Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

How one mom “Walked, moved around, and changed positions” to a successful hospital VBAC! October 23, 2009

Science and Sensibility’s Healthy Birth Blog Carnival #2Walk, move around, and change positions throughout labor

 

This month’s Healthy Birth Blog Carnival is “Walk, move around, and change positions throughout labor.”  This is a repost from a story I wrote back in March however, I feel like it is a really great example of how important movement and position changes are to a successful labor and birth, especially a vaginal birth after cesarean (VBAC)!  This story has been a popular posts with my readers in the past and I hope by participating in this blog carnival it reaches and helps empower more and more expecting women out there!!  In reposting this story I have highlighted all the times where Alyssa used upright positions and movement to cope with pain, help her uterus contract more efficiently, help her baby find the best position in her birth canal, use gravity to her advantage, and be an active participant in her labor!  And there is no doubt in my mind that all of these things helped her have a safe, positive and empowering VBAC experience!

 

 

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Last week I had the honor to be a part of one of the most beautiful VBAC(Vaginal Birth After Cesarean) hospital births I have ever witnessed. I would like to share that couple’s story with you today as both a feel-good tale of personal triumph and a story of inspiration for all those moms planning a VBAC out there that might stumble upon my blog. Since this is a blog about “a nurse’s view from the inside” this story is probably much different than any other birth story you might have read from the mother or father’s point of view. But then again, maybe that isn’t so bad! Enjoy!

 

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It was ten to 11 o’clock am as I walked through the lobby doors of the hospital I work at, rushing towards the elevator so I could punch in on time. As the elevator doors started to close, a hand shoved through the crack, forcing the doors back open. “Please make room!”said the woman, a phlebotomist who works in the hospital, in a shaky voice, “Woman in labor here!!”Following behind was a very pregnant woman, huffing and puffing as she waddled into the elevator, followed by what looked like her husband and her mother. “Don’t touch any buttons!”said the phlebotomist, “We’re going right up to labor & delivery!” Since that was where I was headed too, I smiled at the husband and said, “Don’t worry, you’re here now and she won’t have the baby in your car! I work up on L&D so I’ll show you were to register.” Something told me that if this woman was truly in labor then she would be assigned to me since I was just starting my shift. But she had to “pass” triage first, so after helping the family to the registration desk, I hurried into the locker room to change into my scrubs.

 

 

 Fifteen minutes later the triage nurse came to the main desk, “I’ve got a term mom, 40 weeks 5 days, who’s five centimeters,” she said, “We’re gonna need to put her in a room…. And she’s a VBAC with a ‘birth plan’.” “I’ll take her!,” I said excitingly, knowing that I have my bestdays when I can assist a woman through labor, as opposed to getting stuck on the OR team or in the high risk ward running magnesium. (Not that those women don’t need a lot of TLC too, it’s just that I like labor the most!) Birth plans, natural unmedicated labor, and getting my patients out of bed…those are my specialties!

 

 I quickly set up the room across the hall as the resident finished the patient’s history and physical in the triage room. Then I quietly knocked on the triage room door and let myself in. The patient, Alyssa*, was standing by the bed, rocking her hips back and forth, as the continuous monitors strapped to her abdomen traced the baby’s heart rate and her contraction pattern. It looked like she was contracting every 3 minutes, and the baby’s heart rate was beautiful and reassuring. Her husband, Jared, was leaning nervously against the wall and her mom, Deb, was sitting quietly in the corner. I could really tell that Alyssa was lost in “Laborland” and I wanted to make the transition to her room as seamless as possible as to not break her rhythm and concentration too much. I quietly introduced myself and with the help of Jared and Deb, moved all of their belongings across the hall as Alyssa waddled behind.

  

 I could tell that Alyssa was coping well with the contractions while standing but a quick glance at her prenatal summary revealed that she was Group B Strep positive and would need IV antibiotics (our hospital’s policy and the midwife’s order) and hence, and IV. Now I feel that I am pretty skilled at starting IVs, but I have not yet mastered starting an IV with the patient standing and swaying! So in the two minutes between the contractions, I explained to the Alyssa what I needed to do before the admission process was complete: get 5 more minutes of continuous monitoring on the baby (to equal the “20 minute strip” my hospital’s policy requires before we can switch to intermittent auscultation), take a set of vital signs, draw three tubes of blood, start an IV, and ask a few more questions. “Give me 8 minutes sitting on the bed,” I said, “and I can have everything but the interview done. The rest of the admission can be done with you standing up.” “Okay,” she said, “I can do eight minutes.” Eight minutes later the IV was in, antibiotic running, labs drawn and sent, vital signs done, monitors were removed, and the patient was helped out of bed (Phew!! That was close!! J). And it wasn’t a moment too soon because Alyssa was having a lot of back labor and sitting in bed was just making it worse!

 

 

 

Then there was a knock at the door. Here’s how the subsequent conversation went down…

 

Me: “Who is it?”

Med Student: “It’s just the medical student,” (said as he walked right into the room)

(I hadn’t yet gotten a chance to ask Alyssa if she was okay with medical students so I just kind of looked over at her and Jared and tried to judge their reaction.)

Med Student: “Hi I’m Michael. I have to ask you a few questions.”

(Have? How about “Is it okay if I ask you a few questions? Sheesh!!)

Med Student: “Are you being induced today?” (asked as he stared down at his paper)

Alyssa: “INDUCED! DOES IT LOOK LIKE I AM BEING INDUCED!”

Med Student:“Okaaaaay. Umm, any problems with this pregnancy?”

Jared: “Do you really need to ask these questions right now? The resident already asked her that stuff.”

Med Student:“Umm yeaaaah, I do. There is a lot of repetition but we have to ask again.”

Deb: “Doesn’t her prenatal summary tell you all of that?

Med Student: “Ummmmm….”

Me: “With all do respect, Michael. But I think they are trying to tell you that they do not want any medical students. Or anymore residents for that matter. Okay? So I think we are done here.”

Med Student:“Ummm, what am I supposed to tell the resident?”

Me: “Tell her I said that the next induction that comes in is all yours.”

 

As the med student left, Jared, Deb, and Alyssa all looked at me simultaneously and said “THANK YOU!” “I don’t think he was getting the hint,” said Jared. “Yeah,” I said, “I figured he needed it spelled out.” In hind sight, I think this was one of the moments that really helped me to bond with this family because after all, I understand how difficult it must be for families to come into the hospital and have to work with a nurse that they have even never met during one of the most intimate experiences of their lives!

 

I spent the next fifteen minutes finishing up the patient’s admission assessment as quickly as I could. I told Alyssa that if she was having a contraction to just ignore me, and asked Jared to help answer any questions he knew the answers to. (Unfortunately, our hospital’s pre-registration does not include performing an admission assessment and hence, it has to be done on arrival to the hospital. Usually, if a patient comes in for false/early labor a time or two, it gets done then but Alyssa had not been to the hospital her whole pregnancy, which is great, but it meant that I did have to bother her with some silly questions during labor. Kind of a bummer, but with the help of Jared, it went pretty smoothly.) It was during the admission interview that I found out some of the details of Alyssa’s pregnancy and prior cesarean section. Alyssa had an unremarkable health history and a normal, healthy, uncomplicated pregnancy. She was a G2P1, but since her first baby was born by cesarean section, she technically was considered to be a “primip” (healthcare slang a woman who is about to deliver her first baby) regarding a vaginal delivery.

 

Jared told me that when their son was born two years ago, Alyssa was persuaded into an induction at 39 weeks for “LGA” (a.k.a. large for gestational age, which by the way is NOT recognized as an appropriate indication for induction of labor by ACOG), was first given a few doses of misoprostol to “ripen” the cervix, followed by pitocin to stimulate contractions and continuous external fetal monitoring to monitor those contractions, then given a couple doses of Stadol and eventually an epidural for the pain, followed by artificial rupture of membranes to place a fetal scalp electrode after the epidural dropped Alyssa’s blood pressure and caused a prolonged fetal heart rate (FHR) deceleration, then an intrauterine pressure catheter to assess if the pitocin induced contractions were “adequate”, and eventually a cesarean section after 1 hour of pushing in a back-lying position for “failure to descent & cephalopelvic disproportion (CPD).” Thirty minutes later baby Kevin was born at approximately 2:00am, weighing in at 7lbs, 5 oz.

 

In my opinion, Alyssa was a victim of the “cascade of interventions.” Many maternity interventions, including elective induction, pain medication, artificial rupture of membranes, epidural anesthesia, back-lying positions for labor or for birth, etc. have unintended effects. Often these effects are new problems that are “solved” with further intervention causing a domino effect that ends up creating yet more problems. This chain of events has been called the “cascade of intervention” and unfortunately often leads to vacuum extraction/ forceps delivery, episiotomies or 3rd or 4thdegree tears, and even cesarean section. Many of these women are often also then mislabeled with diagnoses like “CPD,” “failure to progress,” “failure to descent,” and at the end of it all, the obstetricians turn around and say, “Thank God we were in a hospital; look at all the technology we needed! So when will your repeat cesarean be??”

 

This time, however, things were different. After the birth of their son, Alyssa and Jared started to research more about labor and birth, VBAC, and natural birth. They interviewed and chose a doctor (Dr. Z) that was supportive of natural birth and VBACs, with the statistics to prove it! And here they were now, at my hospital, ready and rearing to go! Alyssa said that for the past few days she had been having contractions “on and off” but that they really started to get going at 8:00 am. When the resident had checked her on admission, her water spontaneously broke during the vaginal exam at 11:15am. It was now 11:45am and Dr. Z’s midwife entered the room. Although it had only been 30 minutes since her last vaginal exam, the midwife decided she would check Alyssa again since she seemed pretty active. And boy was she ever! The midwife’s exam showed that Alyssa had progressed to 7-8 centimeters! “I don’t think I can do this anymore,” Alyssa softly whimpered to the midwife. We all reassured her that she was doing so well and that things were getting more intense for a reason and to stick with it!!

 

The midwife then offered to help Alyssa into the shower to help alleviate her back pain. Alyssa seemed skeptical at first but we assured her that if it wasn’t helping, that we could get her right back out. So Alyssa agreed and the midwife and I, along with Jared, helped the patient into the shower. What happened for the next hour was one of the most beautiful displays of love, perseverance, hard work, and dedication I have ever witnessed. Alyssa turned her back to us and rested her hands on the grab bar on the shower and her head on the shower wall. Her cadence was this: Between contractions she would sway side to side, as if she was slow dancing. During contractions she would squat up and down, up and down, moaning in a low tone as she carried out her ritual. She just moved with the rhythm of her labor, listening so instinctively to what her baby and her body were telling her to do.Jared used the hand held shower head to spray Alyssa gently with a stream of warm water up and down her body, concentrating mostly on her lower back. I quietly entered the bathroom a few times that hour to check the baby’s heart rate with the portable doptone, trying hard not to disturb Alyssa’s concentration. Mostly, however, the midwife, her mother, and I stayed outside the bathroom door as to give Alyssa & Jared the privacy they needed to facilitate the progress of her labor.

 

At 12:35pm Alyssa told me that she was starting to feel a strong urge to push. The midwife entered the room and as Alyssa knelt in a hands and knees position in the tub, the midwife checked her cervix. To everyone’s surprise Alyssa only had an anterior lip of cervix left to go (this means she was about 9 ½ centimeters dilated)! After the next contraction, Jared and I helped Alyssa out of the shower to the toilet where we both used warm towels to dry her off. Then Alyssa walked over to the bed, “Can I kneel on my hands and knees?” she asked. “Sure!” we all said in unison, as we helped her up onto the bed. “I feel like I have to push!” Alyssa said convincingly and when the midwife checked her cervix, the anterior lip was gone…Alyssa was fully dilated at 12:45pm, only 1 hour and 55 minutes after arriving at the hospital! “You can start to push anytime,” said the midwife.

 

One of the best things about being a part of this experience was the fact that it was one of the only times that I have been present at a delivery where that a birth attendant has allowed the mother to use spontaneous or mother-directed pushing, as opposed to directed pushing. I knew that Alyssa was interested in using a variety of pushing positions for the second stage of labor from her birth plan and for the next hour and a half the midwife, Jared, Deb, and I helped Alyssa get into a variety of positions including right/left side lying, squatting, hands and knees, and kneeling.

 

(Side Note: I would like to digress for a moment to point out how important it is to be physically fit during your pregnancy whether you are planning for a natural birth or not. Many a woman I take care of blindly fills out a “birth plan” they find online where they can click on the boxes for options that sound “good” to them, without actually researching or thinking over what they are writing down. For example, they say that they want to try squatting during labor and birth, but couldn’t even do a squat at the gym pre-pregnancy. Although it is definitely true that a woman can sum up and realize an incredible amount of strength during labor and birth related to not only hormones but also sheer will power, it should also be known that labor is HARD WORK and pushing out a baby is HARD WORK which both require a great deal of physical strength and stamina. This is yet another reason why it is so important to follow a modified exercise plan and eat a healthy well balanced diet rich in protein and omega-3 fatty acids before, during, and even after your pregnancy.) Let’s continue with Alyssa’s story…

 

What was so amazing was that although there were plenty of times during the labor and pushing phase that Alyssa would doubt her ability to go on (“I can’t do this anymore!” “The baby isn’t moving?” “Is the baby moving?” “I am so tired!”), she never gave up on herself. Each time she made a comment like that, we all took it as a request for more support. And every time we gave her more encouragement, cheers, and reminders of her progress and goals, (“Keep going!”, “You are doing so well!”, “We can see so much more of the baby’s head!”, “She has lots of hair!”, “Just a few pushes more”, “You are so strong, you are going to do this!”, “You can do this!”), she found the ability to keep going! Towards the end of the pushing stage Alyssa was (understandably) exhausted and was pushing in a modified lithotomy position while Jared and I supported both of her legs. Then all of a sudden Alyssa popped up and said (and I quote)…

 

“I need GRAVITY! I need to be UP!” as she sat upright into a full squat and

PUSHED her baby’s head out with one gigantic ROAR!

 

“Whoa, whoa!” the midwife and I said almost simultaneously, “Easy, easy, baby pushes.” “Blow like you are blowing out birthday candles,” I said. The midwife checked for a cord around the neck (which there was none) and cleared the baby’s mouth and nose. And with only a few more “baby pushes” Addison Joy was born at 2:27pm!

 

The room erupted into cheers of excitement and tears of happiness! I put the baby skin to skin on mom as I dried her off with warm blankets and cleared her mouth and nose with the bulb suction. A quick palpation of the baby’s cord revealed that her heart rate was nice and strong and she was pinking right up! Jared and Alyssa kept hugging and kissing each other and talking to their new baby girl, “Hi Addison! Hi baby girl! I am so glad to finally meet you!”  The midwife waited until the cord stopped pulsating before she cut it (per mom and dad’s birth plan) and then checked Alyssa for any tears. Except for some swelling, she only had a small tear on her right labia that didn’t even require any stitches!! We kept mom and baby skin to skin for a full hour after birth and baby Addison nursed almost the whole time. When she was an hour old, I weighed her to satisfy mom’s curiosity and to everyone’s surprise the baby weighed 9 lbs 3 ozs!!!

 

So much for “cephalopelvic disproportion” huh!!

 

And it was as I handed baby Addison back to Alyssa that she looked up at me and said softly, “I needed to know my body could do it. I knew my body could do it! I really needed this. Thank you.” So as you can imagine, I started to well up. I have never felt so honored to be a part of something so special. What a privilege to have a job where I witness the miracle of birth and the miracle of motherhood every week!

 

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So let’s recap shall we. Alyssa, after having a cesarean section for her 7 lb 5oz son two years earlier for “CPD” and “failure to descent”, pushed out a 9lb 3oz baby after a 6 hour and 27 minute labor, including 1 hour and 42 minute of mother-directed pushing, without any pain medications or an epidural, monitored by intermittent auscultation, needing not a single stitch to her perineum! Her tools included good and relevant labor & birth preparation, appropriate and helpful family support, sheer strength, determination, and will power. The midwife’s arsenal included extensive knowledge of and experience with natural birth and labor support, a doptone, a trust in birth, and a belief in Alyssa’s ability to do it! No medications, no vacuums, no scalpels, no scissors, and no doubt!

 

Boy how I love my job sometimes 🙂

 

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*As always, names and any identifying information have been changed to protect privacy.

 

For more information on VBAC please visit: International Cesarean Awareness Network and Childbirth Connection

 

For more information on how you can move and groove through your labor check out: 

  • The Healthy Birth Practice Paper, written by Teri Shilling, MS, CD(DONA), IBCLC, LCCE, FACCE
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  • The Healthy Birth Your Way handout on movement in labor(PDF), produced by Lamaze International and InJoy Birth & Parenting Videos
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  • Companion tip sheets, “Maintaining Freedom of Movement” (PDF) and “Positions for Labor” (PDF)
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    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.”)

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    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

     

    No Doula in the Name of Privacy? Oh Come On! September 26, 2009

    This comment was recently left by a reader named Jessica under one of my older posts.  Since I read every comment that is posted on my blog I happened to stumble upon it this morning.  When I read it I couldn’t help but think “I Hear Ya Sister!!!”and felt that it was so well stated that it needed to be its own post!  I know that there are quite a few doulas out there that read my blog and I just wanted to take this opportunity and give a shout out to them all and say thank you for all you try to do to educate women before they get to me on L&D!  Unfortunately, they don’t all listen but I hope you know that there is at least one L&D nurse out there that appreciates your efforts, both before and during labor!!!

     

    For all you expecting moms out there please check out DONA’s website to learn a bit more about what a doula is, how you can find one, the effects a doula can have on your birth outcome and experience, and how a doula can advocate for you!

     

    And just for the record, there is NOTHING private about a hospital birth experience.  Even in the most well meaning hospitals with the most well meaning birth attendant and the most well meaning nurse(s).  Albeit some women’s hospital births might be more private than others and I personally have had the priviledge to be a part of a few totally amazing hospital births.  But to not hire a doula for your hospital birth (especially at a university hospital!) because you want a “private” experience is a very VERY naive and misguided idea!  I am not saying that to hurt anyone’s feelings and I am certainly not judging anyone out there who decided not to hire a doula for one reason or another.  I am just telling it like it is.  Some food for thought…

     

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

     

    Hi NursingBirth!

    I am a certifying doula and have recently had an interview with a perspective client. She is 36wks pregnant with her first. She was strongly considering a doula, but everyone else in her family was on the fence, and pushing a “private” birth experience. However, they are planning a delivery at a university hospital, she has yet to see the same health care provider throughout her prenatal care, she has no idea which one will be at the birth, or if it will even be someone she has met. They are planning a natural birth. She assured me that the hospital she is birthing at offers a multitude of birth options, including water birth, birth ball, position changes, etc… and the childbirth education from the hospital has given them confidence in their ability to get what they want from this birth. After much “deliberation” they decided that they were not going to hire a doula, based solely on their confidence in the hospital to give them what they want, and their desire for privacy. While I can completely respect their privacy request, I fail to see how birthing in a university hospital will give her much if any privacy…AND if she doesn’t even know who will be her health care provider at the birth…how is she confident that the hospital will give her what she needs? I wish there was some way to help open her naive eyes to the reality of birth in hospitals today. Her chances of getting to work with a mother friendly doc that understands and respects natural birth have got to be low! Reading your blog was comforting (because I know there are others who struggle with this) and depressing(because we have to struggle with this). I don’t want to have her hire me for her VBAC next time around. I want her to have the birth she desires now. I realize there isn’t much I can do for her at this point, which is why I am here, leaving my frustration with a bunch of like minded individuals. I am hoping things will go well for her and in the mean time, I’ve let her know that I am and will be available until the baby is born. just in case. Thanks for the space to rant.

      

    Sincerely,

    Jessica

      

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    Jessica, you can rant here anytime!!!  I Hear Ya Sister!  Loud and clear!!

     

    And now I leave you with one of my FAVORITE Monty Python skits of all time.  I have seen it a million times but it is still as hilarious (and eerily true) each time I see it.  Notice how the doctor invites in an army of people to watch.  It often feels like that where I work no matter what I do!!!

     

     

    Believe! A Tear-Jerkin’ Inspirational Midwifery Ad September 4, 2009

    The other day I stumbled upon a YouTube video advertisement for a midwife in Albuquerque, New Mexico via a friend’s facebook page.  You’d think that I must get sick of watching videos of births and babies since I am, after all, a labor and delivery nurse but alas, I am a true birth junkie and just can’t get enough!!  I don’t know anything about the midwife in the movie but I have to say that not only do I BELIEVE everything she quotes in the video but I wish that every health care professional that provides care for childbearing familes felt and practiced the same way as she does! 

     

    I believe that every mother DESERVES a midwife and that every baby DESERVES to be born into gentle hands!

     

     

     

    The following is from Citizens for Midwifery:

     

    The Midwives Model of Care

    The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes.

    The Midwives Model of Care includes:

    • Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
    • Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
    • Minimizing technological interventions
    • Identifying and referring women who require obstetrical attention

     

    The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.

    Copyright (c) 1996-2008, Midwifery Task Force, Inc., All Rights Reserved.

     

    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:

     

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

     

    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

     

    The Deal with Delayed Cord Cutting or “Hey! Doctor! Leave that Cord Alone!” May 17, 2009

    Recently I have received a few emails/comments asking me about the pros/cons of delayed cord cutting.  Delayed cord clamping/cutting is the process of waiting until the umbilical cord stops pulsating (approximately 5 minutes) and/or waiting until the placenta is delivered (approximately 30 minutes) before the cord is cut after the baby is born.  In today’s hospitals, obstetricians typically wait no longer than 30 seconds after the shoulders are delivered before they clamp the cord.  Why such a short time?  Author Tina Cassidy in her book Birth: The Surprising History of How We Are Born sheds some light on the subject:

     

    “Throughout history, the immediate postpartum period has been as much a victim of fashion and misconception as has labor and birth.  And standard practice still varies among countries, hospitals, doctors, and midwives. 

     

    The first act that usually occurs after the slippery baby emerges is the cutting of the umbilical cord.  …The act also forces the newborn to breathe air through its lungs for the first time.  Perhaps because of the symbolism of that moment, cord cutting has been a magnet for drama, ceremony, and superstition.

     

    In most hospitals today, cutting the cord is such an uneventful routine that it can pass unnoticed by the overwhelmed mother.  Doctors generally wait about thirty seconds a time period long enough, they believe, for the baby to receive all the blood it needs from the placenta.  …They then apply two clamps, break out the scissors, and often ask the father if he wants to cut between the ligatures.  Doing all of this quickly also allows for the baby to be suctioned, weighed, and swaddled, before it gets cold.  

     

    Some childbirth experts argue that, rather than being guided by a clock, it’s best to wait until the cord stops pulsing before cutting, allowing the baby to receive all the blood it was meant to receive from the placenta.  They say it helps the mother as well, because the placenta shrinks as it pumps out extra blood, making it easier to deliver.”

     

    Penny Simkin, author of the book The Birth Partner, also writes about this subject:

     

    “The cord is often cut immediately, but a recent scientific analysis has found benefit to waiting for at least two minutes or until it stops pulsating—in five minutes or so.  Less likelihood of anemia for as much as six months exists in babies whose cords are cut late.  Until the cord is clamped or stops pulsating, blood passes back and forth between the baby and the placenta.  It goes from placenta to baby when ever the uterus contracts, squeezing blood from the placenta through the umbilical cord to the baby.  Between these contractions, with each beat of the baby’s heart, blood is pumped from the baby through the umbilical cord and back to the placenta.  This transfer stops when the cord is clamped or stops pulsating, which occurs when the blood vessels close down.  The best way to make sure that the baby has the right amount may be to place the baby on the mother’s belly and wait for the cord to stop pulsating.  Exceptions to this are when the baby needs immediate medical attention, when the cord is tightly wrapped around the baby’s neck, preventing delivery, and when you have decided on cord blood removal and storage.”

     

    So what can we take from these quotes?  I believe we can take the following two things:

     

    #1  Immediate cord cutting is very convenient for today’s hospital staff and birth attendants.  It allows for the birth attendant to begin inspection of the mother’s perineum and stitching up of any episiotomy or tear that may have occurred (or was cut) during delivery.  It also provides an opportunity to use a sponge stick to provide traction on the placenta (a.k.a. slight tugging) to “assist” the placenta in detaching (Note: The majority of obstetricians do this as it is part of “active management of the third stage” which is predominately and widely taught in medical schools and residency programs across the U.S.)  When the cord is cut soon after delivery, it also allows for the nurses/pediatrician to take the baby away from the mother (either in or outside of the room) and weigh it, tag it, footprint it, give it medications like vitamin K shot and erythromycin eye ointment, and swaddle it. (Note: If you think that sounds assembly line-ish, your right!  These practices are based on a desire for modern maternity hospital wards to increase their efficiency!)  Typically mothers are told “Oh this won’t take very long!  You’ll have the next 18 years to spend with your baby!  It’s too hard to hold the baby and get stitched up anyways!  We’ll give her right back…promise.”  I would like to add that it is my personal philosophy that any practice that is done solely or mainly for obstetrical convenience and not for the safety or wellbeing of the mother or baby is a practice that should be re-thought or abandoned!

     

    #2  The placenta does not stop working when the baby is born.  In addition, blood continues to flow from the baby to the placenta and back again making the claim that the baby will get “too much blood” a physiological fallacy especially if the baby is placed on the mother’s abdomen skin-to-skin above the level of the placenta which assures that blood will continue to flow, but not to excess.  (Unless, of course, the cord is milked, and by that I mean the practitioner puts the cord between his thumb and forefinger and pushes all the blood in the cord into the baby and then clamps it, a practice which is both outdated and harmful in the fact that it will most surely lead to neonatal jaundice.  This old-school practice of “milking” the cord is probably where delayed cord clamping inaccurately got its bad reputation!) 

     

    In my quest for more knowledge on this topic I stumbled upon a YouTube video entitled Better Birth VA – We Can Be Much Kinder” produced by L. Janel Martin. 

     

     

    This video was created in part for the Birth Matters Virginia Video ContestIt is a fascinating video that interviews a variety of midwives/obstetricians including:

     

     

    This list of birth attendants, both obstetricians and midwives, are practitioners who are in support of delayed cord cutting.  More research into their backgrounds and practice revealed to me that they all believe in, work within, and support a midwifery model of maternity care, a woman-centered model that has been proven to reduce the incidence of birth injury, trauma, and cesarean section and promote empowering, positive birth experiences for childbearing families. 

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    Let’s take a moment to learn a little bit more about the research that SUPPORTS delayed cord clamping/cutting:

     

    • Delayed Umbilical Cord Clamping Boosts Iron In Infants (2006): A report of a study conducted by UC Davis nutrition professor Kathryn Dewey that revealed a two-minute delay in cord clamping at birth significantly increases a child’s iron status at 6 months of age.  This study documented for the first time that the beneficial effects of delayed cord clamping last beyond the age of 3 months.

     

    • Early versus delayed umbilical cord clamping in preterm infants (2004): A Cochrane review (considered the “gold standard” of research and evidenced based practice) of studies on babies born prematurely which revealed that delaying cord clamping for greater than 30 to 120 seconds, rather than early clamping as is the current obstetrical practice, seems to be associated with less need for transfusion, less intraventricular haemorrhage, and helped the babies adjust to their new surroundings better.

     

    • Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes (2008): A Cochrane review that showed no significant difference in postpartum hemorrhage rates when early and late cord clamping were compared. The review also reported growing evidence that delayed cord clamping confers improved iron status in infants up to six months after birth, with a possible additional risk of jaundice that requires phototherapy.  (It is important to note however that the act of placing the baby on the mother’s abdomen skin-to-skin above the level of the placenta assures that blood will continue to flow, but not to excess.)

     

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    So let’s break it down shall we?!

     

    The PROS of Delayed Cord Clamping/Cutting

    (This list was written by Marie Berwald, a certified HypnoBirthing practitioner and Yoga instructor from Canada, for a post entitled “Late vs Early Clamping of the Umbilical Cord in Newborn Babies” on her blog Birth Bliss.  Marie supports each one of these points with research so please check her blog out!)

     

    1) The blood in the placenta rightfully belongs to the baby, and babies not receiving this blood have the deal with the equivalent of a major blood loss or hemorrhage at birth.  It is estimated that early clamping deprives the baby of 54 to 160 ml of blood, which represents up to half of a baby’s total blood volume at birth.

     

    2) There is a significant amount of iron in the cord blood which the baby needs for optimal health and for the prevention of anemia.

     

    3) Babies benefit from the increased oxygen available to them from the cord-blood when the taking these first few breathes.  The earlier the cord is clamped, the more likely the incidents of respiratory distress.

     

    4) The blood that babies receives through the cord after birth acts as a source of nourishment that protects infants against the breakdown of body protein.

     

    5) As an added bonus, delayed cord clamping keeps babies in their mother’s arms, the ideal place to regulate their temperature and initiate bonding and breastfeeding.

     

    The CONS of Delayed Cord Clamping/Cutting

     

    1)     May increase the baby’s risk for jaundice, a condition that many newborns develop related to the baby’s immature liver that cannot process bilirubin, a yellow byproduct of the breakdown of old red blood cells.

     

    It seemed to me that the PROS of delayed cord clamping outweigh the CONS however I feel that it is important to explore the subject of newborn jaundice more…that is, Is it something that parents should be worried about?  Is it serious enough to trump all of the research supported benefits of delayed cord clamping? 

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    The answer to my question came from one of the obstetricians featured in the YouTube video featured above, Dr. Sarah J. Buckley.  In an article entitled, Leaving well alone: A natural approach to the third stage of labour  Dr. Buckley writes,

     

    “Early clamping has been widely adopted in Western obstetrics as part of the package known as active management of the third stage. This comprises the use of an oxytocic agent- a drug that, like oxytocin, causes the uterus to contract strongly- given usually by injection into the mothers thigh as the baby is born, as well as early cord clamping, and ‘controlled cord traction’- that is, pulling on the cord to deliver the placenta as quickly as possible.

     

    While the aim of active management is to reduce the risk of haemorrhage for the mother, ‘its widespread acceptance was not preceded by studies evaluating the effects of depriving neonates [newborn babies] of a significant volume of blood.’

     

    Some studies have shown an increased risk of polycythemia (more red blood cells in the blood) and jaundice when the cord is clamped later. Polycythemia may be beneficial, in that more red cells means more oxygen being delivered to the tissues. The risk that polycythemia will cause the blood to become too thick (hyperviscosity syndrome), which is often used as an argument against delayed cord clamping, seems to be negligible in healthy babies.

     

    Jaundice is almost certain when a baby gets his or her full quota of blood, and is caused by the breakdown of the normal excess of blood to produce bilirubin, the pigment that causes the yellow appearance of a jaundiced baby. There is, however, no evidence of adverse effects from this mild jaundice.  In fact, jaundice, which is present in almost all human infants to some extent, and which is often prolonged by breastfeeding, may be beneficial because of its powerful anti-oxidant properties.

     

    Early cord clamping carries the further disadvantage of depriving the baby of the oxygen-rich placental blood that Mother Nature provides to tide the baby over until breathing is well established. In situations of extreme distress- for example, if the baby takes several minutes to breathe-this reservoir of oxygenated blood can be life saving, but, ironically, standard practice is to cut the cord immediately if resuscitation is needed.”

     

    I encourage you to read the full text of Dr. Buckley’s article on her website as she not only talks more about the benefits of delayed cord clamping, but she also supports all of her arguments with research.

     

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    Are you interested in delaying cord clamping during the birth of your baby?  If you are, know that the research supports you!  If your birth attendant states that she/he does not usually practice delayed cord clamping/cutting but doesn’t automatically shoot the idea down, as her/him if she would be willing to learn more about it.  On the other hand be weary of any birth attendant that discourages this practice, tries to talk you out of it, or outright refuses to participate.  This could be a red flag that she/he will not be wiling to support any other desires in your birth plan.  A regular visitor to my blog recently wrote me this email:

     

    Dear NursingBirth,

     

    I belong to an online birth club and a fellow mom wrote this post the other day:

     

    “I met with my obstetrician yesterday for my 32 week appointment and brought my birth plan with me.  She looked over it and proceeded to tell me all these issues with it…  I want to have a natural/med-free childbirth and mentioned if the labor wasn’t progressing I would like to try nipple stimulation or breaking my water first. She told me no, this it is bad for the baby, and that pitocin is less bad for the baby.  I want to let the baby’s cord finish pulsating before cutting it… she said absolutely not, because it increases the risk for jaundice. Then at the end of the appointment she walked out and I over heard her talking to a nurse about all the issues with my birth plan and how I must have just copied and pasted stuff from the internet.  Maybe I’m being overly sensitive, but it just seemed a little harsh and awkward.  What would you guys do?”

     

    Everyone has been writing back to her that she needs to consider finding another doctor but she seems reluctant because she is already 32 weeks along and has had this doctor for her entire pregnancy.  What do you think?

     

    Sincerely, 

    Concerned Friend

     

    My thoughts….this is a RED FLAG to walk right out of that doctor’s office and never look back.  This doctor CLEARLY does NOT practice evidenced based medicine.  Is switching birth attendants during the last few weeks of pregnancy a hassle and nuisance that a mother should not have to go through on top of all the other stresses she is probably experiencing?….ABSOLUTELY!  But is it absolutely imperative that she still switch practices even though it sucks big time….YOU BET IT IS!  I hope that any mother that finds herself in a similar situation truly understands the risk of staying with a birth attendant that does not support her birth plan just because she don’t want to a) hurt anyone’s feelings, b) think she can still have the birth you want without her/his support, c) go through the hassle of finding a new attendant (trust me, I know it is a huge hassle). 

     

    The bottom line for me is this:

     

    IT’S YOUR BIRTH!!  YOU ARE ONLY GOING TO BE GIVING BIRTH TO THAT CHILD/CHILDREN ONCE IN YOUR WHOLE LIFE!!  YOU, NOT YOUR BIRTH ATTENDANT, ARE THE PERSON THAT IS GOING TO HAVE TO LIVE WITH THE CONSEQUENCES OF A BIRTH THAT IS CONTROLLED BY SOMEONE ELSE!!  YOU HAVE THE RIGHT TO HAVE THE POSTIVE, EMPOWERING, SAFE, AND HEALTHY BIRTH THAT YOU DESIRE!!

     

    For help writing a birth plan please check out: