a doctor with his hands up her vagina screwing a monitor onto the baby’s head.  Most babies do recover from said decel and go on to deliver vaginally.  But it is NOT rare for the baby to NOT recover which lands mom…you know where….in the OR.  And guess what!  Since she already has that epidural in place, why they can just cut her open even faster! 


Please know that I am not condemning any woman who requests an epidural in labor, especially if she is on pitocin.  I just want all you women out there to know that sometimes that epidural that they keep waving in your face is just a way for them to shut you up so they can CRANK the pit.



#6  If you feel like you are contracting strongly at least every 2-3 minutes (3-5 in a 10 minute period) and the nurse or birth attendant desires to increase your pitocin, you might want to consider requesting a vaginal exam. 


Now, I know limiting vaginal exams is very important to many women as they are invasive and uncomfortable/painful.  I completely understand!  However, if your care provider wants to increase the pitocin and you feel it is unnecessary, asking for a vaginal exam is a way to reveal if you are making any cervical change.  If you ARE making cervical change then there is no real need to continue to go up on the pitocin!  Remember the TRUE goal of pitocin administration is to stimulate an effective labor pattern that causes cervical change.  It is NOT (despite how many birth attendants practice) just about getting a patient to “max pit.”  Every woman is different! 





#7  You could always try writing something about pitocin administration in your birth plan. 


For example: “If deemed necessary, I would like to try non-pharmacological methods of labor augmentation and induction including (blank) first before resorting to pharmacological methods.  However, if my birth attendant and I agree that pitocin will be administered to me, I request that the pitocin be administered following the “low dose” protocol and is 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.”


I will be very honest with you.  If your birth attendant or hospital does not practice in this way, it is doubtful that this request will be granted.  However, I suppose it can’t hurt and is worth a shot!  At least it can provide a sympathetic nurse with another platform on which to argue with the birth attendant if necessary (like, “But Doctor X, your patient has specifically requested a low dose pit protocol!”


This should be a last resort!  Remember, writing something in your birth plan does not guarantee you it is going to happen if your birth attendant doesn’t practice that way!  Please refer back to point #1 about choosing the RIGHT birth attendant for you!!! 



All My Best,



Super Comment!: Maternal Death in the U.S., or TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth May 27, 2009

Dear NursingBirth,

I’m a huge fan of your blog! Please keep the awesome entries coming! I am learning so much. I am just a novice birth-junkie rather than a birth professional and so am anxious to eat up all the great information you’re giving out here.

Anyhow…. Our state treasurer’s wife (that’s here in Arizona) died today in childbirth, and their baby is said to be in grave condition. They’re not giving causes or reasons. Here’s the link:

Can you think of occurrences in hospital-birth that would end up with a dead mother and a baby in really bad condition? I’d love to hear from someone who knows her stuff. The things that came to mind for me were amniotic fluid embolism, severe uterine rupture, and cesarean gone really wrong.

Keep up the amazing work!!!



Dear Diana J.,


I just read the story you linked to and my heart goes out to that family.  Unfortunately the story you linked to did not go into any details, including the most important detail which is: Did the treasurer’s wife have a vaginal birth or a cesarean section, as the risks are significantly higher with a cesarean section.  I think your question is a good one and since this story has the potential to make national headlines, I think that it is an important enough question to put as its own post on my site.  I hope, however in posting about your question that moms out there who read my blog are not unnecessarily worried or upset that we are talking about maternal death as it is still a relatively RARE occurrence when you think about all the other causes of death in childbearing women. 


Let’s put it into perspective.  As the Arizona Central story stated, “In late 2007, the National Center for Health Statistics, part of the U.S. Centers for Disease Control and Prevention, released a report showing that there were 13 maternal deaths per 100,000 live births in 2004 in the United States.” And since in 2004 there were 4.1 million births in the United States, if you do the math that would make about 533 maternal deaths in 2004.  And don’t get me wrong…that’s 533 deaths to many for sure!  However take a look at this chart published by the Center for Disease Control (CDC) entitled: Leading Causes of Death by Age Group, All Females- United States, 2004.  It shows the following:


Leading Causes of Death for 15-19 year old Females, 2004:

1)      Unintentional Injury (51.7%), 2) Suicide (8.8%), 3) Homicide (7.5%), 4) Cancer (7.3%), 5) Heart Disease (3.1%), 6) Birth Defects (2.8%), 7) Pregnancy Complications (0.9%)


Leading Causes of Death for 20-24 year old Females, 2004:

1) Unintentional Injuries (40.5%), 2) Homicide (8.4%), 3) Cancer (8.0%), 4) Suicide (7.6%), 5) Heart Disease (4.6%), 5) Pregnancy Complications (2.7%), 6) Birth Defects (1.9%), 7) HIV disease/Stroke (1.4%).


Leading Causes of Death for 25-34 year old Females, 2004:

1) Unintentional Injuries (25.3%), 2) Cancer (15.1%), 3) Heart Disease (8.2%), 4) Suicide (7.5%), 5) Homicide (5.8%), 6) HIV disease (4.4%), 7) Pregnancy Complications (2.3%).


And for women ages 35-44 years old, pregnancy complications don’t even crack the top 10. 


Okay so if you are a pregnant mom please know that dying of pregnancy/childbirth related complications is rare and I don’t want to completely freak you out.  But there is something very disturbing about the United States maternal mortality statistics which shocks most people when they hear it….


The United States ranks 42nd in the WORLD for maternal mortality rates, with 1 in 4,800 women dying from pregnancy complications in the U.S. in 2007.  That means that 41 countries other countries in the world have BETTER maternal mortality rates than the United States!


Many of our practices and current situations in this country, including our obsession with medically unnecessary labor induction, our over-medicalized maternity care system, the practice of defensive as opposed to evidenced-based medicine, the lack of a universal health care system, large differences in health disparities among different racial/socioeconomic groups, the obesity epidemic, and our skyrocketing cesarean section rate greatly contribute to our country’s maternal death rate. 


So what exactly is defined as “maternal death.”  According to the World Health Organization, “A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”  Therefore a death of a woman that died from complications arising from a cesarean section a month after she had the baby would be counted in the maternal death statistics where a pregnant woman who died in a car accident or murdered during a domestic violence dispute would not. 


Okay, but you are probably thinking Why?  Why are so many women dying in childbirth in an industrialized, developed country like the United States at a much higher rate than other industrialized, developed countries like Japan, many countries in Europe, or Australia? 


Ina May Gaskin, midwife and founder of the Safe Motherhood Quilt Project, gives us some insight into the situation in her book Spiritual Midwifery, page 455, written in 2002:


“According to the CDC, there has been no improvement in the U.S. death rate (which is nearly twice as high as Canada’s) since 1982.  Sadly, the CDC estimates that the true death rate is as much as three times higher than that which is reported and that half of all the reported deaths could have been prevented through early diagnosis and good care.  Given the situation it makes sense for women to avoid unnecessary surgery while pregnant or in labor.  Women double or triple their risk of dying when they have an unnecessary cesarean.  Medical mistakes do happen, even to people who are well informed about their possibility.”


Also Ina May’s Safe Motherhood Quilt Project website also links to a Maternal Mortality in the USA Fact Sheet that is worth checking out!


The 2008 documentary Orgasmic Birth (which I highly recommend renting) has a 20- minute movie clip as part of the “special features” section of the DVD that provides some eye opening statistics about maternal and infant mortality rates in the United States as compared to other industrialized countries around the world.  In this short movie clip, entitled Birth By The Numbers, Eugene R. Declercq, PhD, Professor of Maternal and Child Health, Boston University School of Public Health, presents the sobering statistics of birth in the United States today.  It is a MUST WATCH CLIP for anyone who is or cares about a mother.


Also, here are some articles from mainstream news sources published in response to the 2007 maternal mortality rankings that provide some insight:


1) More U.S. women dying in childbirth: Death rate highest in decades; obesity and C-sections may be the cause  Associated Press, August 24, 2007

2) Maternal Mortality Shames Superpower U.S.  Inter Press Service, October 13, 2007

3) U.S. ranks 41st in maternal mortality  Seattle Post-Intelligencer, October 12, 2007 


A flyer published by the medical journal The Lancet in 2006 entitled Causes of Maternal Death: A Systematic Review ranks the top 9 causes of maternal death related to pregnancy/childbirth complications in DEVELOPED countries as the following:

1) Other Direct Causes (21.3%), complication of the pregnancy, delivery, or their management which includes (among other things):

            –Anesthesia Complications* (responsible for about 3% of all maternal deaths by itself and includes:    management of the difficult airway in obstetric patient, aspiration of gastric contents under general anesthesia, local anesthetic toxicity, and high spinal or epidural block which paralyzes the breathing muscles of mother).

2) Hypertensive Disorders (16.1%), includes (among other things):



            –HELLP Syndrome*

3) Embolism (14.9%), includes (among other things):

            –Pulmonary Embolism (typically a complication seen post-op surgery)

Deep Vein Thrombosis (DVT) (more likely to develop for women on bed rest or post-op surgery

Amniotic Fluid Embolism (rare and more appropriately known as Anaphylactic Syndrome of Pregnancy)*

4) Other Indirect Causes of Death (14.4%), pregnancy-related death in a patient with a preexisting or newly developed health problem like cardiovascular disease, seizure disorder, respiratory disorder, diabetes, kidney disorder, liver disorder, obesity, etc.

5) Hemorrhage (13.4%), includes (among other things):

  – Obstetrical Hemorrhage (most common causes being uterine atony, trauma, retained placenta, and coagulopathy)

  – Placenta Previa*

            – Placenta Accreta, Increta & Percreta

            – Placental Abruption*

            – True Uterine Rupture*

6) Abortion (8.2%)

7) Ectopic Pregnancy (4.9%)

8.) Unclassified Death (4.8%)

9) Sepsis Infection* (2.1%)  (most likely to occur post-operatively but can occur post-partum or antepartum)


*Comes to mind for me as having the potential to cause a critical illness or death for baby as well.

**Please note mothers undergoing cesarean surgery, especially repeat caesarean surgery are MORE at risk for anesthesia complications, pulmonary embolism, obstetrical hemorrhage, placenta previa, placenta accreta, and sepsis/infection than moms undergoing a vaginal birth.**




You are probably thinking, “So what does all of this mean for me?” “How can I reduce my risk?”  Both are GREAT questions.  It is important to remember that I am not claiming that 100% of maternal deaths are preventable or even foreseeable.  No one is.  I also do not want anyone to get the impression that I am blaming mothers or putting unrealistic pressures on mothers to control things that are sometimes just happenings that are an unfortunate and very sad part of life.  For example, who could have predicted a fatal postpartum hemorrhage for a healthy mom after a normal uncomplicated unmedicated singleton vaginal birth?  No one could!  But what about a mom who experienced a fatal postpartum hemorrhage after elective cesarean surgery….well that one doesn’t sit so well with me!   And which do you think is more likely?  If you guessed the latter you are correct…by at least 4 times as much! 


So how does a mother reduce her risk of maternal morbidity and mortality related to pregnancy and childbirth complications?  The following is a short list you might want to keep in mind.  (Not surprisingly, many relate back to avoiding unnecessary surgery.)


TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth:

1)      Obtain good and thorough prenatal care, keeping all of your appointments, preferably beginning in your first trimester.


2)      Make a conscious effort to eat a well balanced diet during conception and pregnancy that includes adequate amounts of fresh fruits and vegetables, healthy fats, and protein.  There are a variety of prenatal nutrition books out there as well as many childbirth books that have a section on prenatal nutrition.  If you don’t have one buy one or borrow one from the library!!


3)      If you don’t exercise, start!  Many gyms, community centers, and YMCAs offer low-impact, pregnancy-friendly classes for expectant moms.  Even a 30 minute walk three times a week will do!


4)      If you suffer from a chronic disease or illness or are obese, it is important to know that making appointments with health care providers and specialists that can help you to manage your disease and lose weight in a healthy way before and during pregnancy can ultimately help you to reduce your risk of life threatening complications during pregnancy and childbirth.


5)      Consider hiring a birth attendant that practices a midwifery model of care.


6)      Do NOT agree to a medically unnecessary labor induction.


7)      Do NOT agree to a medically unnecessary or elective cesarean section.


8)      If you have a history of a cesarean section, seriously consider a vaginal birth after cesarean section (VBAC) if you have no reoccurring or new reasons or medical indications for a repeat cesarean.  If necessary switch to a birth attendant that supports VBAC and has the cesarean statistics to prove it.


9)      Seriously consider avoiding interventions in labor that evidenced-based research have shown could increase your risk of a cesarean section, fetal distress, and infection including early amniotomy (breaking of waters), accepting pitocin to stimulate or augment contractions without trying other more natural methods for augmenting labor first, going to the hospital during very early labor, accepting continuous external fetal monitoring as opposed to intermittent auscultation for a normal healthy labor and a normal, reactive, and reassuring fetal heart rate pattern, and requesting an epidural or narcotic pain medication (especially in early labor) before trying all methods of non-pharmacological pain management techniques first.  (Check out my post: Top 8 Ways to Have an Unnecessary Cesarean Section)


10)   Empower yourself to make safe, healthy decisions regarding your pregnancy, your labor, your birth, and your baby by doing your own research!!  (Check out my post: Birth Resources EVERY Woman Should Know About).


Top 8 Ways to Have an Unnecessary Cesarean Section April 3, 2009

(Adapted from Top 7 Ways to Have an Unnecessary C-Section)


Happy April everyone!  As you may or may not be aware, the International Cesarean Awareness Network (ICAN) has declared April to be Cesarean Awareness Month.  In honor of this, I decided to share with you a website I recently found that I thought was pretty amusing. 


Blogger Esther Brady Crawford of recently wrote a post entitled “Top 7 Ways to Have an Unnecessary C-Section”.  Not only is it amusing (and perhaps a bit cynical) but it is also: 1) sad that it is so true and 2) very true.  I encourage you to read her original post since she gives her own hilarious explanations for each “pointer” but since I am a big research nerd, I have added my own comments to her original Top 7.  At the end of this post I have included an eighth “pointer” to the list to make it a Top 8.  Much of the research I cite in this post is from the book The Thinking Woman’s Guide to a Better Birth by Henci Goer.


So here it goes…


#7  Go the hospital in the early phases of labor.

          Crawford is just plain right-on with this one!  Too many obstetricians are quick to label a mom as having “dysfunctional labor” if she does not progress at least one centimeter an hour (for first time moms) or two centimeters and hour (for multiparous moms) immediately upon arriving to the hospital.  I have even had some doctors I work with take a call from a mom at home that “sounds like she is in labor” and turn around and tell the residents to “start her on pit as soon as she gets here.”  WHAT??!!  Pam England, CNM, MA writes in her book Birthing From Within, “One advantage to laboring in the privacy of your home, with one-on-one midwifery support, is that should a problem arise that requires medical support at the hospital, you will not wonder whether your labor problems were caused by routine, unnecessary, or ill-timed hospital interventions.”


#6  Don’t eat or drink during a long labor.

          Goer writes that dehydration and starvation caused by restricting food/drink intake during labor causes a woman not only considerable discomfort but can also lead to fever, prolonged labor, increased use of oxytocin (aka pitocin), instrumental delivery, and a non-reassuring fetal heart rate pattern/fetal distress.  And what can all of these lead to…that’s right…a cesarean section!  (Goer, 79-83)


#5  Get an amniotomy too soon.

          Amniotomy (or artificially “breaking the bag of waters”) too soon can lead to umbilical cord compression/fetal distress, abnormal fetal heart rate patterns, cord prolapse (a surgical emergency where the umbilical cord slips out into the birth canal before the baby’s head), increased likelihood of maternal infection and hence a “race against the clock” to get a woman “delivered” before 24 hours is up, and lastly, a greater chance that the baby get “stuck” in a posterior (back of head toward your back) or acynclitic (head tilted off to one side) position which can stall labor and make pushing at best, difficult and at worse, unsuccessful.    Bottom line, if it ain’t broke, leave it alone!  Not obeying that rule could lead you to an unnecessary cesarean!  (Goer, 99-104)


#4  Accept pitocin to induce or stimulate contractions.

          The use of oxytocin (pitocin) for labor augmentation (aka “revving up a slow labor”) or induction (aka artificially starting a labor that hasn’t started on its own) has its own risks.  Although oxytocin is quite effective at stimulating contractions, it often makes contractions stronger and longer than natural contractions, can cause too many contractions too close together (aka uterine tachysystole or hyperstimulation) which can lead to fetal distress, can double the chances of a baby being born in poor condition, and eventually can lead you to the operating room!  (Goer, 65)


#3  Request an epidural.

          Research has shown that epidurals 1) interfere with a mother’s natural release of labor hormones which can in turn (among other things) slow or stop her progress of labor, 2) increase her chances of needing pitocin augmentation for said slowed labor, 3) numb her pelvic floor muscles, which are important in guiding her baby’s head into a good position for birth , 4) can cause maternal fever than can be mistaken as a sign of infection, 5) can cause a significant drop in her blood pressure which can interfere with how much blood supply is getting to the baby and can lead to profoundly negative effects on the baby’s heart rate, 6) significantly impair in her ability to push her baby out effectively.  All of these side effects/risks, as research has shown can, and often does, lead to a cesarean section.  (See “Epidurals: risks and concerns for mother and baby” by Dr Sarah J. Buckley)


#2  Accept hospital staff’s comments on lack of progress without challenge.

          In my opinion, nothing is more detrimental to a woman’s labor progress and ultimately her birth experience than negativity in the labor room from labor & birth attendants, especially the people who are the “professionals” like obstetricians, midwives, and nurses.  As Marsden Wagner, MD, MS writes in his book Born in the USA, fear and anxiety stop labor.  And giving a woman the impression that she is “failing” can lead to a helpless and hopeless attitude and eventually a cascade of interventions that might very well lead to a cesarean section. 


#1 Just ask!

          Believe it or not, there are some OBGYNs out there that will agree to perform a cesarean section on a first time mom without medical indication.  Goer writes, “Popping up lately in the medical literature are arguments that women should be able to have first cesareans for the asking as well.  Again, this is presented as a freedom of choice issue.  But how much real freedom do women have in a culture that portrays labor as torture and C-sections as a ‘no muss, no fuss’ option?”  Goer states that the obstetric belief that choosing between a cesarean and vaginal birth is like choosing “between chocolate and vanilla” is really about six things: money, impatience, convenience, peer pressure, hospital culture, and defensive medicine.  What I find even more disturbing than this, however, is that women who do desire to avoid a cesarean and plan for a vaginal birth after a cesarean (VBAC) are finding themselves with less choice and opportunity to do so in more and more communities around this country as more and more obstetricians are refusing to attend VBACs and hospitals are either banning or placing de facto bans on VBACs.  


And lastly here is my own addition…number 8!


#8  Agree to a labor induction without medical indication.

          Induction of labor comes with risks and the BIGGEST risk is the risk of cesarean section.  When induction of labor is done for a medical reason, either related to mom or baby, and the risks of continuing the pregnancy are greater than the risks of induction, then this is the only time when labor induction is appropriate and warranted.  But when a woman agrees to a labor induction without any medical reason, then she is putting herself at risk for an unnecessary cesarean section, plain and simple. 

          Many obstetricians I work with claim that all the “elective” labor inductions (that is, inductions without medical indication) are because the woman “demands” it.  And don’t get me wrong, there are some women out there who are a bit mislead.  But all to often a woman shows up for a labor induction and it is overwhelmingly obvious that she: 1) wasn’t fully explained both the benefits AND risks of labor induction, 2) wasn’t told that labor induction can take up to three days to complete, 3) wasn’t told that comfort measures like using a jacuzzi tub or shower, walking, using the birthing ball, eating, drinking, and general freedom of movement are MAJORLY restricted during labor induction either because of hospital policy, obstetrician’s philosophy, or the requirement of continuous external fetal monitoring, 4) didn’t realize she had the option to say NO.


So there you have it, the Top 8 ways to have an unnecessary cesarean section.  I wish it wasn’t true but unfortunately it IS!


In closing I would like to leave you with one of my favorite quotes:


“We have a secret in our culture, and it’s not that birth is painful; it’s that women are strong.” ~ Laura Stavoe Harm



Top 10 DOs & DON’Ts of Pooping During Labor & Birth March 15, 2009

On February 8th, 2009 I wrote a post entitled Top Ten Things Women Say/Do During Labor (And trust me… they are totally normal!).  This piece has been the most popular post on my blog yet, which is pretty exciting!  When I originally thought of the piece, I figured that most women would stumble upon it by searching for something like “Things to do in labor” or “Things women say in labor”.  However, upon reviewing the top searches of February/March for this blog, I was surprised to find that they didn’t include those phrases at all!  Instead they all had one simple thing in common: POOP.  That is right… poop! 


Here are the top 7 searches for NursingBirth in the last two months:  (Note: The wording is not altered at all…these phrases were actually typed into a search box and searched for!):


#1 Pooping in labor

#2 Will I poop while I push?

#3 How many women poop during delivery?

#4 Labor and delivery nurse poop

#5 L&D nurses and bowel movement during delivery

#6 Woman in labor thinks she has to poop

#7 What will happen if I poop during delivery?


Since I am a labor & delivery nurse, I am naturally inclined to jump on any opportunity to talk about bodily functions (especially during awkward times like dinner or outings with the in-laws J) and consequently, I have been inspired to write a post about, what seems to be, the number one thing on every pregnant woman’s mind…POOP!


So here they are:  The Top 10 DOs & DON’Ts of Pooping During Labor & Birth


#1 DON’T forget that life does go on after an embarrassing moment.  How many of you have accidentally passed gas during sex?  You’re all “hot and heavy” with you man (or woman) and you’re both getting into it and then…whoops!  If he/she happened to make a big deal out of it, hopefully you kicked him/her to the curb!  Let’s face it, the people that are closest to us often see us in embarrassing situations at one point or another in our lives: bowing down to the porcelain god after a night of partying, passing gas during lovemaking, runny nosed and hacking up a lung during a bout with the flu, squatting to pee in the woods during an outdoor sporting event etc. etc. etc.  And if those things happened in the company of someone who really loves you, they probably still loved you just as much, or even more, afterwards.  Cuz hey, you’re human!  (By the way, I have personally experienced all of those things so if you are laughing and thinking the same thing…you are not alone!  And for the record, the guy that I passed gas on during sex ended up marrying me this summer so it couldn’t have scared him that much!)


#2 DO understand that the vast majority of women poop during the birth of their babies and that this phenomenon is NORMAL.  If you think about it, when your birth attendant tells you to “bear down and push” they are really telling you to “push like you have to poop!”  It is the exact same motion.  And if you do poop, your nurse, midwife, or doctor is usually reassured that you are pushing correctly!!  In fact, the WORST thing you can do is not push right because you are afraid to poop!  I have seen it happen before and it is such a shame because these women just end up pushing for way longer than they should have all because they let their fear of embarrassment overcome them.  As a labor & delivery nurse, I do not keep records of exactly how many women poop during birth (can you imagine pooping statistics!  haha! J) but you can rest assured that it is the VAST MAJORITY of women.  If someone you know tells you they didn’t poop during childbirth they either are: #1) part of the very small minority of women who actually don’t, or #2) just didn’t realize they did.  And to be honest, #2 is way more likely!


#3 DON’T invite anyone to be present at your birth that you are not totally and completely comfortable with them seeing you in your most vulnerable and trying moments.  Let’s be honest, even in the closest of relationships not many women are comfortable going to the bathroom and pooping in front of their significant other or family members but it is important to understand that the circumstances of childbirth are way different than just your daily morning bowel movement.  My mother doesn’t prefer to be there when my grandmother is bathing, dressing, and going to the bathroom but when my grandmother broke her arm this past winter and needed surgery, that is exactly what my mother did because she needed her.  And I would do the same thing for my mother as I know she would (and has) done for me!  Passing a bowel movement or gas during labor & birth are normal bodily functions that happen during normal labor (as is burping, throwing up, grunting, groaning, crying, etc).  Labor and birth are NOT spectator sports and you are NOT a “hostess” and therefore if you are going to be too preoccupied with the thought of how embarrassing it will be to poop in front of your mother or sister or best friend, then perhaps you should think more carefully about who you invite to your birth.  Just because a family member loves you and “really wants to be there” at your birth, it doesn’t automatically make them a fitting labor companion.  Remember, excessive worry and fear during labor releases hormones that can physically slow or stop your progress!


#4 DO go to the bathroom and empty your bowels (only if you feel the urge) in early labor.  Feeling like you have to “poop” during active labor or transition is almost always the baby putting pressure on your rectum.  Even if you end up passing some stool during the pushing stage, the rectal pressure you were feeling right before was NOT poop, it was the BABY and therefore you would have STILL felt intense rectal pressure even if you had emptied your bowels earlier!  However, if you are in early labor and you feel like you have to poop and you can easily pass stool without straining, then go ahead.  In early labor, it won’t hurt the baby or your cervix.  That being said…


#5 DON’T try to go into the bathroom during active labor or transition and “try” to have a bowel movement right before the pushing stage just because you are afraid of pooping during birth.  If you are in active labor/transition and you feel rectal pressure, please know that it is the BABY pressing on your rectum that is giving you that sensation.  Therefore straining to have a bowel movement during this time could at best, worsen your hemorrhoids and at worst, injure your cervix by causing it to swell or tear.  There is an appropriate time to start pushing, and many women tell me it is the best part (because they can actually do something about all that pressure!) but it is only time to push when your birth attendant gives you the okay. 


#6 DO make a pact with your labor companions (husband, partner, mother, sister, etc.) to NOT tell you that you are or did poop during your baby’s birth if you happen to be really self conscious about it.  The vast majority of the time the mother doesn’t even know that they did poop because the nurse, midwife, or doctor quickly wiped it away.  Trust me, as a nurse, you see it all the time and if vomit, pee, spit, poop, or blood bothered us, we wouldn’t be nurses, midwives, or doctors!


#7 DON’T ask for an enema/accept an enema before or during labor.  Please!  Given enemas to women in labor is an outdated and unnecessary practice. writes:

“A substantial portion of women in labor will have bowel movements, whether or not enemas are given,” especially during both early labor and pushing (Mahan and McKay 1983:247). Available evidence indicates that enemas do not in fact decrease the chances of elimination during birth nor the incidence of fecal contamination during labor, whereas they do often cause considerable pain and distress to the laboring mother (Romney and Gordon 1981; Whitley and Mack 1980). Moreover, the expulsion of feces during labor does not seem to increase infection rates: in a study of 274 birthing women randomly assigned to enema or no enema groups, no difference in infection rates was found (Romney 1981), and the risk of neonatal infection was very remote (seven babies from each group showed signs of infection which may or may not have had to do with bowel organisms). Another finding of this study was that the two groups had similar durations of labor, contradicting the notion that enemas shorten labor.”

Also as a side note, please don’t take Immodium AD before labor to “prevent” pooping!  It will at best, not work and at worst, make you constipated.


#8 DO remember that your body will probably “cleanse” itself out during “pre-labor”.  After all, mild diarrhea or loose stools can be a sign of “pre” or “early” labor.  And even if you do experience “pre labor diarrhea” you might still poop during delivery and that is okay!


#9 DON’T limit your food intake during labor if you are hungry because you are afraid that you will poop (or throw up for that matter).  A runner does not prepare for a marathon by starving themselves and you shouldn’t prepare for birth by starving yourself either.  Both you and your baby need energy to have the endurance for a successful vaginal birth.  If you aren’t hungry, well then that is different, and you should still be encouraged to drink at least 4 oz of water, juice, or Gatorade every hour.  If you are preparing for a normal vaginal delivery, even if you are being induced, you should not have to follow a “clears only” or “nothing by mouth” diet.  Good prenatal nutrition recommends women eat 6 small meals per day with frequent healthy snacks so why should we starve women during labor?  The answer is: we shouldn’t!!


If after reading all of the above you are still worried about pooping during delivery, then:


#10 DO realize that “WORRY is the WORK of pregnancy!”  In her book Birthing From Within, certified nurse midwife Pam England tells the story about a patient of hers (Hannah) that worried a lot about having a natural birth experience after having had a highly medicalized birth with her first baby.  She writes that Hannah longed to hear her say things like “Don’t worry” and “Everything will be alright” but instead England encouraged her to face her fears.  She instructed Hannah to write down all of her worries and explore each of them with questions like “What, if anything, can you do to prepare for what you are worrying about?” and “If there is nothing you can do to prevent it, how would you like to handle the situation?” 


England lists the “Ten Common Worries” of Pregnancy as:

1)      Not being able to stand the pain

2)      Not being able to relax

3)      Feeling rushed, or fear of taking too long

4)      My pelvis not big enough

5)      My cervix won’t open

6)      Lack of privacy

7)      Being judged for making noise

8.)      Being separated from the baby

9)      Having to fight for my wishes to be respected

10)  Having intervention and not knowing if it is necessary or what else to do


I would like to add #11:

            11) Fear of pooping in labor/Fear of embarrassment regarding bodily functions


In summary, if you are a pregnant mom reading this post, please know you are not alone in your worries!  Please use these next few months, weeks, or days, preparing not only physically, but mentally and emotionally for the amazing journey you are about to embark upon.  Please understand that getting ready for labor doesn’t just mean a tour of the hospital or learning about birth technology/interventions, but also means acknowledging and talking about your worries and fears with people you trust, especially your birth attendant!  No mother can give birth if she feels unsafe, senses danger, or has never explored her fears, even if they seem “trivial.”  Please know that although the thought of it might be “mortifyingly embarrassing,” when you actually are working hard to push out your baby, anyone that really cares about you and loves you will not be bothered by a little poop and most likely, you will not even notice it!  Please know that although birth might be one of the messiest experiences of your life, no amount of fluids, cursing, farting, vomiting, striping naked, howling, crying, peeing, bleeding, or pooping will take away from how honestly empowering, mind blowing, and touching this experience can be for you and your family J.


Top Ten Things Women Say/Do During Labor (And trust me… they are totally normal!) February 8, 2009

You’ve read about it.  You’ve talked about it.  You’re totally prepared for it…right?  Until it actually happens, no couple can be totally ready for what they will feel, say, and do during childbirth…especially when she gets to transition.  Transition, the shortest of the three phases of the first stage of labor, is the most intense as well as the most physically and emotionally demanding phase.  For those that have been planning a natural childbirth, it is also a time when many women want to change their birth plan and ask for pain medication.  The good news is that since transition is the shortest phase, when she finally gets to it (at about 8-10 centimeters) she is almost there!! 


The following is a list of the top ten things I have discovered to be very common among women working through labor, especially if she is doing it naturally!  If you have experienced or assisted someone through labor, you might remember these moments with a chuckle.  If you are about to embark on a natural birth, either personally or as a coach for your wife, partner, sister, daughter, niece, or best friend, my hope in writing this list is to alert you to these very thoughts, feelings, and actions that you/she will probably experience. 


It is easy to get scared when your loved one is in so much pain she wants to change her birth plan.  Not to say, of course, that a woman shouldn’t have that right.  There is a great chapter in the book The Birth Partner by Penny Simkin that describes this very phenomenon and suggests reviewing the “Pain Medications Preference Scale” and discussing the use of a “code word” before going into labor.  I highly recommend this book as part of your childbirth preparation.  However, if more couples knew about these thoughts, feelings, and actions, they might realize what their labor & delivery nurse, midwife, or doula already know…that she is acting totally normal!


10) “I don’t know how much longer I can do this!”

            Many L&D nurses are used to hearing this phrase typically as a woman begins the transition phase.  When you hear it, know that reminding your loved one of how much progress she has made and how little she has left to go will probably help her cope.  Many women mistakenly feel that if their labor took hours and hours to get to this point that it will take a comparable amount of time to get to the second (or pushing) stage.  Except in the rare case of arrested dilatation, this is NOT the case!  She is way more than half way there, in fact, she is almost done!


9) “I’m done!”

            Wanting to “give up” and just have it be over with is also a common desire of a woman going through natural labor.  It may be helpful to remind her that the pain she is in right now does not feel as bad as holding her baby will feel good!


8.) Throw Up/Burp Frequently

            Vomiting is a common sign of the transition phase, whether or not a woman has been eating throughout early labor.  Some coaches find this hard to handle.  Think of it as a way of “making more room” for the baby J.  In fact if something was rhythmically squeezing your insides, you would probably throw up too!  And let’s be honest, with a new baby around, you are bound to see a lot more throw up!  Since vomiting, like holding your breath or making a bowel movement, is a vagal response, it inadvertently helps your cervix dilate and hence, is a great sign to a labor & delivery nurse!  The body does awesome things to help the process along!


7) “No really, I have to poop!”

            As the baby descends further into the pelvis with each contraction, the pressure on the rectum becomes incredibly intense.  So intense, in fact, that it feels exactly like the need to have a bowel movement.  I can’t tell you how many times I explain to a patient who is in early labor that if she feel rectal pressure “like she has to poop” that she has to call me first and NOT just get up to the bathroom.  But time and time again when my patients begin to feel this pressure what doe they do?  They almost always get up and try to poop!  Many a woman I have found on the toilet straining to pass a BM and when questioned, try their best to convince me, “No, you don’t understand, I swear I have to poop!”  Okay, okay, if you had just eaten a meal and it was during early labor, I would agree.  But you are 8 centimeters now so TRUST ME!  It is the baby! (SEE: Top 10 DOs & DON’Ts of Pooping During Labor & Birth)


6) Shake/Tremble

            The hormonal rush a woman experiences during labor, especially natural labor, is overwhelmingly intense.  These hormones will cause all women to being to shake as they approach full dilation.  This shaking, in fact, continues for at least an hour post partum, even after a cesarean section or medicated labor.  Many partners and family members try to pack a woman with blankets to help her out only to find that she insists on not only ripping off the blankets, but sometimes even her clothes!  In reality, it is unlikely that she is cold and if you continue to ask her if she is, she will just start to get irritated with you.  It’s normal to shake, I promise J


5) “Can’t you just take/cut the baby out of me!?”

            Even the most level-headed, experienced mom can sometimes feel so out of control that she begs for a c-section.  Trying to rationalize with her is not going to make it better.  As an L&D nurse, both you and I know, as well as she, that a cesarean might seem like less pain now, but it is a hell of a lot more pain later!  It might be helpful to gently remind her that she is almost done and that everything she is doing to regain control of her breathing is helping the baby.  But please don’t try to reason with her…you are just going to upset her!


4) Cry

            Whenever a patient of mine begins to cry, my heart always starts to break.  It is at this moment that most L&D nurses, partners, and other birth coaches wish they could trade places with her, if even for a moment, to just give her a small break!  (Alas!  If only it was possible!)  If my patient begins to cry, I try to gently persuade her to save her tears for happy times when the baby is born and that crying is only going to give her a headache and make her feel more terrible. 


3) “Don’t touch me there/like that!”

            Many birth coaches are hurt to discover that the techniques that were working wonders in early labor only make their loved one upset and annoyed during transition.  In my experience the major culprit is rubbing her belly!  I know, I know…all the Hollywood movies show the father of the baby rubbing mom’s belly as she moans through her contractions.  Looks loving and almost romantic right?  WRONG!  (At least during transition anyways!)  To all the well intentioned fathers and birth coaches out there, my humble advice to you is this: unless she asks, don’t rub her belly…seriously, don’t!


2) Ignore You

            The only time I start to feel bad for the partners and labor coaching working with my patients is when their loved one starts to ignore them.  In reality, it is a fantastic coping mechanism!  Fact: Women often do not know what they want during transition.  They feel out of control and utterly uncomfortable in every way.  So when you ask her if she wants a sip of water or a cool cloth on her forehead or to change position what does she do?  She ignores you!  It is hard for me to explain that this is normal while in the labor room so since I have the opportunity now, I would like to let all birth coaches know that your loved one is no longer with us.  She is in her own world so she can make it through!  Hence don’t ask her any questions, especially silly questions!  My humble advice is to just do what you think will help and she will tell you otherwise if it is not working.  Many women can only talk in one work responses at this point anyways: “No!,” “Stop!,” “Drink!,” “Stronger!,” “Softer!,” “Oww!”  So just hold the straw up to her face; if she wants to drink she will!  If not, she’ll tell you!  And while I am on the subject, please don’t take offense if she is short with you.  Just do what she asks with an understanding smile and for the love of God please don’t sass her back!  She is, after all, having a baby!


1) “This is the last/only time I am going to do this!  No more babies for me!”

            If every labor and delivery nurse had a dollar for each time we heard a woman say this during labor, we could bailout this country single-handedly!  This comment makes me chuckle every time I hear it.  Let it be known that once she has that baby in her arms, she is going to forget all about the pain.  What she will remember is how well loved and supported she felt during the whole process.  And if you have done your job right, she is going to want a lot more kids someday!