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

      

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

     

    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!!!

     

     

    The WORST Idea Since Routine Continuous Fetal Monitoring for Low Risk Mothers September 7, 2009

    My husband (being the techie cutie that he is) reads CNET news, a website about computers, the Internet, and groundbreaking technology as part of his morning routine.  The other day, while I was enjoying my Kashi cereal and checking out the latest blog posts on my Google Reader, my husband hollered over to me from his office and said,“Hey Melissa, have you heard of LaborPro?”  Until that moment I was having a pretty good Sunday morning.  I mean, I woke up refreshed and smiling, the sun was shining, and I was looking forward to what I felt was going to be a “good” day at work.  But my attitude quickly turned from happy-go-lucky to blinding rage when he uttered those eight little words. 

    (Okay, okay, so I think I am being a bit dramatic.  Maybe blinding rage is a bit strong.  But I was pretty upset!!)

    So what is LaborPro and why did it put me into such a tizzy you ask?  According to Trig Medical’s website (the Israeli company that is developing and recently won a Frost & Sullivan Technology Innovation of the Year Award for this GARBAGE), LaborPro is “a novel labor monitoring system that using ultrasound imaging measures continuously and objectively fetal position, presentation and station along with cervical dilatation. LaborPro quantitatively assesses and records vital labor parameters in real-time to enable obstetricians to make informed and accurate decisions throughout the labor process to improve both the quality and cost of obstetric care.”

     

     

     

    The website lists LaborPro’s capabilities as able to:  

    • Determine continuous station & position of fetal head by ultrasound imaging,
    • Provide radiation-free pelvimetry & birth canal modeling.
    • Perform one-step computerized “non-invasive” trans-vaginal digital examination (I’ll touch on that in moment)
    • Determine intermittent or continuous accurate measurement of cervical dilatation
    • Record comprehensive labor data recording

     

    It also toutes its “unique benefits” as the following: 

    • Non-invasive, precise measurement of station & position
    • Improves assessment of non-progressive labor
    • Supports decision-making before operative delivery
    • User friendly, on-screen display of all labor parameters
    • Enhances patient comfort and sense of security

     

    Okay okay okay….Just HOW does it do this you ask?  Well it’s EASY!  (*rolling eyes*)  Well according to the website’s one mintute educational video (check it out here, it’s worth it).  FIRST you have to place “just four little electrodes” externally on the mother’s pelvis in order to continuously assess fetal station and position and also enables the user to “recognize CPD early”.  SECOND you just have to clip (or screw) “just a few position sensors” to the woman’s cervix to accurately and continuously measure cervical dilation.  And THIRD you just have to screw “just a small little electrode” into the baby’s head.

    Fetal Scalp Electrode  (notice the little corkscrew tip)

    Close up of a fetal scalp electrode, or FSE (notice the little corkscrew tip, that screws into the baby's scalp.)

    According to Frost & Sullivan, the organization that awarded Trig Medical for the LaborPro technology writes, “The LaborPro is staff and mother-friendly and requires only basic training in ultrasound usage, obviating the need for an obstetric ultrasound expert,” adds Ms. Prabakar. “Moreover, the technology employs non-invasive, radiation-free pelvimetry as well as a single-step computerised digital examination. All labor progress tracking data including the fetal heart rate monitor are integrated in the LaborPro display and automatically recorded by the system, which helps reduce staff workload.”

     

    Oh great!  We only need “basic ultrasound skills” to work it!  (*double eye rolling*)  Here’s a novel idea!  How about every hospital (including my own) in the United States that has a L&D floor actually provide labor support training to their nurses instead!  That would go a lot farther for us than freaking ultrasound skills!! 

    (Just for the record, my hospital does NOT include labor support training as part of orientation and we are NOT alone.  At my hospital, if you want to learn how to provide labor support you have to seek out other learning opportunites on your own, like I had to.  But we do get extensive training on how to work and interpret the fetal monitor.  Oh and about 1/3 of our three month orientation is dedicated to learning how to care for a patient who is being induced.  In fact, I had to teach myself how to do intermittent auscultation and hence, I am one of the only nurses that I work with that isn’t “scared” of intermittent auscultation and will actually advocate for it!) 

    The most terrifying thing is that although at this time LaborPro is not available in the United States (Oh Hallelujah!!!) there is another company called Barnev based out of Andover, MA that has developed an almost identical product they call BirthTrack™ Continuous Labor Monitoring System which they describe as “a revolutionary continuous labor monitoring technology that provides obstetric caregivers invaluable, precise, objective, real-time information about the physical progress of labor. The BirthTrack System provides tools for a more informed decision making process through which hospitals can reduce the risks and costs of childbirth and assure the safety and comfort of mothers-to-be and their babies.”  I remember hearing about this product a couple of years ago when it was still in “development.”  Well guess what?!  Development is over!!  Marketing here we come!!  (GAG me!)

     

    So now there are at least TWO companies that are actively marketing this HORRIFIC, INHUMANE, and OUTRAGEOUS product.  Just wait  until LaborPro makes it to the United States (which according to their website they are actively persuing).  Then they will probably start to compete with eachother!  Now now only will labor & delivery wards around the country have to deal with Similac and Enfamil representatives competing for our money and attention in house (which already makes me sick to my stomach), but now I have to worry about this??!!  THIS IS TERRIFYING!!!

     

    I’m telling you right now, I will UP AND QUIT my job and never look back if either LaborPro or BirthTrack EVER  appears in even just one, JUST ONE of my hospital’s labor rooms.  QUIT ON THE SPOT!  And I will make a Hollywood exit too!  A HUGE scene!!!  Hooting and hollering!  You just wait!!  LOL!  As if our moms aren’t already strapped down enough with the often unnecessary and sometimes downright harmful technology we already have.  This is just TOO MUCH TO BEAR!

    I have taken care of MANY a laboring woman (often as a result of an induction, mind you) who are connected to:

     (1)  an IV line with IV fluids and Pitocin running through,

    (2) an electronic fetal monitor to measure fetal heart rate,

    (3) a tocodransducer to measure contraction pattern

    (OR a fetal scalp electrode to measure fetal heart rate and an intrauterine pressure catheter to measure contraction frequency and strength),

    4) an epidural catheter in the back giving a continuous flow of anethetic and narcotic medications into the spinal column,

    (5) a foley catheter in the bladder since it is very rare that one can empty their bladder with an epidural,

    (6)  a pulse oximeter to continuously measure blood oxygen level (necessitated by the epidural),

    (7) a blood pressure cuff to record one’s blood pressure every 15 minutes since an epidural can drop your blood pressure dangerously low, and finally

    (8) if the baby has shown any signs of distress, an oxygen mask for your face!

     

    Well I have a message for both Trig Medical and Barnev, LABORING WOMEN DO NOT NEED ANY MORE THINGS SHOVED UP THIER VAGINA!!!!  And furthermore,  CLIPING ANYTHING TO A WOMAN’S CERVIX OR SCREWING ANYTHING INTO A BABY’S HEAD DOES NOT COUNT AS “NON-INVASIVE”!!!  LABORING WOMEN AND BABIES ARE NOT ROBOTS THAT DON’T FEEL ANY PAIN OR DISCOMFORT!!!!  RESEARCH HAS SHOWN TIME AND TIME AGAIN THAT LESS IS MORE WHEN IT COMES TO LABOR FOR HEALTHY MOMS AND BABIES!!!  CONTINUITY OF CARE IS MUCH MORE EFFECTIVE, LESS PAINFUL, LESS INVASIVE THAN ANY “COMPUTERIZED FINGER.”

    Furthermore, LaborPro and BirthTrack are a slap in the face to every labor and delivery nurse that cares about giving appropriate, effective, competent, physiological, and compassionate care to childbearing families.   Unfortunately I would bet my hard earned money that at least half of the doctors I currently work with would think that this is a good idea. 

    Okay, okay, now that I am all riled up again I have to go to work  😦   Please check out Rixa’s post over at Stand and Deliver about BirthTrack.  It was written about a year ago and I stumbled upon it when I was searching for a picture of a fetal scalp electrode!!

    Change has GOT to come!  It’s GOT to!  For the health and wellness of our mothers and babies!!  Remember ladies, YOU actually have more power than ME and all the other L&D nurses out there!!  That’s right!  If you do not hire birth attendants that do not support evidenced based medicine and physiological birth and do not patronize hospitals that do not support a family-centered approach to maternity care then and only then will they start to listen.  You know why?  Because when the customers aren’t comin’, it hits them where it hurts… in their WALLET!!

     

    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.

     

    Natural VBAC Hospital Birth: One Reader’s Empowering Experience September 3, 2009

    Dear NursingBirth,

      

    I wanted to share with you my birth story.  I thought since I did an all natural VBAC, it might be something you would want to share.  Thanks for the posts.  YOUR blog helped me get though my second birth! Your stories of inspiration that you have are amazing, and just your general  tone.  The fact that there are nurses out there like you made me have the confidence to trust the nurse with me, but also not be totally trustworthy. It helped me realize that I am the final decision maker.

     

    In preparing for my VBAC I read your Injustice in Maternity Care Series and your story “I Needed to Know My Body Could Do It!”: A VBAC Story over and over.  I also read Active Birth by Janet Balaskas which I think helped me a lot, and with our first daughter (my c-section) we took Bradley classes so we both thought we were so prepared.  This time I had my mom, a friend and my husband as my birth team and we took control, which reading about it from your point of view gave me the courage to do so!!!


    Thanks for all you do!  I love the blog!

     

    Sincerely,

    Katie C.

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

    Dear Katie C.,

     

    I would LOVE to reprint it and am honored that you would even send it to me!  Thank you for reading and THANK YOU for being such an awesome and empowered woman and mother!!  It is women like you that are an inspiration to ME!

     

    I just love everything about your birth story!!  First off, CONGRATULATIONS on your VBAC and on the birth of your daughter!!  What a wonderful time for you and your family!  It also must be really nice to NOT have to recover from major abdominal surgery and take care of a newborn and 3 year old!  Second, one HUGE pat on the back to you for choosing to go back home during your initial trip to the hospital when you were found to be 2 centimeters.  That took A LOT of courage and trust in your body and your abilities, especially since the on-call doctor was pressuring you to stay.   And I completely agree with you; choosing to labor at home until you were more “active” most definitely had a significant impact on your successful unmedicated VBAC.  Thirdly, KUDOS to you for being an active participant in your birth!!  It no doubt helped your labor progress to be upright and moving during your labor!  I am so proud of you!!  While it’s true that no one can really “plan” their birth, you did everything you absolutely could to stack the cards in your favor!!  Yay!  Yay!  Yay!!!

     

    Thank you again for reading and sharing!

     

    All My Best,

    NursingBirth

     

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    Katie C’s VBAC Birth Story

    College Station, TX

     

    Starting on Friday, May 22, I started having very mild but consistent contractions at 5 minutes apart at lunch time.  The rest of the day they came and went, some getting farther apart but stronger slowly as the day went on.  I also had a lot of brownish and pinkish spotting.  Figured that maybe I was in very early labor.  Did my usually stuff that day and went to bed about 9:00pm, just in case this was it. Saturday morning I woke up about 1:00am with contractions strong enough that I couldn’t sleep.  I got up and ate some peanut butter toast and drank a bunch of water and tried to go back to sleep.  Contractions were about 7 minutes apart but stronger and enough so that I was having a hard time sleeping.  Likely because I was excited.  Got up and took a bath but that didn’t help.  Tried to go back to sleep.  Got up and ate 2 huge bowls of apple cinnamon cheerios.  Finally fell back asleep about 4:30 am.  Woke up at 7am and was just very tired.  Contractions were completely bearable but figured that we were starting (maybe) and so I had Madison go to Jaxson’s (and George and Amie) house for a few hours while my mom and I stayed home to see if anything would progress.

     

    Lamaze International's Tips for a Normal Birth #5:  Eat and drink as your body tells you to. Drinking plenty of fluids during labor will keep you from getting dehydrated and give you energy.

    Lamaze International's Tips for a Normal Birth #5: Eat and drink as your body tells you to. Drinking plenty of fluids during labor will keep you from getting dehydrated and give you energy.

     

    As the day went on they got stronger but not really closer.  I called L&D and she said 3-5 minutes apart, not able to talk through them, so I just figured I would wait.  Wasn’t ready to go to the hospital yet anyway.  I called Meredith (a friend), who was working about 2 hours away, to let her know that she might have to come back that night. We decided that she would come back that night instead of waiting for a call at 2:00 am and have to drive then.

     

    Lamaze International's Tips for a Normal Birth #6: Think carefully about who you want to give you support during labor and birth. Consider hiring a doula or other professional labor support person to give you, your partner, and any other support person who's with you, continuous emotional and physical support.

    Lamaze International's Tips for a Normal Birth #6: Think carefully about who you want to give you support during labor and birth. Consider hiring a doula or other professional labor support person to give you, your partner, and any other support person who's with you, continuous emotional and physical support.

     

    My back started hurting and I called another friend of mine who does massage. She wanted me to come to her studio, but I really didn’t want to leave the house, so I decided to stay home. Rob called his mom and went to meet her and take Madison to her house so that we wouldn’t have here with us. By the time Rob got back, about 6:30pm, contractions were 5 minutes apart and getting stronger. I could still talk and walk, but it took effort. I called Meredith back and she said she was on her way to my house. At 7:30pm I started to panic.  The contractions seemed very strong to me, I was concentrating on them and they were consistently 5 minutes apart, so we decided to head to the hospital.  I called Meredith and told her to meet us there.  Once I got there, my contractions stopped pretty much, likely due to my nerves.  They got me into a room and set and checked me and I was 2cm and 80% effaced.  I was devastated!  I told them I wanted to go home.  The doctor on call was leery of that since I was a VBAC and they said they would really like me to stay but I refused and we packed up and came home.  (In hind site, this was the reason it all worked out!! Best Decision!!!)

     

     

    I went to bed disappointed and tired, since I had been contracting for nearly 30 hours at this point and I just wanted to either be in labor or not.  I ate a snack and went to bed.  At about 3:00am I was woken by very strong contractions, 7 minutes apart, strong enough that I would flip to hands and knees in bed and rock and moan through them. Rob decided I was in labor, though I was still not sure!  LOL!  I started just sleeping in between them.  (Must have been some natural coping mechanism, since I did it until about 6:30 am!)  We started timing for real at 7:00am.  Meredith came over and she helped my mom.  My mom would time the start to start and Meredith would time the duration. They were about 5 minutes apart with about 30 seconds of what I would call pain.  The actual contraction would last about a min or longer.

     

     

    As the morning went on, I could no longer do anything during the contractions except hang onto Rob and moan.  Contractions got stronger and longer.  They were 4-5 minutes apart, and lasting (pain) about 70 seconds.  During one contraction while I was hanging on to Rob I had a huge rushing feeling, almost like a pushing sensation (or so I thought) so I just said, “We have to go NOW!” We packed up and went up to the hospital.  I had 4 contractions in the car, which were the hardest ones!  [At that point I preferred to be standing during them, since sitting or lying down was excruciating.] We got back to the hospital and I was moaning and hanging on Rob and everyone in the ER was looking at me funny.  It made me laugh.  They probably all thought I was crazy!  

     

     

    I went back up to L&D and they put me in the same room and got me all set up again.  The nurse said, “We were waiting for you!” I was so nervous that I would only be 3 centimeters and they wouldn’t let me go!  She checked me (about 11:00am) and I was 6cm, fully effaced!!!  I cried when she told me, I was so happy!!  Rob, Mom and Meredith clapped!  LOL!  They told me I had to stay.  I said that was fine!  They put me on the monitors and said I would be able to get off of them, but then the Dr. on call said “NO!” so I was worried I would be stuck in bed.  The nurse said, “You can move as much as you want, so long as the cord is long enough,” so I got out of bed and stood next to it for most of the day.  We said I didn’t want to be checked again except by the doctor or if they thought I was complete (i.e. pushing) so when the doctor got there at 1:00pm she checked me and I was a stretch 8!! I was still concerned that it wasn’t going to happen, but everyone else was excited.

     

    Lamaze International's Tip #4 for a Normal Birth: Plan to move around freely during labor. You'll be more comfortable, your labor will progress more quickly, and your baby will move through the birth canal more easily if you stay upright and respond to the pain of your labor by changing positions. Try rocking, straddling a chair, lunging, walking and slow dancing.

    Lamaze International's Tip #4 for a Normal Birth: Plan to move around freely during labor. You'll be more comfortable, your labor will progress more quickly, and your baby will move through the birth canal more easily if you stay upright and respond to the pain of your labor by changing positions. Try rocking, straddling a chair, lunging, walking and slow dancing.

     

    Transition for me was the second hardest thing I have ever done.  I refused pitocin (which they really didn’t push since I was a VBAC) and did not let them break my water. I stayed at a 9 centimeters for almost 3 hours, then at 9 ½ centimeters for a while until I begged them to stretch my cervix!!  LOL!  I was on the bed with the back raised on my hands and knees and suddenly had a contraction that felt better when I kinda of pushed at it. My mom went to get the nurse and she tried to check me like that but said I really needed to lie down.  I said I didn’t want to push lying down and she said, “Sweetie you can push however you want, but I need to make darn sure you are complete so you don’t swell.” I knew that was true so I got down and she checked me and then had the doctor come in and doctor said, “I’d call that complete!” I was so freaking happy! However I was also exhausted and once I was lying down, though I was hurting, I just couldn’t get back up again.  They broke my water sometime in there.  [I think it was earlier when I was at a 9 ½ centimeters but I can’t remember.]

     

     

    The first few pushes I really thought I was doing it but I think the contractions were just not strong enough.  I actually asked the doctor how far down Hana had to be to use the vacuum!  I was exhausted!  The doctor said that she wasn’t going to use the vacuum, so I was just going to have to push!  I started pushing about 4:45 pm.  She would come down (once I finally figured out just how freaking hard you have to push!!) and then scoot back in.  They explained to me that a little bit of pitocin would help to bring the contractions a little closer together, so I would be more effective in pushing, since I was having over a minute between them and Hana would just scoot back in.  I finally agreed to it at about 5:45pm.  The started it at about 6pm.  The doctor suggested a pudendal block, in case I needed an episiotomy (which while I wanted a natural tear, I wasn’t against at that point and I never thought I would come through it with no tear or cut).  I even got a mirror to see my progress, and knew right then that something was going to have to give! I made them put the mirror away!

     

     

    I started pushing 5-6 times per contraction and the doctor had been with me the whole time.  She had them break the bed and get all the stuff ready and I asked “Is she coming out this way?” and the doctor laughed and said, “I’m not doing a c-section today!” She asked me also if I wanted to feel Hana’s head, but I just couldn’t bear the thought for some reason.  I kept pushing and finally she said, “Ok, this next one you’re going to have your baby!” and so I hauled back and pushed harder than I thought possible and her head popped out and I kept pushing (oops!!) and Hana was born Sunday May 24th at 6:28pm!!!  It was the most amazing thing in my life and no doubt pushing was the hardest thing in the world.

     

    Lamaze International's Tips for a Normal Birth #10: Keep your baby with you after birth. Skin-to-skin contact keeps your baby warm and helps to regulate your baby's heartbeat and breathing. Keeping the baby with you in your room helps you to get to know your baby, respond to your baby's early feeding cues and get breastfeeding off to a good start.

    Lamaze International's Tips for a Normal Birth #10: Keep your baby with you after birth. Skin-to-skin contact keeps your baby warm and helps to regulate your baby's heartbeat and breathing. Keeping the baby with you in your room helps you to get to know your baby, respond to your baby's early feeding cues and get breastfeeding off to a good start.

     

    They gave her to me and after a few minutes (she was breathing but a little blue still) they took her over to rub her and clean her up some.  I was shaking so bad at that point that Rob had to hold her. I ended up with a 4th degree tear… not from her head, but her shoulder popped out when I pushed and the doctor wasn’t expecting it, and so that’s that.  But it isn’t so bad!  She stitched me up, and while it is sore, it beats the hell out of a c-section! Right after she was born I said, “I had a baby out of my vagina!” much to the amusement of the nurses and pretty much everyone in the room! But I can’t tell you just how amazing it was for me. I had been waiting 3 years for that.  And now I have it!  Hana was given back to me and she latched on right away and nursed like a champ for 15 minutes on each side (I was STILL being sewn up!) and finally Rob and Hana went off to the nursery.  To our surprise (and the doctor’s too) she was 8lbs 1 oz, 19 inches long.

     

    Happy Birthday Hana!!!!

    Happy Birthday Hana!!!!

     

     

    I am recovering very well and almost feel like new!!

     

    For more information on Vaginal Birth After Cesarean (VBAC) check out the International Cesarean Awareness Network's website at http://www.ican-online.org/

    For more information on Vaginal Birth After Cesarean (VBAC) check out the International Cesarean Awareness Network's website at http://www.ican-online.org/

     

    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!

     

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

    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!!

     

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

    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!