© 2016 Pregnancy Podcast. All Rights Reserved.
Pregnancy Podcast
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San Diego, California 92109
www.PregnancyPodcast.com
First Edition.
The contents of this book (“Content”) are for informational and educational purposes
only. The Content is not intended to be a substitute for professional medical advice,
diagnosis, or treatment. Always seek the advice of your physician, midwife, pediatrician, or
other qualified health provider with any questions you may have regarding a medical
condition. The Content is general in nature, and not specific to you, the reader, and is not
intended as individual medical advice. The Content provided is intended as a sharing of
knowledge and information and the author encourages you to make your own prenatal,
birth, and postnatal care decisions based upon your research and in partnership with a
qualified healthcare professional.
Table of Contents
Part One: The Basics of a Birth Plan
Chapter 1: Your Birth Plan
Chapter 2: Why You Need a Birth Plan
Chapter 3: Planning for the Unexpected
Chapter 4: Building Your Team
Your Partner
Doula
Choosing Your Care Provider
Additional People
Part Two: What to Include
Chapter 5: Planning for Your Venue
Hospital
Home
Birth Center
Chapter 6: Labor Room Environment
Chapter 7: Labor Positions
Chapter 8: Interventions
Induction
Electronic Fetal Monitoring
IV Fluids
Antibiotics (Group B Strep)
Epidural
Episiotomy
Assisted Delivery
C-sections
Vaginal Birth After Cesarean (VBAC)
Chapter 9: Natural Birth
Chapter 10:Water Birth
Chapter 11: The Placenta and Umbilical Cord
Delayed Cord Clamping
Placenta Encapsulation
Cord Blood Banking
The Third Stage of Labor
Chapter 12: Breastfeeding
Colostrum
Formula
Pacifiers
Chapter 13: Procedures After Birth
Skin to Skin
Vitamin K
Erythromycin
Part Three: Guide to Writing Your Birth Plan
Chapter 14: Step-by-Step Guide
Part Four: Template and Samples
Birth Plan Template
Sample Home Birth Plan
Sample Birth Center Plan
Sample Hospital Birth Plan – Plan B to Home or Birth Center
Sample Hospital Plan – Without Interventions
Sample Hospital Plan – With Interventions
Sample Cesarean Section Birth Plan
Additional Resources
Works Cited
Part One: The Basics of a Birth Plan
Chapter 1: Your Birth Plan
Your birth plan is the blueprint of how you envision your birth and what
happens directly following the arrival of your baby. Once your birth plan is
written this one piece of paper is going to have an abbreviated version of what
is important to you, what you want to happen, and what you want to avoid.
A birth plan is really more than a piece of paper you give your care provider. A
birth plan is the process you go through to prepare for the birth experience
you want. The process of creating your birth plan is going to lay the
foundation for you to be prepared for the scenario in which everything goes
exactly as planned, and more importantly, for what should happen in the event
things do not go as planned. The importance of a birth plan has a lot more to
do with the process of writing it than it does with the finished product.
By the time you are finished with this book you are going to be really educated
about everything that can impact your labor and birth. You will be on the same
page as your care provider, your partner, and anyone else who will be by your
side when you give birth. You are going to be confident in the decisions that
you are making, and confident in your ability to have the birth experience you
want. You will also be prepared for whatever happens on the magical day you
get to meet your baby – even if things do not go as you envision. The more
preparation that goes into your birth plan, the more you can be in control of
your experience and the way in which your baby enters the world.
There are an infinite number of options you have as to how you plan your
birth, and you always have options. Even if you end up having an emergency
cesarean section, the planning you do during your pregnancy is going get you
and your care provider prepared to handle things like what procedures are
done with your baby as soon as they are born.
It is up to you whether you want to take ownership of choosing how your
birth goes or if you want to leave all the decision making up to your doctor or
midwife. If you are reading this book you are already on your way to having an
empowered birth and setting yourself up for success to have the birth you
want for yourself and your baby.
Chapter 2: Why You Need a Birth Plan
“If you fail to plan you plan to fail.” – Benjamin Franklin
Going into labor without a plan is like running a marathon without any
training or a roadmap of your route. The key to getting the birth you want is to
plan. There are so many factors that are going to influence how your labor
progresses, what procedures are done, and how your birth experience plays
out. Your knowledge of these procedures and factors, and how you prepare
for them, is going to determine what type of birth you have and how your
baby enters the world.
If this is your first baby you are probably pretty overwhelmed with how much
information is out there. Even if this is your second or third baby, each
pregnancy and birth is so unique that there will always be unknowns. There are
a lot of things that happen in between you going into labor until you are
holding your beautiful new baby. Knowing what step is coming next, and how
you want to handle it is going to prepare you to know what to expect.
You have options with infinite choices to make about everything during your
pregnancy and birth. Your choices start with how you take care of yourself
during your pregnancy, who you choose as your care provider, and what
resources you trust for information. Your education will be the basis for you
to find out what your options are. As you are creating your birth plan, you are
going to find out your options and how your choices are going to affect you
and your baby. Everything during labor is connected and understanding how
one option will affect the next one is going to give you more control of the
route you take to meeting your baby.
A birth plan allows you to make choices. You get to choose where you want to
have your baby, who you want to be there, what procedures are done to you,
and what procedures are done to your baby. If you don’t make these choices
someone else will make them for you. You know your body, your lifestyle,
your preferences, and your priorities better than anyone. Would you plan a
wedding by hiring a wedding planner, telling them to just take care of
everything, make all of the decisions, and then plan to show up on your big
wedding day and hope for the best? Planning a wedding is often a yearlong
process of hashing out details to ensure everything goes just the way you want
it. The day you give birth is one of the most important and amazing days of
your life. The moment your baby is born will forever change who you are.
Wouldn’t you want to put the same care you would in planning for a wedding
into making sure the very first day of your baby’s life goes the way you want?
How your day goes, and how you and your baby experience it is a direct result
of your available options and choosing which options are best for you and
your baby.
Chapter 3: Planning for the Unexpected
Labor is a bit of a wild card. There are so many variables and it can be tough
to predict exactly how everything is going to go down on the big day. If you
are a first-time mom having a baby is uncharted territory and there are a lot of
unknowns. As you plan you have to be preparing for some flexibility. The
more educated you are the better prepared you will be for whatever comes up.
Of course you are planning for the labor and birth experience you want but a
big part of that is to know how will handle any situation. If you only plan for
the best-case scenario and something unexpected happens suddenly you aren’t
in control.
Until you are in labor, there are a lot of things you will not know. Depending
on the type of birth you are planning for, you have no idea when you will go
into labor, or how long you will be in labor. You won’t know whether any
complications will come up, how you will cope with contractions, or how you
will react to medications. You also will not know how your baby will handle
labor and birth, or whether an emergency will come up. The unknown can be
scary, but it doesn’t have to be. You are on your way to being prepared for
everything so you are going into your birth with confidence instead of
uncertainty.
By preparing for anything you are setting yourself up for the best possible
scenario no matter what happens. Knowing your plan B, understanding what
you can do to avoid anything you do not want to be a part of your birth, and
preparing for several scenarios is going to give you a better likelihood of
everything going right.
Chapter 4: Building Your Team
Your Partner
Your partner’s involvement starts with them going with you to your doctor or
midwife appointments. You can expect to have somewhere around 14
appointments throughout your entire pregnancy. So on 14 days you will see a
doctor or a midwife, that’s it. Make it a priority for both of you to go to all of
them, or at least attend as many together as you can. This gives your partner a
chance to be included and have some input in any major medical decisions, ask
any questions, and hear everything first hand.
Your partner needs to be involved in creating your birth plan and by the time
it is done they should know it inside and out. They are going to be an advocate
for you during your labor and birth. If they know exactly what your
preferences are they will be able to speak up for you and help you get the birth
experience you want.
Birth is one of the most physically and emotionally challenging workouts you
will ever go through. Your partner won’t just be sitting back and relaxing while
this is going on. Your partner should expect to be there for you both
physically and emotionally. Partners are a HUGE part of the birth of your
baby. They are the cheerleader, coach, trainer, and major support. They need
to be rested and prepared to be present for the entire thing. Your partner may
also need to be an advocate for you and speak up in the event you are having
trouble doing it. They should know what procedures you are on board with
and what you want to avoid. Creating a birth plan is a great exercise for you
two to get on the same page and get clear about what you do and do not want.
For more information for dads and partners you can listen to episode 13 of
the Pregnancy Podcast at PregnancyPodcast.com/episode13.
Doula
A doula is a professional who has been trained in childbirth and who provides
emotional, physical, and educational support to a mother and their birth
partner. They are there to help with your labor, birth, and into the postpartum
period. There are several types of doulas and a birth doula is someone you may
want to consider involving in your birth experience. A birth doula usually
meets up with you in your third trimester and helps you discuss and work
through any anxiety and fears you have, will assist you in creating your birth
plan, provide continuous support during your birth, and will provide
nonjudgmental unbiased support to help you create the birth you want. Your
doula doesn’t just support you during your birth; they are also there to support
your partner. Their expertise and experience with birth can be a huge
advantage in helping your partner be right by your side and focused on you. A
doula does not perform any medical procedures, deliver your baby, or give you
any medical advice.
Having a doula attend your birth can be an amazing help in creating the birth
experience you want. A doula can assist you whether you are having your baby
at home or in a hospital setting, and whether you are planning a natural birth,
or having a planned C-section. In a review of numerous studies, involving over
15,000 women, it was found that having continuous support during birth had a
major impact on birth outcomes. Involving a doula will increase the likelihood
of you having a spontaneous vaginal birth, meaning you wouldn’t require any
intervention to go into labor, decreases the likelihood of using pain
medications if that is something you are wanting to avoid, decreases your risk
of a C-section or an instrumental delivery with forceps or a vacuum, and
decreases the length of your labor (Hodnett E.D., 2012).
For more information on doulas you can listen to episode 23 of the Pregnancy
Podcast at PregnancyPodcast.com/episode23.
Choosing Your Care Provider
Choosing your care provider is the cornerstone of your prenatal care and birth
experience. This is your expert resource that you will be working with
throughout your pregnancy to make some very important decisions. You need
to see them as an integral member of your team, and most importantly you
need to trust them and be comfortable with them. Trust and confidence are as
important as their qualifications, where they went to school, and how many
babies they have delivered. It is absolutely critical that you include your care
provider in discussions as you are creating your birth plan and that you work
with them to come up with your plan. Creating a birth plan without their
involvement is useless; they must be involved and supportive of your choices.
Generally, your primary care provider will be a midwife or an OB-GYN. Both
types of professionals have to apply for a license, take an exam, and are
required to complete continuing education throughout their career.
An OB-GYN is a doctor, but more specifically, they are an
obstetrician/gynecologist. Obstetrics deals with pregnancy, childbirth, and the
postpartum period, with a focus on situations requiring surgical interventions.
Gynecology is focused on the health of the reproductive system and breasts. If
you are in a high-risk pregnancy chances are you will be seeing an OB-GYN or
a specialist. If you know you are planning a cesarean section you will be seeing
an OB-GYN.
Midwives deal with pregnancy, childbirth, postpartum care and overall care for
women. Midwives are not trained or licensed for surgery. Midwives specialize
in normal, low-risk childbirth. Typically this means you don’t have any
complications. There are also Certified Nurse Midwives who are also
Registered Nurses. If you are under the care of a midwife and something
comes up which makes you high-risk, your midwife may get an OB-GYN
involved, or if it is more appropriate, refer you to an OB-GYN for your care.
Remember, most pregnancies are normal, low-risk, and require very little, if
any, intervention.
Certified Nurse Midwives, Certified Midwives, or Professional Midwives,
typically staff birth centers. A Certified Nurse Midwife has a bachelor’s degree
in nursing, and then goes through a 2-3 year graduate level training in
midwifery. Certified Nurse Midwives are licensed in all 50 states in the U.S.
Another credential is a Certified Midwife which does not have a nursing
background, and Certified Midwives are only licensed in 5 states in the U.S.
Certified Professional Midwives do not have college degree requirements, and
instead gain their training through clinical training under the supervision of a
midwife, and are only licensed in 27 states.
Both Midwives and OB-GYNs are highly regulated and go through a lot of
education and experience before being licensed. They are different and each
has its specialty.
Choosing your care provider isn’t as black and white as having a baby at home
with a midwife or having your baby at a hospital with an OB-GYN. The only
way to know whether a particular person is the right fit for the pregnancy and
birth you want is to ask questions and explore your options. Ultimately, your
care provider will have a big impact on your experience and how your baby
enters the world, and it is critical that you are on the same page and working
towards the same goals.
There are some specific questions you can ask an OB-GYN or midwife when
you are finding the right care provider.
What is your general philosophy on pregnancy care, labor, and birth?
How long have you been in practice?
How many births have you attended?
How many patients do you have at a given time?
Is your practice a solo or group practice? If it is a solo practice, who covers for
you when you are not available?
How much time is available during each prenatal visit?
Are you available to answer questions in between visits?
Will you assist me to develop a birth plan or will you review one I have
written?
What procedures are routine?
Will you be present throughout my labor?
Will you attend my birth? If you are unavailable, who will attend?
Questions if you are looking to avoid certain interventions:
What percentage of your patients utilize pain medication during labor?
What percentage of your patients has an episiotomy?
What is your C-section rate?
If you are interviewing a midwife you may also want to ask:
Did you graduate from a nationally accredited midwifery education program?
Are you certified by the American College of Nurse-Midwives?
Do you have an OB-GYN that you work with in the event one is needed?
Your doctor or midwife is your trusted partner during your pregnancy and
labor. They are there to guide you through the process and ensure that you
and your baby are healthy. Throughout your pregnancy you should have an
open line of communication with them about what you do and do not want
during your labor and birth and it is critical that you are on the same page.
Your doctor or midwife has years of education, training, and experience and
they will have policies, procedures, and opinions that will impact how things
go on the big day. Communicating with your care provider about your birth
plan involves knowing what their policies and procedures are so you can plan
accordingly. You will be relying on their knowledge and expertise to guide you
through a lot of decision-making. Including them in making your birth plan is
critical to you getting the birth experience you want.
For more information on choosing the right care provider you can listen to
episode 34 of the Pregnancy Podcast at PregnancyPodcast.com/episode34.
Additional People
If there is anyone else that you want by your side through your labor and birth
you are welcome to include them in your planning. This could be a sibling,
your mom, your favorite aunt, anyone you want. The decision to include
anyone in your birth should be your decision. Do not let anyone pressure you
into having him or her there if that is not what you want. If you do choose to
have someone additional present, they don’t necessarily need to be involved in
making the decisions that go into your plan. However, you do want them to be
clear on what your plan is, and what their role is.
Part Two: What to Include
Chapter 5: Planning for Your Venue
Where you choose to have your baby is going to have a lot of influence on the
type of birth you are planning. Birth is not an all or nothing decision where
you are either having a baby in hospital with tons of interventions, or having a
baby at home with no interventions. There are an infinite number of options
available to you to really prepare for and craft the birth experience you want.
Whether you are planning to give birth at home, at a birth center, or in a
hospital, each venue has its pros and cons. This chapter explores these three
options and gets into some of the things you will want to take into
consideration when planning your home, birth center, or hospital birth.
If you are planning to have your baby at home or in a birth center there is
always the possibility you could end up at the hospital. You can have your
birth plan for your home or birth center birth, and also create a plan B in the
event you end up in the hospital. Hopefully it stays tucked away and you never
have to use it, but it will give you some peace of mind that you are prepared
for anything.
Hospital
Whether you are planning a cesarean section or having a natural labor you
could do either in a hospital. About 98% of all births in the United States are
in hospitals so if you live in the U.S. there is a good chance that is where you
are planning to give birth.
It is likely that you have more than one hospital in your area. Use the selection
to your advantage to shop around and find the hospital that is the best fit for
you. A hospital will give you a tour, which will give you a good feel for the
labor and delivery unit, the staff, and the overall environment. There could be
big differences in how you feel at one hospital compared to another so shop
around and go with the one you think will be the best fit for the birth
experience you want.
It is really important to know what the policies of your doctor or midwife are,
and what the policies of the hospital are. Hospitals are major organizations.
They have policies and procedures in place to protect both patients and
hospital staff. These policies will have an impact on your labor, birth, and stay.
If there are any interventions you would like to include, or if there are any that
you would like to avoid, talk to your care provider about what the policy of the
hospital is beforehand so you can plan accordingly.
It is a good idea to talk to your doctor or midwife before you go into labor to
find out if they will be there for your labor and birth, when during the process
they will show up, and how long they will stay. In some cases you won’t see
your care provider until you are ready to push. You want to know what their
policy is beforehand so you are not disappointed when you expect them to be
there and they aren’t. It is also possible that you have had your prenatal care at
a practice with several doctors or midwives and the person who will be present
for your birth is the person who happens to be on call when you go into labor.
Generally you will have several nurses taking excellent care of you during most
of your labor and they will alert your doctor or midwife when they need to be
there. Talk to your care provider beforehand so you know when you can
expect to see them.
A pro to being at a hospital is that they should be equipped for any type of
emergency. You could be planning on having your baby in a hospital setting if
you have a high-risk pregnancy or if your care provider is expecting any
complications. Keep in mind that most births do not involve an emergency,
but if this is something that you are concerned about you can rest assured that
the hospital and staff are well equipped to handle anything.
There are many procedures and amenities that are only available at a hospital.
This would include continuous electronic fetal monitoring, availability of an
epidural or Pitocin, and the ability to have a cesarean section. All of these
interventions and more are covered in depth in chapter 8.
When you are about to deliver, you will find that there are suddenly more
people in your hospital room. In general there will be at least three nurses, and
your OB-GYN or your midwife. Once your little one is born there will
probably also be a pediatrician or a family physician there to check in on your
baby, while your care provider is checking on you.
In most cases, your care provider will put your baby directly on your chest
right after birth. If there are any issues of course they will address those, their
number one job is to make sure you and your baby are healthy. The good news
is that you are in a hospital so if anything isn’t perfect they have the staff and
the resources to treat it.
How long you stay at the hospital depends on several factors including the
policy of the hospital, and how you and your little one are doing. Most moms
spend 24-48 hours in the hospital. You may end up spending a longer amount
of time there; it is really going to be on a case-by-case basis. Make sure you
discuss the length of your stay with your care provider, well before you go into
labor, so you know what the policy of the hospital is and what you can expect.
Once you have your baby, if you are feeling ready to go home or maybe not
quite ready to leave, speak up and find out what your options are. Chances are
you will be spending at least one night in the hospital, and your partner can
spend the night with you. Some hospitals or rooms will be equipped with a
chair that turns into a bed or a cot for your partner. You can always ask your
care provider what the accommodations are at the hospital and you can bring a
pillow or anything else that would help your partner be more comfortable.
Take advantage of being surrounded by so many experts in the hospital. This
is especially true after your baby arrives. You can get assistance with
breastfeeding, swaddling, if you have questions about how to change a diaper,
whether your baby’s sleeping is normal, whatever questions you have, ask
them. Take advantage of the staff while you have access to them. It is likely the
hospital has a lactation consultant on site. Have them come by for a short visit.
Getting off on the right foot with breastfeeding can make a huge difference
for both you and your baby.
On the other hand you may find that you just need a little peace and quiet and
some time without people constantly going in and out your room to check on
you or your baby. Ask your nurse or care provider if you can get a few hours
without being disturbed, or perhaps you can put a do not disturb sign on your
door. It is not unreasonable to ask for a break from people coming in and out
of your room at all hours to check on you or your baby.
Keep in mind you are the captain of the ship. It is up to you to make informed
decisions and even if something is routine, you have options. Throughout your
pregnancy you will be working with your care provider on your birth plan.
Although you should see eye to eye on things by the time you go into labor do
not hesitate to ask questions and remind them that you have a birth plan, and
what your wishes are.
For more information on hospitals you can listen to episode 37 of the
Pregnancy Podcast at PregnancyPodcast.com/episode37.
Home
It was not too long ago in our history that all births took place at home. Over
the last century the number of women giving birth at home has sharply
declined. The decline in home births is due to many factors beyond just the
advancements we have made in medicine. The laws of your country or state,
the coverage of home birth by your insurance or health care, and social
attitudes have all played a part in directing where you go to have your baby.
Home births are natural births and almost always attended by a midwife. You
will not have access to an epidural, continuous electronic fetal monitoring, or
Pitocin. In the U.S. midwives cannot legally use forceps or a vacuum for an
assisted delivery. A midwife can perform an episiotomy if necessary, although
it is pretty rare. Overall, intervention use is much lower with midwife-led care
than doctor led care. For many women the unavailability of these interventions
is a big reason they choose home birth with a midwife and it is by design that
most interventions are avoided in home births.
Home births are less expensive than hospital births, but they are not always
covered by insurance. You will need to check with your care provider and your
health coverage to find out if home birth is covered. It could also be a good
idea to find out how your insurance coverage will work in the event you do
end up at the hospital, just so you are prepared for anything. Trying to locate
this information online may be tough and getting on the phone with your
health insurance may be more helpful. You might be on a hold for a little bit
before you will reach someone but in the long run you will save time and get
direct answers to your specific questions.
Worldwide the most popular choice of place to have a baby is not at home. As
of 2012 about .89% of all births in the United States took place at home. This
was a pretty big increase from just .54% in 2004 (MacDorman M.F., 2014). As
of 2013 in the U.K. 2.3% of births took place at home (Office for National
Statistics, 2014). As of 2013 only .3% of births in Australia occurred at home
(Australian Institute of Health and Welfare, 2013). In Canada public health
coverage of home birth services varies from province to province, as does the
availability of doctors and midwives providing home birth services. In Ontario
about 2.49% of births were home births in 2013 (Murray-Davis B., 2015). In
British Columbia just over 4% of births take place at home, and this is the
highest rate of any province in Canada (Midwives Association of British
Columbia, 2010).
If you are planning a home birth you will be working closely with your
midwife to plan the details of your birth and it is really important to know
what the policies of your midwife are. They will be knowledgeable on the
governing laws where you live that could affect your birth. Most jurisdictions
will have some type of criteria a woman needs to meet for a midwife to attend
a home birth. An example of this could be that you need to give birth between
37 and 42 weeks.
In 23 U.S. states there are no licensing laws for direct-entry midwives or
Certified Professional Midwives, and practicing midwives can be arrested for
practicing medicine without a license (Midwives Alliance North America). If
the state you live in does not have licensing for direct entry or Professional
Midwives your only option for an attended home birth is with a Certified
Nurse Midwife, since they are licensed in all 50 states.
If you and your midwife are planning for a home birth you two will be doing
everything you can to support that. The number one priority of your midwife
is the safety of you and your baby. Generally speaking, home births are
low-risk pregnancies without complications. Throughout your prenatal care
you will be monitored by your midwife who will be making sure everything is
going smoothly, that you remain low-risk, and that home birth is still a good
option for you. Prenatal visits could be at your home, the midwife's home, or
at a clinic.
You will probably need some supplies for a home birth that you would not
need if you were having a baby in a birth center or hospital. Ask your midwife
what you need, they should be able to give you a list of supplies and let you
know what they will be providing. There is a perception that home birth is
really messy. It doesn’t have to be and with some planning ahead of time
cleanup is super easy. You will be bonding with your baby after birth so you
do not need to worry about cleanup, that will be done by the midwife, your
partner, and anyone else there to help. Some items you may want to consider
are protective coverings for your floor and furniture. This could be plastic or
rubber sheeting, a shower curtain, towels, sheets, or large disposable pads. You
may want some type of protective covering for your bed. Some other items
you may want to have on hand are a birthing ball or any other equipment or
tools you plan to use during labor. A mirror so you can see your baby's head
crown, if you think that may be helpful. Food and drinks for both during and
after labor, for you, and anyone else who will be there, and anything else that
would be helpful. Luckily you are at home, and everything you own is within
reach. You may want to pack an emergency bag in case you need to transfer to
a hospital. For more information on what to pack in your hospital or birth
center bag you can listen to episode 24 of the Pregnancy podcast at
PregnancyPodcast.com/episode24 and download a free checklist. You should
have all the supplies on hand that you need by week 37, just in case your little
boy or girl decides to show up early.
If you are considering a water birth there may be some additional supplies you
need. You can read more on water birth in chapter 10.
At the start of your labor you are going to call your midwife. They may head
over to your house right away and be involved right from the beginning of
labor, or they may wait until your labor has progressed. You should discuss
this with them beforehand so you know when you can expect them to come to
your house. Home births frequently have several support people present like
your partner, another family member, friend, or a doula. Your midwife will
primarily be running point to let you do what you need to do during labor with
your partner or doula, and of course if you need their support in any capacity
they are there for that. They will be monitoring you and your baby and make
sure everything is going smoothly. A home setting will give you a lot of
freedom for how you labor in different places and positions. You will be able
to eat or drink whatever you want. This is encouraged because you will be
expending a lot of energy in labor and you will need fuel and to stay hydrated.
You can have your partner or another family member catch your baby when
they are born and when you meet that little boy or girl they will be placed skin
to skin on your chest immediately. Your home environment will allow you to
be in control of how and where you labor.
Once your baby is born your midwife will be checking you and your baby to
make sure everyone is healthy and doing well. Especially in a home setting, you
really get to enjoy the time after birth without interruption and focus on
bonding. After delayed clamping, your midwife will be cutting the umbilical
cord, unless your partner or someone else wants to do it. Once the placenta is
out they will be disposing of that, unless you are keeping it for encapsulation.
At some point they will also weigh and measure your baby but the focus is on
allowing you to bond with your little one and they will work around that.
Since you are not in a hospital, you will be advised to take your baby to see a
pediatrician within three days after birth. Have a pediatrician already picked
out and make sure they know that you are planning a home birth, that they are
supportive of that, and will get you an appointment right away after your baby
is born.
The big question surrounding home birth is, is it safe? Following are some of
the key studies so you can decide for yourself whether or not you feel home
birth is a safe option.
Overall, studies show a lower rate of interventions in home births including
epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and
operative vaginal and cesarean deliveries. Women who planned birth at home
also had fewer infections, less perineal and vaginal lacerations, hemorrhages,
and retained placentas. Home births compared to hospital births also are
associated with a higher overall satisfaction with the experience from women
who gave birth at home (International Journal of Women's Health, 2015).
The official statement of the American Congress of Obstetricians and
Gynecologists (ACOG) is that although the Committee on Obstetric Practice
believes that hospitals and birthing centers are the safest setting for birth, it
respects the right of a woman to make a medically informed decision about
delivery. Women inquiring about planned home birth should be informed of
its risks and benefits based on recent evidence. Specifically, they should be
informed that although the absolute risk may be low, planned home birth is
associated with a twofold to threefold increased risk of neonatal death when
compared with planned hospital birth. Importantly, women should be
informed that the appropriate selection of candidates for home birth; the
availability of a Certified Nurse Midwife, Certified Midwife, or physician
practicing within an integrated and regulated health system; ready access to
consultation; and assurance of safe and timely transport to nearby hospitals are
critical to reducing perinatal mortality rates and achieving favorable home birth
outcomes (American Congress of Obstetricians and Gynecologists, 2011).
The stats cited in the opinion of the American Congress for Obstetricians and
Gynecologists comes from a meta-analysis by the American Journal of
Obstetrics and Gynecology of 12 studies which included a total of over
340,000 planned home births and over 207,000 planned hospital births. A
meta-analysis is an analysis that combines results of several studies. The big
focus of this study is that the overall neonatal death rate was almost twice as
high in planned home versus planned hospital births. There was no difference
found in perinatal death for home versus hospital births. Neonatal death
occurs within the first four weeks of life, whereas perinatal is within the first
week, and includes stillborn babies. This study was a controversial one in the
midwife community and there are some concerns raised about the methods
and the data (Hart, 2010).
A review published by the International Journal of Women’s Health in 2015
looked into 31 studies published primarily in the last 10 years from a lot of
different countries. This review is not a meta-analysis, so data from multiple
studies is not combined. The review concluded that while evidence regarding
neonatal outcomes related to home birth remains inconclusive, what is clear is
that when guidelines and systems of transfer are in place, there is either
minimal or no increased risk associated with home birth for low-risk women
(Zielinski R., 2015).
A study from the Netherlands, where home birth rates are among the highest
in the world, found no increased risk of adverse perinatal outcomes for
planned home births among low-risk women. This included over 743,000
women. The authors noted that the results might only apply to regions where
home births are well integrated into the maternity care system (Jonge A.,
2014).
Here is where the research gets even more confusing. The 2014 Netherlands
study was an update of one originally done in 2009. The 2009 study included
over 500,000 women and data from this was used in the results of the
meta-analysis used by the American Journal of Obstetrics and Gynecology,
however, data from the Netherlands study on neonatal mortality was excluded.
The findings on the high rates of neonatal mortality were the basis of ACOG’s
argument against the safety of home birth, and had all of the results from the
Netherlands study been included; the numbers would have been much lower
(Jonge A., 2014).
If you are planning a home birth you should still have a solid backup plan.
There is always the possibility you could be transferred to a hospital. Some
reasons you could be transferred to a hospital are; if labor isn't progressing, if
you have meconium in your amniotic fluid, a placental abruption, umbilical
cord prolapse, if you do not deliver the placenta or it's not intact, or if your
baby shows signs of distress, like an abnormal heart rate or trouble breathing.
There is also the possibility that you decide you want to transfer to a hospital.
A big part of planning a home birth is knowing what your plan is in the event
things do not go as you envision. Most transfers to a hospital are not calls to
an ambulance in a dire emergency. Often there are signs that a transfer would
be beneficial way before an emergency arises. Some hospital transfers still
result in a natural birth so don’t assume that transferring automatically means
you will be having an emergency C-section. Talk to your midwife about what
happens if you want to go to a hospital. You should know to whom your care
transfers to and whether your midwife would stay with you for your labor in
the hospital. Most importantly, you need to know that whatever happens is
okay. A planned home birth that ends up in a hospital is not a failure.
Sometimes things do not go as planned, and that is okay.
For more information on home birth you can listen to episode 42 of the
Pregnancy podcast at PregnancyPodcast.com/episode42.
Birth Center
A birth center is a middle ground between a home birth and a hospital. You
get the benefit of a natural birth, with some of the safety net that you would
have in a hospital setting. Birth centers are generally based on midwife-led care
focused on prenatal and postpartum care for low-risk women. The majority of
birth centers are freestanding centers completely separate from a hospital.
More birth centers are popping up in hospitals with the same focus of natural
birth but they are fully integrated within the hospital system in the event
resources or care from the hospital are needed.
Birth Centers are becoming more popular in the U.S. In 2004 there were 170
birth centers and a total of .23% of births took place in a freestanding birth
center. By 2013 there were 248 birth centers, which accounted for .39% of
births. The number of women giving birth in a birth center is still less than
home births but the number will continue to grow as more birth centers pop
up around the country (MacDorman M.F., 2014).
The Commission for Accreditation of Birth Centers certifies birth centers that
meet standards set by the American Association of Birth Centers.
Many birth centers will also work closely with other professionals like nurses,
acupuncturists, doulas, massage therapists, counselors, chiropractors,
childbirth educators, nutritionists, and lactation consultants. Some birth
centers will have some of these professionals on staff, or have a close working
relationship with professionals they can recommend and refer you to. Birth
centers strive to be a comprehensive one-stop shop for your prenatal, birth,
and postpartum care.
The cost of prenatal care and birth tends to be less expensive at a birth center
compared to a hospital. You will need to check with the birth center and your
health insurance to find out if a birth center is covered, and up to what
amount. It could also be a good idea to find out how your insurance coverage
will work in the event you do end up at the hospital, just so you are prepared
for anything. Some birth centers may offer assistance or reduced rates if you
are low-income. If you are concerned about the cost ask if there are any
programs you could qualify for to reduce the fees.
If you have more than one birth center in your area go check them out and ask
for a tour. This will give you an opportunity to meet some of the midwives
and get a feel for the place to see if it would be the right fit for you. Birth
centers are unique settings and there can be big differences between them. If
you are looking at a couple options you may also want to find out the
proximity to a hospital or the procedures in place at each center if a transfer
becomes necessary. You also can, and should, have a tour of your backup
hospital. If you have multiple hospitals in your area, go tour them so you can
choose the best one for you in the event you end up there.
Birth centers focus on wellness care for low-risk women. Your prenatal
appointments will take place at the birth center, they tend to be longer than
typical appointments with an OB-GYN, and focus on education and
answering any questions you have. Many birth centers will involve you as
much as possible in your prenatal care from asking you to take some tests at
home to checking your own weight. You are much more of an active
participant, rather than a patient at a birth center. You being an active
participant is part of the model of midwife-led care.
Depending on the structure of the birth center you may have an assigned
midwife who will be present for your birth or you could end up with the
midwife on call. Make sure you know the policy of the birth center so you
know who you can expect to be present for your birth.
The labor and birth experience at a birth center is very similar to a home birth,
both in the setting and the policies. In a birth center you are encouraged to eat
and drink to keep your energy levels up. A birth center is set up like a home
setting; there is usually a bed, tools like squatting bars and birthing balls, and
often a tub for water births. Midwives in a birth center encourage you to labor
in the way that is most beneficial for you, and however and wherever you are
most comfortable.
Birth centers do not utilize or offer most interventions like routine IV fluids,
continuous electronic fetal monitoring, inductions, epidurals, or assisted
delivery. Generally for these interventions you would need to be transferred to
a hospital. The rate of episiotomies tends to be really low at birth centers, but
if one is needed your midwife can perform one. For more information on
episiotomies and some things you can do to avoid tearing and an episiotomy
you can listen to episode 22 of the Pregnancy podcast at
PregnancyPodcast.com/episode22.
Birth centers should have procedures in place in the event a transfer to a
hospital is needed. In most cases if you need to be transferred it is not an
emergency situation. You should discuss how this works and whether your
midwife would be able to continue your care in a hospital or whether they
would transfer you to an OB-GYN. The birth center should have OB-GYNs
they work with regularly and that are supportive of natural birth.
After the birth of your baby you can expect to be able to focus on your little
one. Your midwife will of course be checking to make sure both you and baby
are healthy and doing fine. Your stay after birth at a birth center is much
shorter than a hospital stay and often you can expect to go home the same day.
Talk to your midwife ahead of time so you know how long you can expect to
be there.
Now that you have an overview of what a birth center is and how it works,
let’s examine some of the statistics and the safety concerns at birth centers.
There is not a ton of research on birth centers, and as more open up around
the country, hopefully we will see more published data. Keep in mind women
who are good candidates for prenatal care and birth at a birth center are
low-risk without complications.
A study of over 15,000 women who planned to give birth at birth centers
between 2007 and 2010 has some great stats to give you a good idea of why
some women choose to give birth at a birth center. 94% had a vaginal birth.
This means that the C-section rate for low-risk women who chose to give birth
at a birth center was only 6%, of course the women who had a cesarean were
transferred to a hospital. 84% of women were able to give birth at the birth
center. Of all of the participants, 4.5% were referred to a hospital before being
admitted to the birth center, 11.9% transferred to the hospital during labor,
2.0% transferred after giving birth, and 2.2% had their babies transferred after
birth. Of the women who transferred to a hospital during labor, 54% ended up
with a vaginal birth, 8% had a forceps or vacuum-assisted vaginal birth, and
38% had a C-section. The majority of the in-labor transfers were for
non-emergency reasons, such as prolonged labor. 0.9% of the total
participants transferred to the hospital during labor for emergency reasons,
0.4% of mothers, and 0.6% of newborns transferred after birth for emergency
reasons (Dekker, 2013).
Chapter 6: Labor Room Environment
In the wild most animals retreat to a quiet safe place to give birth. If there is
any sign of danger their bodies will literally halt the birth so they can react to
the threat and find safety. Humans operate the same way. Oxytocin is a major
hormone during birth. It isn’t a coincidence that this is also the hormone
released when you have an orgasm. Oxytocin is known as the love hormone
and many people argue that the environment you give birth in should be
similar to the environment you make love in. Your labor will progress best in
an environment where you feel safe and relaxed. No matter where you are
having your baby you could make some adjustments to your surroundings to
create the environment that works best for you.
Bright light is perfect for a beach day but may not be perfect for birth. Even in
a hospital filled with fluorescent lighting you can shut off some of the lights or
possibly dim them if you find it helpful. If your care provider or a nurse needs
brighter lights for a specific procedure you can ask them to dim or turn off
some of the lights when they are not needed. Candles may not be permitted at
a birth center or hospital due to fire risk. An alternative would be to use
battery powered candles. Some birth centers may have these available and if
not you can always bring them with you.
Sound can be a game changer for your environment. This could include music,
meditations, or even white noise or ocean sounds to drown out other noises
that can be a distraction. Often you can request to turn the volume down or
off on monitors or other machines that beep or make noises. Even the volume
of voices can affect your environment. If you prefer to keep your labor room
as quiet as possible do not hesitate to ask anyone present to speak at a low
volume if that is important to you. When your baby is born they will be able to
recognize your voice and your partners voice and the quieter the room is the
better they will be able to hear you and know mama is right there.
Your sense of smell can have an impact on your mood and your environment.
Essential oils are becoming increasingly popular for use in labor for relaxation.
Diffusing oils may be against the policy of a hospital or birth center and it
would be helpful to know what their policy is before bringing a diffuser with
you. If you are interested in incorporating essential oils in your labor and birth
it may be helpful to put oils on cotton balls and store them in a Ziploc bag. In
the event a particular scent is no longer helpful for you, it is much easier to
seal up a plastic bag and open a new one, than to clear the air and get a smell
out of an entire room from a diffuser. Not all essential oils are recommended
for expecting moms and if you have any concerns about using particular oils
consult your care provider.
A great way to make any environment feel more like home is to add pictures.
This could be a picture of your family, a drawing from a big brother or sister
to be, or an affirmation that you want to be reminded of during your labor.
During your labor and birth you should be surrounded by supportive people
you have invited to be in your space. If someone is there it should be because
you asked him or her to be there. Do not let anyone pressure you into
including him or her if you do not want them present. This is your day and
you are running the show.
Someone you may want to include is a birth photographer to document your
day. If this is something you are considering talk to the photographer
beforehand about your labor room environment so they can plan ahead to
work with the lighting and surroundings you prefer. If you want photos of the
birth it is a good idea to coordinate with your care provider to find out what
their guidelines are for photography.
Overall your labor environment needs to be a place that you feel comfortable
in. If there is something that you could add to your space that would make a
difference for you add it. If something about the environment is not working
for you, ask if you can adjust it, remove it, or turn it off. The more
comfortable you are in your surroundings the more relaxed and at ease you
will be to focus on meeting your baby.
For more information on your labor room environment you can listen to
episode 41 of the Pregnancy Podcast at PregnancyPodcast.com/episode41.
Chapter 7: Labor Positions
For most of our entire human history a mother in labor was free to move
around and change positions to whatever was most comfortable and suited her
best at the time. It really wasn’t until we made labor and birth a medical
process that women began laboring on their backs in a bed. There was even a
time when the mom was strapped and restrained to a bed to make sure she
stayed put. Can you believe that? Part of the changing of our practice,
especially in the United States, was a shift of the focus from the birthing
mother to the doctor delivering the baby. A mom on her back in a bed made
the doctor’s job much easier because they had access to see everything going
on. Convenience for the doctor doesn’t necessarily equate to the best position
for the mother. Some of the negatives of lying on your back with your legs
raised are that it works against gravity, your major blood vessels are
compressed, and there is a higher probability of a vaginal tear or an
episiotomy.
When you are in labor you may not be thinking 100% clearly, and may not
recall all of the positions you prepared for during your pregnancy. This is an
area where your partner can really come in handy. Go over positions with your
partner so that when you are preoccupied with giving birth to your little one
your partner can help to suggest some other positions. Also, if there are any
positions they are physically supporting you in they will know what to do. If
you are having a doula attend your birth they will also be an excellent resource
of ideas of some different positions to try.
Standing and walking can be especially helpful in the early stages of labor.
Standing and walking use gravity so it is going to encourage your baby to
descend further into your pelvis. It helps deliver more oxygen to your little
one, it may speed up labor, and it may make contractions more comfortable
for you than if you were sitting or lying down. A walk is also a great distraction
to spend some time in the earliest stage of labor. Walking may not be
recommended if you have high blood pressure, and if you have any questions
about that please bring them up with your care provider.
Especially during the first stage of labor, when your cervix is dilating and
effacing, you really want to work with gravity, not against it. In a review of
women during the first stage of labor, it was concluded that there is clear and
important evidence that walking and upright positions in the first stage of
labor reduces the duration of labor, the risk of cesarean birth, the need for
epidural, and does not seem to be associated with increased intervention or
negative effects on mothers' and babies' well-being. Better quality trials are still
required to confirm with any confidence the true risks and benefits of upright
and mobile positions compared with recumbent, or lying down, positions
(Lawrence A., 2013).
Some positions you may find helpful in the earlier stages of labor are:
Rhythmic moving like swaying or rocking, if mobility is limited, even sitting in
a rocking chair, if one is available, can be helpful
Lunging may be able to help your little one rotate, if they are not in the
optimal position, and can help them descend
Sitting on a bed, chair, or toilet facing forward or backwards
Hands and knees or kneeling
Lying on your side, particularly lying on your left side, as that will maximize
blood flow to your uterus and your baby
There are some props that may assist you during labor and this could include:
Birthing ball
Squatting bar
A bed sheet to knot and use over a door or to loop around a squatting bar to
help pull you up and use as leverage
Birthing stool
If you want to utilize any of these during your labor or birth find out if they
will be available where you are giving birth or if you need to bring them with
you. If you are including a doula they may also be able to provide some tools
or props for you.
Squatting in particular is really helpful for the second, or pushing stage. When
you squat the opening of your pelvis increases, which gives your little one
more room. Squatting encourages your baby to descend downwards better
than any other position. In a squatting position you are still able to shift your
weight around and maintain some movement. It is great for circulation of
blood to your baby, it may increase their rotation, and overall squatting makes
it easier for your little one to make their way out.
In one review that compared women who labored in the second stage of labor,
researchers concluded that women should be allowed to make choices about
the birth positions they might wish to assume. Overall the findings suggested
several benefits to being in an upright position for women who did not have
an epidural, but there was also an increased risk of blood loss. Specific to the
benefits, the researchers found that for women who labored during the second
stage in an upright position there was a 27% decrease in assisted deliveries, a
7% decrease in episiotomies, and fewer abnormal fetal heart rate patterns
(Gupta J.K., 2012).
If you are limited in your mobility you still have options for positions. Even
hooked up to an IV pole or a fetal monitor you will have some room to move,
sit up, squat, or stand.
There was a study done in Italy that concluded women should be encouraged
to move and deliver in the most comfortable position for them. This study
compared women giving birth in an upright position to women who labored
and gave birth lying down. Women who used upright positions more than
50% of the time had more effective uterine contractions and more perineal
muscle relaxation, and their births were significantly shorter. In addition they
had lower rates of request for epidurals or other medication, less assisted
deliveries, and less cesarean sections. The study notes that no differences were
found in terms of neonatal outcomes (Gizzo S., 2014).
You can see that there is definitely scientific evidence showing a benefit to
being in an upright position. Overall the studies really show that you should
have the freedom to move as you see fit. If you have any limitations due to
interventions during your labor and birth, work with your care provider to find
the best positions for those circumstances. If you are uncomfortable and want
to try a different position, definitely speak up.
For more information on labor positions you can listen to episode 36 of the
Pregnancy Podcast at PregnancyPodcast.com/episode36.
Chapter 8: Interventions
An intervention is any procedure performed by a care provider to assist in the
delivery of your baby. Interventions include inductions, continuous electronic
fetal monitoring, administering IV fluids, antibiotics for group B strep, an
epidural, episiotomy, assisted delivery (using forceps or a vent house suction
cup), and a cesarean. By learning what each procedure entails, and when and
why it is performed, you will be better able to make decisions as to whether or
not you really need or want to include it in your birth plan.
Modern medicine is amazing and there is no doubt that lives of both mothers
and babies have been saved by interventions. When they are needed we are
very lucky to have access to medical interventions. All interventions carry risks
with them. Remember, your job is to make informed decisions based on what
is best for you and your baby. Just because something is suggested by a care
provider does not mean it is mandatory, and you always have the final say.
For any intervention there are some excellent questions you can ask your care
provider before opting into a procedure:
Why do I need this procedure?
What are the benefits to my baby and me?
Are there other options available? If there are, what are they?
What are the risks of the procedure?
What are the risks if the procedure isn’t done?
Can I delay the procedure? Wait an hour or a day and what are the risks of
delaying the intervention?
For more information on interventions you can listen to episode 8 of the
Pregnancy Podcast at PregnancyPodcast.com/episode8.
Induction
You already know that pregnancy is measured in 40 weeks and your due date is
the end of week 40, or about 280 days from your last menstrual period. This
calculation assumes a 28-day cycle, with ovulation about day 14. Your due date
is an estimate of when your baby will arrive; it is not an exact science. Often
when your baby is late, it is likely that they really aren’t late at all, but rather,
your due date is off.
Inducing labor is any procedure that is used to stimulate uterine contractions
during pregnancy before labor begins on its own. A care provider may
recommend inducing labor for various reasons and primarily an induction is
recommended when there's concern for the health of mom or baby. Weighing
the risks of an induction against the benefits will help you decide if this is the
best course of action for you and your baby.
The last few weeks of pregnancy are really critical to your baby’s development.
Maternal antibodies are being passed to your baby—these will help fight
infections in their first days and weeks of life. Your baby is gaining weight and
strength, they are increasing iron stores, and developing more coordinated
sucking and swallowing abilities. The last few weeks are also when your little
one’s lungs mature and prepare for that first breath of air. Your baby is storing
brown fat that will help them maintain their body temperature in the first
weeks following birth. As your baby and your body get ready to go into labor
your placenta triggers an increase in prostaglandin that softens the cervix to
prepare it for effacing and dilating. Your levels of estrogen rise, and the levels
of progesterone decrease which makes the uterus more sensitive to oxytocin,
which is the hormone responsible for contractions. Nearing labor your baby
will move further down into the pelvis. While all of this is going on internally
you may notice that you have extra energy, which allows you to make any final
preparations, and you may have trouble sleeping, which is thought to help
prepare you for being awake at all hours with a new baby. It is really this
symphony of everything working together in sync that starts your labor. In a
perfect world, everything works like it is supposed to, your body is ready, your
baby is fully mature and ready to make their entrance into the world, and you
naturally go into labor.
In determining if labor induction is necessary, you and your doctor or midwife
will be taking several factors into consideration. Some of these include your
health, the health of your baby, your baby's gestational age and size, your
baby's position in the uterus, and whether your cervix is dilated or effaced.
There are several reasons your care provider could recommend an induction.
The most common is if you are approaching two weeks past your due date,
and labor has not started naturally. Many hospitals have a policy of induction
at 10 days after the expected due date, and many birth centers require you go
into labor within 42 weeks. If you reach the limit set by your care provider
they may recommend an induction. Some additional reasons your doctor or
midwife could recommend an induction are:
Your water has broken, but you're not having contractions. When your
amniotic sac ruptures before labor begins, it is called premature rupture of
membranes. It is the policy of many hospitals that when your water breaks you
have 24 hours for labor to begin before they will want to induce labor. The
reason for this is that you are at an increased risk for infection once your
amniotic sac has ruptured.
There's not enough amniotic fluid surrounding your baby. This condition is
called oligohydramnios. During pregnancy a sac filled with liquid called
amniotic fluid surrounds your baby. Amniotic fluid helps protects your baby
and the umbilical cord from trauma and infection. Your levels of amniotic
fluid will fluctuate, depending on how hydrated you are, how much your baby
swallows and urinates, and your baby’s kidney function. The levels of amniotic
fluid are measured using an ultrasound. If your care provider determines that
your amniotic fluid levels are too low then you may be diagnosed with
oligohydramnios. Please know that this happens to a very small percentage,
about 4%, of pregnant women. This number does increase to about 12% in
women whose pregnancies go two weeks past their due date, because the
amniotic fluid usually starts decreasing at this time (March of Dimes, 2011).
Your care provider suspects you are having a large baby. There are many
reasons why some babies are larger than others. This can be due to genetics or
to underlying health issues like gestational diabetes. There is no way to
measure a baby’s size and weight accurately before birth. These measurements
are usually taken with an ultrasound and they are not 100% accurate. The
medical term for a big baby is macrosomia. Most guidelines consider a baby to
be big if they weigh over 4,500 grams, or 9 pounds 15 ounces. The main
concern with birthing a big baby is the risk of shoulder dystocia, which
happens when your baby’s shoulders become stuck. Shoulder dystocia is
regarded as an emergency, with the potential to cause injury to the baby.
In cases of gestational diabetes, the evidence recommending induction before
41 weeks to avoid a big baby is weak. The World Health Organization does
not recommend induction for gestational diabetes unless the condition is not
controlled or if the placenta is not providing enough nourishment to the baby.
Intrauterine Growth Restriction (IUGR) At Term, which means your baby is
small for their gestational age. Just as with a big baby, this can be due to
genetics. Some babies are just small and some have restricted growth because
they are not receiving enough nourishment from the placenta. Again, as with
big babies, these measurements are taken with an ultrasound and it is not
100% accurate, and it relies on accurate dating of your due date. Ultrasounds
during pregnancy are more accurate before 20 weeks, when the margin of
error is 7-10 days; the margin for error later can be closer to 3 weeks.
Some additional reasons for an induction can be that you have a medical
condition that might put you or your baby at risk, such as high blood pressure
or diabetes, if there is an infection in your uterus, if your baby has stopped
growing at the expected pace, or if your placenta has begun to deteriorate.
The last reason for an induction could be pure choice or convenience. Perhaps
you live far from the hospital or birthing center, you have a history of really
fast deliveries, or you prefer to give birth with a specific practitioner. In these
cases your care provider should confirm that your baby's gestational age is at
least 39 weeks, preferably 40. This is really critical because making sure your
little one is full term helps reduce risks of health problems for them. Any
decision to induce labor should be discussed with your doctor or midwife in
detail to weigh any potential risks with the benefits.
There are multiple methods for inducing labor. Your doctor or midwife can
strip or sweep the amniotic membranes. To do this your care provider inserts
their gloved finger beyond your cervical opening and rotates it to separate the
amniotic sac from the wall of your uterus. This doesn't actually induce labor,
but it might speed the beginning of spontaneous labor, especially if your cervix
has already started to dilate. This procedure can cause some intense cramping
and spotting and if you leave your care provider’s office and bleeding becomes
heavier than a normal menstrual period, you will definitely want to contact
your doctor or midwife right away.
Another method to induce is to ripen your cervix. There are a couple of ways
this can be done. With a synthetic prostaglandin, which is taken orally or
placed inside your vagina, or a mechanical dilator is used to physically open
your cervix.
There are two basic types of prostaglandins, misoprostol (known under the
brand name Cytotec) and dinoprostone (which goes by the trade names
Cervidil and Prepidil). Both medications ripen the cervix, meaning they cause
it to efface or thin, and cause uterine contractions. After prostaglandin use,
your care provider will initially monitor your contractions and your baby’s
heart rate.
Misoprostol was originally approved as a medication to prevent ulcers. While it
is commonly used for labor induction today, especially in the United States, it
does not technically have approval from the FDA for this use (U.S. Food and
Drug Administration, 2015). In the U.S. the use of Misoprostol to induce labor
is off label, meaning it is not technically approved for that use, and warnings
about risks associated with its use for induction of labor remain on the label.
When it is used to induce it is effective at causing uterine contractions and
ripening of the cervix.
The other prostaglandin used to induce labor is dinoprostone, which goes by
the trade names Cervidil and Prepidil. Similar to Misoprostol it also softens the
cervix and causes uterine contractions. The FDA approves dinoprostone for
labor induction.
Risks associated with the use of prostaglandins include uterine
hyperstimulation, which means it over stimulates your uterus to contract too
much, and maternal side effects such as nausea, vomiting, diarrhea, and fever.
In comparing the two prostaglandin options, many studies show Misoprostol
compared with dinoprostone appears to show less oxytocin augmentation for
labor induction at term. In plain terms, less people required synthetic oxytocin
during their labor after using misoprostol. The other outcomes of both drugs,
like APGAR scores and C-section rates were similar. However, these findings
were based on small-scale trials. Further studies assessing the effectiveness and
safety of misoprostol and dinoprostone in selected groups of patients are
warranted (Wang L., 2015).
There is documented concern of risks associated with misoprostol (Cytotec)
that include hyperstimulating the uterus, prolonged contractions, postpartum
hemorrhage, and uterine rupture among many others. Ina May Gaskin, who is
perhaps the most respected figure in midwifery, wrote a strong and emotional
article against the use of misoprostol (Gaskin, Cytotec and the FDA, 2013).
If you opt to induce labor with a mechanical dilator, one option is to use a
small balloon-tipped catheter that is inserted beyond your cervical opening.
Then saline is injected through the catheter, which expands the balloon, and
causes your cervix to widen. The other option is a laminaria, which are small
rods made from seaweed that are inserted into your cervix and absorb
moisture and get thicker, which opens your cervix. Both of these procedures
can cause some cramping.
Another method you care provider can use is to break your water. This is also
known as an amniotomy or rupturing the membranes. An amniotomy is
typically done only if the cervix is partially dilated and thinned and your baby's
head is deep in the pelvis. Your doctor or midwife does this by making a small
opening in the amniotic sac with a thin plastic hook. When this happens you
may feel a warm gush of fluid when the sac opens. If your care provider
ruptures your membranes they will monitor your baby's heart rate both before
and after the procedure, as well as examine the amniotic fluid for traces of
fecal waste, known as meconium.
When you naturally go into labor the hormone oxytocin is responsible for
causing contractions. There is a synthetic version of this, most commonly
known by the brand name Pitocin, which is most effective at inducing labor if
your cervix has already begun to dilate and thin. This is given through an IV.
Your care provider may also recommend Pitocin to augment or stimulate
contractions if your labor is not progressing as quickly as they would like. With
the use of Pitocin your care provider will monitor your contractions and your
baby's heart rate will be continuously monitored. Synthetic oxytocin can make
labor contractions really strong and lower your baby's heart rate. This is why
continuous fetal monitoring is used with this method. It should also be noted
that the amount of synthetic oxytocin you are administered could be adjusted
so if you do go this route you can start off with a low dose, then gradually
increase it if necessary.
Keep in mind that your care provider may also recommend a combination of
methods to induce labor. The length of time between an induction and going
into labor will depend on how you respond to the procedure. If your cervix
needs to ripen, it could take a couple of days before labor starts. If your cervix
has begun to soften, efface, and dilate, it could be as quick as a few hours.
The use of induction of labor has increased in the United States concurrently
with the increase in cesarean delivery rates. In 1990 9.5% of births were
induced and in 2008 this number rose to 23.1%. Because women who undergo
induction of labor have higher rates of cesarean delivery than those who
experience spontaneous labor, it has been widely assumed that induction of
labor itself increases the risk of cesarean delivery. According to the American
Congress of Obstetricians and Gynecologists this is not the case. Studies that
compare induction of labor to its actual alternative, expectant management
awaiting spontaneous labor, have found either no difference or a decreased
risk of cesarean delivery among women who are induced (Caughey A.B.,
2014).
If an induction is not successful your care provider may suggest a cesarean
section. If you and your baby are not showing signs of distress cesarean
delivery may be avoided by allowing longer duration of induction or oxytocin
before deeming the induction a failure. If you do have an induction and you
are not going into labor, be sure to discuss all options with your doctor or
midwife and find out if you can hold off on a C-section, if that is your
preference.
Although there is some disagreement as to whether induction increases your
chance of a cesarean there are some other risks involved.
Inducing labor too early might result in a premature birth. This poses risks for
your baby, such as respiratory issues. This is why it is so critical to be accurate
with your due date. If you schedule an induction and your due date is off by a
week or 2, your baby may not be full term. When babies are born prematurely
they are at greater risk of respiratory problems, low blood sugar, jaundice,
irregular heart rate and the inability to stabilize temperature. They are also
more likely to have difficulty with establishing breastfeeding.
Medications used to induce labor — synthetic oxytocin or a prostaglandin —
might provoke too many contractions, which can diminish your baby's oxygen
supply and lower your baby's heart rate.
Your baby and your uterus are protected from infection by the amniotic sac.
Once this breaks, germs like bacteria can get in more easily and cause an
infection, so rupturing your membranes increases your risk for infection.
Labor induction increases the risk of the umbilical cord prolapse, which
happens when the umbilical cord slips into the vagina before your baby, which
can compress the cord and decrease your baby's supply of oxygen, which can
be a serious complication.
Uterine rupture is a rare but serious complication in which the uterus tears
open along the scar line from a prior C-section or major uterine surgery, which
causes heavy bleeding. In these cases an emergency C-section is done to
prevent life-threatening complications.
Labor induction increases the risk of uterine atony, which occurs when your
uterine muscles don't properly contract after you give birth, and this can cause
hemorrhage after delivery.
For more information on induction you can listen to episode 20 of the
Pregnancy Podcast at PregnancyPodcast.com/episode20.
There are some ways you can try to induce labor naturally. Before you attempt
any method you want to make sure your care provider is on board and that
you are confident your due date is correct. Do not attempt to naturally induce
labor until your due date or longer. Any form of induction is an induction,
even if it is something you are doing at home, and you wouldn’t want to jump
start labor unless your body is ready and your baby is full term. Keep in mind,
the only surefire way to go into labor naturally is to wait it out and let your
baby and your body tell you when it is time.
If you would like to find out more about inducing labor naturally you can
listen to Episode 21 of the Pregnancy Podcast at
PregnancyPodcast.com/episode21.
Electronic Fetal Monitoring
During your labor your doctor or midwife will be checking the heartbeat of
your baby. This is monitored because your little one’s heart rate is thought of
as the best way to check their well being during labor. Your baby’s normal
heart rate can be anywhere between about 110 to 160 beats per minute, and
their heart rate is constantly changing. This constant changing is referred to as
the variability or beat-to-beat variation. A healthy beat-to-beat variation is
generally at least five beats per minute. Your baby’s heartbeat will speed up,
which is known as fetal heart accelerations, when they move in the womb,
when your doctor or midwife is feeling your belly and putting pressure on it to
determine where your baby is, or if their head is touched during a vaginal
exam. You can see that some variations are common and are no big deal.
Detecting an abnormal fetal heart rate does not always mean there is a
problem.
Labor and birth is going to be the most stressful event of your baby’s life, and
the reason for this is that each time you have a contraction, the blood flow to
the placenta is temporarily diminished and this reduces your baby’s oxygen
supply. This might sound a little scary, but this is totally normal. This is how
we are designed to work, and our babies are designed to cope with this. The
decrease in oxygen supply to the placenta is short and the oxygen supply will
increase as soon as your contraction is over. When you have a contraction and
the supply of oxygen to the placenta is reduced your baby’s heart rate slows
down, and then returns to their normal heart rate after the contraction is over.
There are some instances in which your baby’s oxygen supply can be reduced
too much which can compromise their health and well-being, this situation is
referred to as fetal distress and is detected by significant changes in their heart
rate. The goal of using electronic fetal monitoring is to identify babies who are
short on oxygen and identify what the underlying cause is to correct it.
Monitoring heart rate can also alert your doctor or midwife in the event an
emergency arises in which your baby needs to be born immediately either via
cesarean section or through an assisted birth.
The method of monitoring your baby's heart rate depends on your doctor or
midwife, the policy of the venue where you are giving birth, your risk of
complications, and how your labor is going. There are two methods that can
be used to monitor your baby's heart rate; monitoring is done either through
auscultation or electronic fetal monitoring.
Auscultation is a method of periodically listening to your baby’s heartbeat.
This is usually done with a Doppler transducer, but your care provider may
also use a fetal stethoscope, or a Pinard, which is a trumpet shaped device that
amplifies sound. In most cases a Doppler is used and this device is shaped like
a microphone and when it is held up to your belly you can hear the heartbeat
amplified through a speaker. Chances are you have seen this at one of your
prenatal appointments. As long as everything is going fine during your labor
your care provider will be checking this from time to time. In general with
intermittent monitoring they will be checking about every 15 minutes during
the first stage of labor, when you are dilating. During the second stage of
labor, or the pushing stage, they will be checking more frequently, generally
about every five minutes. This could be more frequent; ultimately it is up to
your care provider to decide how often they want to check your baby’s heart
rate.
Electronic fetal monitoring uses instruments to continuously record the
heartbeat of your baby and the contractions of the uterus during labor. The
machine used is a cardiotocograph, or CTG, and more commonly known as
an electronic fetal monitor. This provides an ongoing record so your care
provider can go back and look at the results of how your contractions and
your baby’s heartbeat have changed over time. This record can either be a
print out or show up and be recorded on a screen.
Electronic Fetal Monitoring can be external, internal, or both. With external
monitoring a pair of belts is wrapped around your abdomen. One of the belts
is using a Doppler to detect your baby’s heart rate, and the other belt measures
the length of contractions and the time between contractions. This is by far
the most common method of monitoring. It is not considered invasive
because the belts are just strapped around your belly but you will be connected
via wires to the CTG machine so you may not be able to move or walk around
too much. There are some instances in which external monitoring is not
working well or if your doctor or midwife has some concern and wants a more
accurate reading and may recommend internal monitoring.
With internal monitoring a wire, called an electrode, is placed on the part of
your baby closest to your cervix, usually their scalp, and this records the heart
rate. There is a tiny screw that is used to hold it in place. Your contractions
may also be monitored intermittently by using an intrauterine pressure
catheter. Which is a tube that is inserted into your uterus, through your vagina.
Internal monitoring is only used after your water has broken, and you are
dilated at least 1-3 centimeters. One reason for internal monitoring could be
that you are having twins, in which they want to make sure they can
differentiate the heartbeat of each baby, usually referred to as baby A and baby
B. Another reason for internal monitoring is if mom is significantly overweight
in which case it can be tough to detect a heartbeat with an external monitor.
Internal monitoring is not a routine procedure and your care provider will only
be using this if there is cause to do so. With internal monitoring there is a
slight risk of infection and the possibility that the electrode can cause bruising
on your baby. There may also be some discomfort when the electrode is put in
your uterus. There are some instances in which internal monitoring is not
recommended and this would be if you are HIV positive or if you have an
active herpes infection. With internal monitoring you will be required to stay in
bed and will not be able to move around very much.
If you are having a home birth or a birth center birth, you will be monitored
intermittently via auscultation, and not with a CTG machine. If you are having
your baby at a hospital you may have some options about how you are
monitored and whether it is intermittent or continuous. Some reasons your
care provider may prefer continuous monitoring are if you get an epidural,
have Pitocin, which is synthetic oxytocin to induce or augment your labor, or
if you are high-risk or incur any complications. A few examples of things that
could make a pregnancy high-risk include diabetes or high blood pressure, or if
your baby is not developing or growing as well as they should be.
Electronic fetal monitoring is often continuous but it doesn’t necessarily have
to be as long as you and baby are doing well. Ultimately this is something you
will need to discuss with your care provider. If you are having a hospital birth
you will probably be hooked up to a monitor for about 20-30 minutes once
you arrive at the hospital in labor. If everything is going well, you may be able
to have the belts removed and hook it up intermittently. There is some
research that there is no evidence of benefit for the use of an electronic fetal
monitor upon admission to a hospital when in labor and admission CTG
increases the cesarean section rate by approximately 20%. The findings of this
review support recommendations that the admission CTG not be used for
women who are low-risk on admission in labor and goes on to recommend
that women should be informed that admission CTG is likely associated with
an increase in the incidence of cesarean section without evidence of benefit
(Devane D., 2012).
One big issue with electronic fetal monitoring and continuous monitoring is
that it impacts your ability to move around because you are tethered to a
machine with wires. One other option you may have is telemetry monitoring.
A telemetry monitor uses a transmitter on your thigh to transmit your baby's
heartbeat via radio waves. It is usually transmitted to a nurse’s station so you
can be walking around and have much more mobility while you are in labor
and still have constant monitoring. Not all hospitals will have a telemetry
monitor available but if it is something you are interested in you can ask your
care provider if this is an option. This would allow you much more mobility
than a standard CTG machine.
If you are being monitored electronically there is a volume dial on an
electronic monitoring machine. If you find it distracting you can always turn
the volume down, or even turn the monitor away so you are not looking at it.
You want your partner paying attention to you not the machine and if it is a
distraction to them you can turn it down or turn it away. If you are listening to
the heart rate and it suddenly stops, do not panic. The transducer probably
shifted out of place and a nurse or your care provider should be able to adjust
it. If you are paying attention to the machine don’t stress out if there are
changes in your baby’s heart rate. Some changes are completely normal so
don’t focus 100% of your energy on trying to be a pro at reading the results of
the monitor.
A review of 13 trials and over 37,000 women compared intermittent
monitoring with continuous monitoring and found overall, there was no
difference in the number of babies who died during or shortly after labor.
Neonatal seizures in babies are very rare, but they occurred significantly less
often when continuous monitoring was used. There was no difference in the
incidence of cerebral palsy. The research showed that continuous monitoring
was associated with a significant increase in cesarean section and instrumental
vaginal births (Alfirevic Z., 2013).
Electronic fetal monitoring is almost always used in situations where your baby
is considered high-risk. This makes sense on the surface but there is no hard
evidence that continuous electronic fetal monitoring has improved outcomes
for babies in high-risk pregnancies (Grivell R.M., 2015).
IV Fluids
Most hospitals require a saline lock, sometimes called a hep-lock. This is an IV
catheter that is put in on the top of your hand. The needle is taped in place
with a small tube that is capped off. With a hep-lock in you are not hooked up
to an IV pole. In the event you needed something intravenously your care
provider can simply connect an IV tube to the hep-lock. There are several
reasons why an IV might be used in labor and birth. The most common
reason your care provider will put you on an IV is to keep you hydrated.
Staying hydrated during labor sounds great on the surface but this can also
cause edema, which is swelling due to excess fluids in your body.
IV fluids can also cause your baby to maintain higher fluid levels at birth,
leading to more excess fluid loss after birth, which your care provider may
interpret as weight loss due to not eating enough. Often this results in a fear
that your baby is not getting enough nutrition from breastfeeding and formula
may be started when it is not necessary. An observational study published in
the International Breastfeeding Journal found that timing and amounts of
maternal IV fluids are correlated to newborn weight loss (Noel-Weiss J., 2011).
The authors of this study recommend using the 24-hour weight, rather than
the weight at birth, as the baseline weight when following infant weight over
time. This recommendation has not gained traction in the medical community.
This may be something to keep in mind if you receive IV fluids during labor.
In the past, hospitals discouraged drinking and eating during labor. This
practice is improving with most care providers supporting consumption of
food and drinking water at least during the first stage of labor. Midwives at
birth centers and attending home births often encourage you to eat and drink.
Labor is a marathon and you need to stay hydrated. If you want to avoid IV
fluids make sure you are hydrated and drink water or eat lots of ice chips. If
you do receive an IV most IV poles have wheels so you can walk around and
can still maintain some mobility.
Antibiotics (Group B Strep)
Group B streptococcus (GBS) is a type of bacterial infection. This bacterium
naturally lives in the gastrointestinal tract and is present in the vagina and/or
rectum of about 25% of all healthy women. This bacterium can come and go,
and once you have it that does not mean you will always have it. Most women
who are colonized with group B strep do not experience any symptoms, and
normally this is not a big deal. It can become an issue when you are pregnant
and there is a possibility of passing group B strep to your baby. GBS can cause
bladder and uterine infections for you and in serious cases; GBS can cause
meningitis, sepsis, pneumonia, or stillbirth.
Group B strep can be a serious complication for a newborn baby. There are
two types of infections that could affect your baby, early or late-onset GBS.
Early-onset GBS is the most common and symptoms usually show up within a
few hours after birth and can include sepsis, pneumonia, and meningitis, which
are the most common complications. GBS can also cause breathing problems,
heart and blood pressure instability, and gastrointestinal and kidney problems.
Late-onset GBS usually show up within a week up to three months after birth
and the most common symptom is meningitis. Late-onset GBS could have
resulted from GBS being passed from mom to baby, or your baby could
possibly contract it from coming into contact with someone who was
colonized. This section is focused on early-onset.
If you do have GBS that does not mean that your baby will have it also. GBS
is passed from mom to baby during birth, and there are some things that can
be done to prevent your baby from being colonized. In the United States
about 1 in every 2,000 babies is affected by GBS. Of mothers who carry GBS,
without treatment, approximately 1 out of every 200 babies will be affected.
With treatment this drops to 1 in 4,000.
Testing for GBS during pregnancy has become routine because it can be a
dangerous complication. The test for GBS is done between week 35 and 37.
This isn’t done earlier because it is possible that you could test negative early
on, but that it would be present later in your pregnancy and at birth. Your care
provider wants to know if you are colonized during labor, which is when it
could potentially be passed to your baby. This is a non-invasive test and your
care provider will take a swab of your vagina and rectum, then the sample is
sent to a lab where a culture is analyzed for the presence of GBS. Results
should be available within 24 to 48 hours.
If the results of your group B strep test are negative then there is nothing to
worry about, if the result is positive, you and your care provider will be taking
some precautions. You will be considered to be at a higher risk of passing it to
your baby if you go into labor or your water breaks before week 37, if your
water breaks more than 18 hours before your baby is born, if you have a fever
during labor, if you have a urinary tract infection as a result of GBS, or if you
had a previous baby with GBS.
In the U.S. it is common practice to treat a mother with antibiotics if they are
colonized with group B strep, even if she is considered low-risk. Without
antibiotics there is a 50% chance your baby would become colonized, and with
antibiotics, that drops significantly. Antibiotics are given to you in the
beginning of your labor through an IV, then every four hours during active
labor until your baby is born. The reason you don’t get antibiotics before you
are in labor is that since GBS lives in your gastrointestinal tract, it could
potentially come back after antibiotics, but before you give birth. The
antibiotic most commonly used is penicillin, if you have an allergy to penicillin
there are a few other antibiotics that may be given and you can talk to your
care provider about alternatives.
GBS is normally not passed to your baby if you are having a cesarean section.
If your water breaks, the chances of an infection are higher and antibiotics may
be recommended, even if you are planning a cesarean section.
Getting antibiotics does not necessarily mean that you will be continuously
hooked up to an IV. Once your labor starts you will have an IV put in and it
takes about 15-30 minutes. The antibiotics are only given every 4 hours until
birth, and for many women this is only once or twice. In between getting
intravenous antibiotics you can have a help-lock in, which means the needle
stays in your hand, but it is capped off and disconnected from the IV tubes.
This allows you to be able to move around without being hooked up to tubes
and an IV pole.
Antibiotics given to you during labor will cross the placenta and enter your
baby. The big question is what impact is this going to have on your baby?
Group B strep is pretty serious and your number one priority is making sure
your baby doesn’t get a group B strep infection. At birth, your baby’s
gastrointestinal tract is sterile, and bacteria originating from both you and their
environment rapidly colonize. If you have any concerns about how antibiotics
could affect the gut microbiome of your little one, there is a lot you can do to
help make sure they do have a healthy gut. One of the best things you can do
for this is to breastfeed. If you have concerns, definitely discuss them with
your care provider. If you and your care provider decide the best course of
action is for you to have antibiotics to protect your baby from a serious
infection, that will likely outweigh concerns of your baby’s gut bacteria in the
short term.
There is some interesting research that taking a probiotic may decrease your
risk for group B strep. Our bodies are a really complex system with a lot of
different bacteria. 25% of pregnant women are colonized with group b
streptococcus. This is just one of a ton of different bacterium living in our
bodies. A study done with the effects of lactobacilli, which is another bacteria,
found that high numbers of lactobacilli in women may contribute to a low
vaginal pH and seems to have a negative influence on group B streptococci.
This particular study used panty liners to introduce lactobacilli to the
participants (Rönnqvist P.D., 2006). You might be grossed out by the thought
of using a panty liner colonized with bacteria, but there is a much easier way to
introduce lactobacilli to your body.
A very small study found that a prenatal probiotic has the potential to reduce
GBS colonization (Hanson L., 2014). This study was significant because it
justified a controlled clinical trial. At the time of this writing Stanford
University is in the middle of a clinical trial with the purpose of determining if
oral probiotic supplementation during the second half of pregnancy decreases
maternal GBS colonization. The importance of this study is that it may offer a
safer alternative to antibiotic treatment of GBS colonized pregnant women.
Final results of the study are not expected until 2018 (Stanford University,
2014).
You are already taking a prenatal vitamin; it wouldn’t be a big deal to add a
probiotic. It doesn’t need to be a fancy or expensive probiotic but you do want
to look for one that has lactobacillus, and most will. In the small study
mentioned above no women reported any negative effects from taking a daily
probiotic, and half reported improved gastrointestinal symptoms (Rönnqvist
P.D., 2006). Yes of course it is possible that you still end up with GBS, but it is
also possible that you could prevent it.
Epidural
The term epidural is commonly used to encompass any type of anesthetic
medication used for labor and birth. There are actually three separate
procedures that can be done that are often lumped under the umbrella term,
“epidural”. The three procedures are epidurals, spinals, and the combined
spinal epidural.
An epidural blocks the nerve impulses from the lower spinal segments. The
end result is decreased sensation in the lower half of the body, with continuous
delivery of medication. A tiny catheter is in inserted into a space between your
vertebrae. Once it is in place, medication is delivered through the thin tube. It
will take around 15 minutes to work and if more medication is needed or
wanted, more can be delivered.
A spinal is a one-time injection directly into your spinal fluid. This is also
sometimes called a spinal block, and there is no continuous medication being
delivered. This gets to work pretty quickly, usually within about 5 minutes, but
it will only last an hour or two.
A spinal is frequently used in conjunction with an epidural to make a
combined spinal epidural. This takes effect within about five minutes, like a
spinal and then works to deliver continuous medication like an epidural.
For the purposes of this section we are talking about an epidural as in the
catheter in your back delivering continuous medication whether that is solely
an epidural or the combination of a spinal and epidural. If you want to get into
more detail as to your options between just an epidural and a combined spinal
epidural you will need to talk to your care provider. While they do differ, both
are delivering continuous medication. With an epidural an initial dose of
narcotic, anesthetic, or a combination of the two is injected, then the
anesthesiologist will pull the needle back into the epidural space, thread a
catheter through the needle, then withdraw the needle and leave the catheter in
place. Epidurals are common and in the United States over 60% of moms who
have a vaginal birth receive an epidural (Osterman M.J.K., 2011).
The medications used for an epidural can be a combination of more than one
drug. What medications are used, in what amounts, and for how long will all
depend on your individual needs, your care provider, and the hospital.
Different techniques, medications and doses all have different results and risks,
so it is really important to talk to your care provider about what their policy
and practices are. Knowing what your medication options are lets you make
the best choice for you and your baby. Generally, the medication you will
receive is a combination of a local anesthetic used to decrease feeling in a
specific area, like bupivacaine, chloroprocaine, or lidocaine, and an opioid like
fentanyl or morphine, which decreases the required dose of the anesthetic and
prolongs the effect, while stabilizing your blood pressure. The end result is
relief from feeling contractions with minimal effects. Depending on the
hospital and where you live, additional drugs could be added to an epidural. In
the U.K. diamorphine is also added to an epidural for a cesarean section. If
you are not familiar with diamorphine, it is medical grade heroin. When you
are talking about medications via an epidural you are dealing with some
powerful and very effective drugs.
An epidural will almost always come along with IV fluids and continuous
electronic fetal monitoring. If you know that you want an epidural but would
like to minimize IV fluids or electronic fetal monitoring, you may have limited
options. Talk to your care provider and find out what their policy and
recommendation is.
A walking epidural is really just a lower dose of medication from a combined
spinal epidural that allows you to maintain more feeling. You may not
necessarily be able to actually walk around with this. Also you will likely be
hooked up with the epidural in your back, an IV delivering fluids through a
tube in the top of your hand, and an electronic fetal monitor strapped to your
belly so you will have limited mobility, even if you do feel enough sensation to
stand up. A lower dose of medication and more sensation means it may be
easier to feel when you are having a contraction or when you need to push
during the second stage of labor.
An option you may have access to is patient-controlled epidural analgesia.
Patient controlled means a pump is connected to the epidural that has a button
you can push if you would like more medication. This gives you more control
over the amount of medication you are receiving. You don’t need to worry
about overdosing because the pump is going to be preprogrammed with limits
on how much medication can be delivered.
Depending on how numb you are with an epidural you may have difficulty
telling when you are having a contraction and this can make pushing difficult
to control. A review of 38 different studies involving nearly 1,000 women
shows that an epidural tends to make the second “pushing” stage of labor
longer (Anim-Somuah M., 2011). If you are having a tough time pushing
during the second stage of labor it is possible that your little one needs some
assistance and a vacuum or forceps will be used. Women who get an epidural
are at an increased risk for an instrumental or assisted delivery, and this almost
always comes with an episiotomy.
In the past, many doctors wanted you to be in active labor before starting an
epidural. The concern was that an epidural might slow down your
contractions. Today, many care providers will allow you to start an epidural
whenever you ask for it. Talk to your care provider about when you can get an
epidural this so you know what their policy is. If you know the second you get
to the hospital you’re going to want an epidural, you can ask the
anesthesiologist to put the catheter in place once you are settled into the
delivery room, and you can always wait to start the medication when your
labor becomes more active. You also have the option to hold off, which could
be beneficial if being more mobile is helpful for you. Your mobility will be
more limited with IVs, an epidural, and fetal monitoring. You can get an
epidural up until your baby’s head is crowning. It is very unlikely, especially if
this is your first baby, that you will get to that point in a super short period of
time.
Aside from the obvious of not feeling the discomfort of contractions there can
be some benefits to an epidural. First, having an epidural can allow you to rest.
This could be a big benefit if you have had a particularly long labor. Another
benefit is that an epidural does not knock you out, so you will still be alert and
be an active participant in your birth. As your needs change during labor, the
type, amounts, and strength of the medications can be adjusted. To minimize
feeling contractions during labor an epidural is the most widely used, and the
most effective, medication and delivery system available today.
As with any medication there are possible side effects that you might
experience. A few of these are shivering, ringing in your ears, backache, or
soreness where the needle is inserted. The narcotics delivered through an
epidural can cause itchiness, particularly in your face. The medications used
could also make you nauseous, although keep in mind you could also be
nauseous from labor without an epidural. An epidural can make it difficult to
tell when you need to urinate, and you could end up with a catheter to empty
your bladder. About 14 out of every 100 women who get an epidural end up
with a catheter. An epidural raises your risk of running a fever in labor, which
affects about 23 out of 100 women (Institute for Quality and Efficiency in
Health Care, 2012). Unfortunately we do not know exactly why this happens.
Having a fever does not increase your risk or your baby’s risk of an infection,
but since a fever is a sign of an infection, it is possible you or your baby could
end up with antibiotics unnecessarily. An epidural may cause your blood
pressure to suddenly drop; this happens in about 14 every 100 women
(Institute for Quality and Efficiency in Health Care, 2012). The issue with your
blood pressure dropping is that it also affects blood flow to your baby. A drop
in blood pressure is often treated with IV fluids, medications, and oxygen. One
side effect that affects about 1 in 100 women who receive an epidural is a
severe headache, which is caused by leakage of spinal fluid (Institute for
Quality and Efficiency in Health Care, 2012). This can be treated with a
procedure called a “blood patch”, in which a small amount of your blood is
injected into the epidural space. You can reduce the risk of headache by lying
as still as possible during the procedure while the needle is being placed. In
rare instances an epidural could affect your breathing and very rarely could
cause permanent nerve damage or result in an infection. This is an overview of
the side effects and this list is not specific to particular medications so you
definitely want to discuss any possible side effects of the specific medications
you will be given with your care provider.
There are no perfect studies with controlled test groups and it is tough to
assess exactly what the impact of an epidural on your baby is. Any medication
that you use during labor enters your baby’s bloodstream through the
umbilical cord. Many of the effects on your baby are a direct result of the
possible side effects the epidural can have on you, like running a fever or
having a drop in your blood pressure. The research available indicates
epidurals have no known long-term disadvantages, but more studies and
research are really needed.
The research on epidurals and their impact on breastfeeding is a little tough to
dissect. The studies are about split in half between those that showed a
negative association between epidurals and breastfeeding and about half of the
studies showing no effect (French C.A., 2016). It is really difficult to pinpoint a
correlation between one intervention, like an epidural, with an outcome, like
breastfeeding, because there are so many other variables. If you are planning
on an epidural and you are concerned about your baby breastfeeding take
advantage of being in a hospital and ask to see a lactation consultant to really
make sure you get off on the right foot with breastfeeding.
Much of the data on epidurals shows an increase for fetal malposition,
meaning the baby is in a "face-up" position at delivery; this usually makes for a
longer labor, higher doses of Pitocin, and a significantly higher rate of
C-sections. Epidurals are also associated with a longer second stage of labor,
and fetal distress (Osterman M.J.K., 2011).
If you are planning on getting an epidural or have any questions about it talk
to your care provider. Some questions you can ask them are:
What combination and what dosage of drugs will be used?
What are the potential side effects of these drugs?
What are your policies for procedures like an assisted delivery if an epidural
creates a need for it?
How can the medications affect my baby?
Will I be able to get up and walk around or how could my mobility could be
impacted?
Are there any restrictions of what liquids and solids I can eat or drink during
labor?
For more information on epidurals you can listen to episode 38 of the
Pregnancy Podcast at PregnancyPodcast.com/episode38.
Episiotomy
It is fairly common for first time mothers to have some tearing during a
vaginal delivery. There is also the possibility that you could have an
episiotomy. The tear or incision is to your perineum, which is the spot
between your vaginal opening and your anus. Although all of this can sound
scary, the benefits of a vaginal delivery far outweigh the downside of a tear or
an episiotomy.
To state the obvious, when your baby is born your vagina has to stretch so
they can come out. Generally they are head first, and their head is the biggest
part, once their head is out the rest of their body comes pretty easily. This
happens in the second stage of labor, which is the pushing stage. Keep in
mind, your body and these parts are made to stretch. Humans have been
giving birth for a really long time, the equipment we have works, and it was
made to do this. Unfortunately, sometimes when your skin is stretching during
birth it can tear. This tends to be common with first time moms, and is less of
an issue in subsequent births. There are some cases where your care provider
may recommend an episiotomy. An episiotomy is a surgical cut a doctor or
midwife makes to the opening of the vagina during the last stages of
childbirth, when your baby is coming out.
The good news is that there are some things you can do leading up to, and
during, your labor and delivery to help prevent tearing. If you prevent tearing,
you will also prevent an episiotomy.
Perineal massage is one thing you can do, and you can start doing this at home
after week 34 of your pregnancy. To get started, you want to wash your hands
and you will be using a mild lubricant, like K-Y jelly, almond oil, or coconut
oil, to name a few options. You put the lubricant on your thumbs and place
your thumbs just inside your vagina and you are going to press downward
toward your rectum. When you do this you hold for one to two minutes, then,
you slowly massage the lower half of your vagina. You are going to repeat the
massage for about 10 minutes, every day until delivery.
Applying a warm compress or warm oil to your perineum helps increase blood
flow to the area, and softens the tissue and the muscles there. This can help
prevent tearing. If you are considering a water birth, the warm water should
help soften the tissue to prevent a tear. Applying oil might be a little difficult
for you to do yourself during labor so you want to enlist the help of your
partner, your doula, a nurse, your midwife, or your doctor.
Using a lubricant, like a warmed mineral oil, can help to decrease friction and
help your baby slide out a little bit easier. Again, this will probably be tough for
you to do yourself so enlist the help of your doula, a nurse, your care provider,
or even your partner.
Slow pushing is another excellent way to allow your skin time to stretch during
labor. Your initial thought is probably that you want to push your baby out as
quickly as possible but there are benefits to slowing down this process. To
slow down pushing try exhale pushing. To do this you slowly breathe in and
slowly exhale; it may also help to make a low or deep sound as you push. This
will make the pushing stage a bit slower than taking a deep breath, holding it
and then pushing. When your baby starts to crown, you can switch to using
short, almost grunting, pushes. It can be hard to keep these techniques in mind
when you are in the midst of labor. Talk about this with your partner, your
doula, and any staff who will present to remind you to do this and they can
help guide you through pushing.
Vaginal tears are classified by four degrees with first-degree being the most
minor and fourth-degree being the most severe. First-degree tears only involve
the skin around the vaginal opening or perineal skin. These usually are not very
painful although you could experience some burning or stinging with
urination. A first-degree tear may or may not require stitches and usually heals
within a few weeks. Second-degree tears involve the perineal muscles, which
are the muscles between the vagina and the anus that support your uterus,
bladder, and rectum. A second-degree tear usually requires stitches and heals
within a few weeks. Both first and second-degree tears are typically stitched in
the delivery room with a local anesthetic. Third and fourth-degree tears
involve the perineal muscles and the muscles that surround the anus, and in
the case of a fourth-degree tear involve the tissue lining the rectum. These
tears can require repair in an operating room, and can take months to heal.
Some complications can be fecal incontinence and painful intercourse. Third
and fourth-degree tears are much less common than the milder first and
second-degree. Often a care provider will recommend an episiotomy if they
believe it could prevent a third or fourth-degree tear.
Episiotomy has become one of the most commonly performed surgical
procedures in the world, but that doesn’t necessarily mean that its wide use is
warranted. The Journal of the American Medical Association suggests that
between 30% and 35% of vaginal births in the U.S. involve an episiotomy
(Hartmann K., 2005). In other parts of the globe, rates range from 3.7% in
Denmark to 75.0% in Cyprus (Blondel B. & Committee, 2016). Among
midwives, who generally perform fewer interventions than a traditional
physician, episiotomy rates in the U.S. are at or below 3%.
In the past, routine episiotomies were recommended. Research has shown us
that routine episiotomies are not a good thing, and a better policy is restricting
their use. The Journal of the American Medical Association found evidence
does not support maternal benefits that were traditionally ascribed to routine
episiotomy. In fact, outcomes with episiotomy can be considered worse since
some proportion of women who would have had lesser injury instead had a
surgical incision. Those who have an episiotomy may be more likely to have
pain with intercourse in the months after pregnancy and are slower to resume
having intercourse. Clinicians have been the primary agents to exercise choice
to conduct or not conduct an episiotomy, rather than patients. Rates of
episiotomy of less than 15% of spontaneous vaginal births should be
immediately within reach. The AMA suggests episiotomies should be at 15%,
but in the U.S. the rate is closer to 30% (Hartmann K., 2005).
While routine episiotomies are generally not practiced today, the procedure is
warranted in some cases. Your care provider might recommend an episiotomy
if extensive vaginal tearing appears likely, if your baby is in an abnormal
position, if your baby is very large (as in cases of fetal macrosomia), or if an
issue arises where your baby needs to be delivered quickly.
If you need an episiotomy and you haven't had any type of anesthesia or if the
anesthesia has worn off, don’t worry you won’t feel anything. You will receive
an injection of a local anesthetic to numb the tissue. You won't feel your care
provider making the incision or repairing it after delivery.
There are two types of episiotomy incisions. The first is a midline or median
incision, which is done vertically. This is the easiest to repair, but it has a
higher risk of extending into the anal area. The second is a mediolateral
incision, which is done at an angle. This offers the best protection from an
extended tear going to the anal area, but is often more painful and might be
more difficult to repair. Research shows that a midline incision results in
deeper perineal tears, otherwise there was no statistical significant difference in
the two (Sooklim R., 2007). The type of incision used is usually at the
discretion of your doctor or midwife so this may be something you want to
bring up ahead of time if you prefer one over the other. After an episiotomy,
your care provider will repair the incision with stitches that will dissolve, and
again you shouldn’t feel a thing. If you do have any discomfort, be sure to ask
for another local anesthetic, there is no reason for you to be in any pain during
this procedure.
If your care provider uses forceps during your delivery you may benefit from
an episiotomy. A study showed that in a forceps delivery, performance of an
episiotomy decreases the risk of perineal tears of all degrees. When they
analyzed the type of episiotomy, mediolateral incisions seemed to be more
protective against perineal trauma in women undergoing forceps delivery
(Bodner-Adler B., 2003).
For more information on episiotomy you can listen to episode 22 of the
Pregnancy podcast at PregnancyPodcast.com/episode22.
Assisted Delivery
An assisted delivery, sometimes called an instrumental delivery, is when your
doctor will help in the birthing process by using instruments such as a
ventouse suction cup or forceps to help you deliver your baby. Often an
assisted delivery is accompanied by an episiotomy to allow for more room for
the instruments and a quicker delivery.
The word “ventouse” comes from the French word for “suction cup”. A
ventouse suction cup can also be referred to as vacuum-assisted vaginal
delivery, or a vacuum extraction. This method uses a metal or plastic suction
cup, which is placed onto the head of your baby, and the suction draws the
skin from the scalp into the cup. When your baby's head is delivered, which is
usually the most challenging part of delivery, the device is detached.
An alternative to a ventouse suction cup is forceps, which are a surgical
instrument that resembles a pair of tongs that fit to surround your baby’s head.
Any method of assisted delivery does come with risks to you or your baby. A
review of 32 studies, involving over 6,500 women, compared a ventouse to
forceps. The review found that forceps were more effective to achieve a
vaginal birth, however, with forceps there was a trend to more cesarean
sections, and significantly more third- or fourth-degree tears, this included
with and without an episiotomy. There was also a higher rate of vaginal
trauma, use of general anesthesia, and flatus incontinence, which is
uncontrollable gas, or other continence issues. Lastly a facial injury to the baby
was more likely with forceps. Among different types of ventouse, the metal
cup was more likely to result in a successful vaginal birth than the soft cup,
with more cases of scalp injury and cephalhematoma, which is the swelling of
an infant's scalp as a result of hemorrhaging or a collection of blood. Overall
forceps or the metal cup appear to be most effective at achieving a vaginal
birth, but with increased risk of maternal trauma with forceps and neonatal
trauma with the metal cup (O'Mahony F., 2010).
C-Sections
A cesarean section, also known as a C-section, is a surgical procedure used to
deliver a baby through incisions in the mother's abdomen and uterus. A
C-section could be planned ahead of time if you have a complication that
would make a vaginal delivery difficult or you have had a previous C-section
and aren't considering vaginal birth after cesarean (VBAC). Often a cesarean is
not planned and the circumstances of your birth change when you are in labor,
which lead to a C-section.
Since 1985, the international healthcare community has considered the ideal
rate for cesarean sections to be between 10-15%. The World Health
Organization’s official stance on C-sections is that cesarean sections are
effective in saving maternal and infant lives, but only when they are required
for medically indicated reasons. The World Health Organization states that
cesarean section rates higher than 10% are not associated with reductions in
maternal and newborn mortality rates. Cesarean sections should ideally only be
undertaken when medically necessary. The effects of cesarean section rates on
other outcomes, such as maternal and perinatal morbidity, pediatric outcomes,
and psychological or social well being are still unclear. They conclude that
more research is needed to understand the health effects of cesarean section
on immediate and future outcomes (Department of Reproductive Health and
Research World Health Organization, 2015). There is some additional research
from the Journal of the American Medical Association showing the optimal
cesarean delivery rate should be closer to 19% (Molina G., 2015). Even with
an optimal rate of 19%, actual C-section rates are much higher than that.
The overall cesarean delivery rate in the United States increased 60% from
1996 through 2009, from 20.7% to 32.9%. Since 2009, the cesarean rate has
declined slightly, to 32.7% in 2013. Even with the decline in the C-section rate,
nearly one-third of babies are delivered by this method. Of course the rate of
C-sections is much higher in high-risk pregnancies but the rate of C-sections
for low-risk pregnancies is still just over 1 in 4 births. Low-risk cesarean
delivery is defined as a cesarean delivery for a baby at 37 weeks or more,
singleton, meaning not twins or multiples, the baby is vertex, meaning they are
head first, and it is the mom’s first pregnancy. The rate of C-sections to
low-risk women has declined in recent years, it was 32.5% in 1990, and as of
2013 was 26.5% (Osterman, 2014).
If you have a non-emergency planned C-section to take place before 39 weeks
your doctor may want to test your baby's lung maturity. The last few weeks are
really critical to lung development. This test is done with an amniocentesis,
which uses a needle to take a sample of amniotic fluid from the uterus. There
can be risks associated with an amniocentesis as it is considered an invasive
test. Be sure to discuss the possible risks with your care provider.
For more information on an amniocentesis you can listen to episode 16 of the
Pregnancy Podcast at PregnancyPodcast.com/episode16.
A cesarean section is going to be accompanied by a catheter and IV fluids.
You can also expect to receive antibiotics through your IV. Antibiotics will
help prevent infection after the operation. A review of 95 studies involving
over 15,000 women found that routine use of antibiotics during cesarean
section reduced the risk of infections in mothers as well as the risk of serious
complications of infections by 60% to 70%. This was whether the antibiotics
were given before or after clamping of the umbilical cord. The review notes
that none of the studies looked properly at possible adverse effects on the
baby. Although there are benefits for the mother, there is some uncertainty
about whether there are any important effects on the baby (Smaill F.M., 2014).
If antibiotics are given before the cord is clamped they would also go to your
baby. If you have any concern about how antibiotics could affect your baby
talk to your care provider and to ask them about it and find out if it is their
practice to administer antibiotics before or after clamping the umbilical cord.
The majority of C-sections are done with an epidural or a spinal block that
numbs just the lower part of your body. With a spinal or epidural, or a
combination of the two, you remain awake and alert during the procedure.
These types of medications are extremely effective and you will not feel any
pain during the procedure, but you may still feel some pressure or a tugging
sensation during the surgery. In an emergency scenario, you could be put
under general anesthesia, which knocks you out. In this case you would not be
able to see, feel or hear anything during the birth. General anesthesia is not
routine and should only be used if absolutely necessary.
If you would like your partner to be present during the surgery they should be
able to be there, assuming there isn’t an emergency and you are not under
general anesthesia. They will get to put on a lovely operating room outfit and
will be seated by your head so they are not watching the actual procedure, but
will be right there by your side to meet your baby.
The process of a cesarean section can vary depending on your individual
circumstances but overall the procedure is going to take about 45 minutes to
an hour. In this time, your baby is usually delivered in the first 5-15 minutes,
and the remainder of the time is used for closing the incision. This procedure
will be done in an operating room by an OB-GYN.
The procedure is going to start with cleaning your abdomen and your doctor
making an incision through your abdominal wall. The incision is most
commonly done horizontally near the pubic hairline, and this is known as a
bikini incision. If the circumstances require that your baby needs to be
delivered very quickly, a vertical incision can be used and this is from just
below your navel to just above the pubic bone. The incisions are going to be
made layer by layer, these will go through your fatty tissue and connective
tissue and separate the abdominal muscle to access your abdominal cavity.
Next, an incision is made into the uterus. This incision could be horizontal or
vertical, and it does not have to be the same type of incision made in your
abdomen. The most commonly used uterine incision is a low transverse
incision, similar to the bikini incision. This has fewer risks and complications
than the other types of incisions and it may allow you to attempt a VBAC, or a
vaginal birth after cesarean, in your next pregnancy with little risk of uterine
rupture. Another option for the type of incision is a classical incision, which is
made vertically. A classical incision is usually reserved for complicated
situations such as placenta previa, extreme emergencies, or for babies with
abnormalities.
Your doctor will put up a screen above your waist so you are not watching the
surgery take place. If you want to see the actual moment your baby comes out
you can request that your doctor or a nurse lowers the screen slightly so you
can see your baby. They probably will not remove the screen entirely, but they
should be able to lower it a bit.
Once all of the incisions are made, your baby is going to be ready to make
their big entrance into the world. Your doctor will suction out the amniotic
fluid and then deliver your baby. Your baby’s head will be delivered first and
your doctor will clear your baby's mouth and nose of any fluids. Since they are
not going through the vaginal canal, which naturally squeezes fluids out of
their lungs, they may need some assistance getting fluids out. Then once their
whole body is delivered, your doctor should hold your beautiful baby up so
you can see him or her. Some care providers will first pass your baby to the
nurse for a quick evaluation, and if your baby is healthy then you should be
able to get skin to skin right away, which is really important. You and your
baby will be monitored closely for complications after the surgery and during
your recovery.
Getting skin to skin is critical, especially for a baby who is born via a cesarean.
There are many benefits of skin to skin contact. Being skin to skin stabilizes
your baby’s heart rate, breathing, and temperature, and reduces stress in both
you and your baby. It also increases your interactions with your baby and
increases the likelihood and length of breastfeeding. You can talk to your
doctor about how soon you can hold your baby after they are born and let
them know that it is a priority for you. Most hospitals are supportive of skin to
skin contact right away, but definitely bring it up with your care provider well
before your baby is born to find out how skin to skin contact works with a
cesarean delivery.
Even with a cesarean you can still potentially delay clamping of the umbilical
cord, have your placenta encapsulated, or bank cord blood. These topics are
covered in detail in chapter 11. Work out the details of the timing of the cord
clamping with your care provider beforehand. Regardless of what you choose
to do with cord clamping, blood banking, or placenta encapsulation, the
placenta will need to be removed from your uterus, you could feel some
tugging while this is going on. Then the last thing your doctor will do is close
up all of the incisions with sutures.
There are two options for how cesarean section uterine incisions can be
closed, either with a single layer or a double layer of sutures. In the 1990’s, the
single-layer technique was touted as having fewer complications and became
pretty widely accepted in the medical community, because short term it
seemed like the single layer technique was better. There have been questions
raised about whether a single-layer closure is linked to complications in the
long term, specifically with a subsequent pregnancy. There have been links to
higher rates of uterine rupture and placenta accreta, both of which can be
life-threatening complications.
Ina May Gaskin, who is known as the authority on midwifery, has written a
strong letter against the practice of suturing the uterine incision in one layer
(Gaskin, Reprint of Email From Ina May Gaskin).
A study involving over 2,000 women from 1988-2000 concluded that a
single-layer closure of the previous lower segment incision was the most
influential factor and was associated with a 4-fold increase in the risk of uterine
rupture compared with a double-layer closure (Bujold E. B. C., 2002). A study
published in 2006 concluded that single-layer uterine closure might be more
likely to result in uterine rupture. Of the 948 subjects in this study most had a
double-layer closure and only 35 participants had a single-layer closure so that
group was a much smaller sample size (Gyamfi C., 2006). A study published in
2010 with 288 participants concluded that prior single-layer closure carries
more than twice the risk of uterine rupture compared with double-layer
closure. Single-layer closure should be avoided in women who could
contemplate future vaginal birth after cesarean delivery (Bujold E. G. M.,
2010).
The International Cesarean Awareness Network (ICAN) is a non-profit
organization aimed to reduce the current high cesarean rate and they published
a paper that argues pretty strongly against the notion that a single-layer closure
is associated with a higher risk of uterine rupture in a subsequent pregnancy
and they argue that a single-layer closure has lower rates of complications
following the surgery (Humphries, 2014). ICAN cites a study done with 768
women, of which 267 had a single-layer closure, and the study concluded that
a single-layer uterine closure is associated with decreased blood loss, a shorter
operating time, decreased cases of endometritis, and a shorter postoperative
hospital stay. They go on to state that a single-layer closure is not associated
with uterine rupture or other adverse outcomes in the subsequent pregnancy
(Durnwald C., 2003).
If you are concerned about how your care provider will stitch up your incision
from a cesarean section talk to them about it and ask them what their
preferred procedure is and why. If you have any questions about long term
risks if you have another baby then be sure to ask.
Like any other major surgery, C-sections carry risks and you will want to
discuss these with your care provider in detail. Some of the risks include:
Endometritis, which is inflammation and infection of the membrane lining the
uterus, and this can cause fever, foul smelling vaginal discharge and uterine
pain.
You could have increased bleeding because you are likely to lose more blood
with a C-section than with a vaginal birth.
You could have an adverse reaction to the anesthesia.
Blood clots can be a pretty serious risk and your chances of them are higher
with a C-section than a vaginal delivery. Walking can help prevent blood clots
and this is why your doctor will have you walking shortly after your surgery.
The incision could get infected.
Although it is rare, there is the possibility of an injury to nearby organs during
the surgery, and this would require additional surgery to repair the injury.
There is an increased risk of complications in subsequent pregnancies, like a
potential uterine rupture.
There are also some risks to your baby from a cesarean section. Problems
breathing, like transient tachypnea, which is abnormally fast breathing during
the first few days after birth, or respiratory distress syndrome which makes it
difficult for your baby to breathe. Although it is rare, there is also the
possibility of an accidental cut to your baby's skin during surgery.
There are a lot of reasons that you could be planning a scheduled C-Section
for the birth of your baby. This is something you are going to be working with
your doctor on and make sure that you are weighing all of your options,
looking at all the scenarios, and doing what is best for you and your baby.
Cesarean sections can be a lifesaving procedure, and there are times when it is
safer to deliver a baby via C-section, and in those cases, we are very lucky to
have that option available to us.
Some health conditions like heart disease, diabetes, high blood pressure or
kidney disease could make a vaginal delivery very stressful to your body and
your doctor may suggest that a C-section is a better option. If you have an
infection that could be passed to your baby during a vaginal birth, like herpes
or HIV, a C-section could prevent your baby from becoming infected. A
C-section may also be needed if you have a mechanical obstruction like a large
fibroid obstructing the birth canal, a severely displaced pelvic fracture, or if
your baby has severe hydrocephalus, which is a condition that can cause their
head to be unusually large. Your baby could have an illness or a congenital
condition, like open neural tube defects, which could make a vaginal birth
stressful for your little one. A C-section can be planned if your baby has a
condition called macrosomia, which is a big word for having a large baby.
Sometimes care providers will be concerned that a large baby will not be able
to safely travel through the birth canal.
If your baby is in an abnormal position a C-section may be recommended.
This could be if their feet or bottom enters the birth canal first, which is
breech, or if your baby is positioned side or shoulder first, which is transverse.
In cases of twins it is pretty common for one baby to be head down, and the
other to be breech. Often if the first baby is head down and can be delivered
vaginally, your doctor will deliver the second baby vaginally, even if they are
breech. If you are expecting twins, find out what your care provider’s policy is.
A C-section could be planned if there is a problem with your placenta. This
could happen if have placenta previa, where your placenta covers the opening
of your cervix. If you had some other kind of invasive uterine surgery, like a
myomectomy, which is the surgical removal of fibroids you could have a
planned C-section. Also if you have already had a previous C-section and are
not considering a VBAC.
Other complications like preeclampsia, which is pregnancy-induced high blood
pressure, or eclampsia, which is a very rare progression of preeclampsia, your
practitioner might suggest a cesarean to protect both of you and your baby.
Obesity significantly increases your chance of needing a C-section. This is
partially due to other risk factors that often accompany obesity, and partially
because obese women tend to have longer labors, which can increase your risk
of having a C-section.
The last reason you may have a planned C-section is just because that is how
you want to deliver your baby, and an elective C-section is an option. Doctors
generally will not do an elective C-section prior to 39 weeks. You know those
last few weeks are really critical for lung development. If this is something you
are considering, as with any intervention, you definitely want to talk it over
with your care provider, do your research, and weigh the pros and cons to
make sure you are making the best decision for you and your baby.
There are quite a few reasons that you could have an unplanned or an
emergency C-section. Don’t let this list freak you out. The more you plan and
prepare for the birth experience you want, the more you will minimize the
chances of a cesarean section. Even if the last thing in the world you want is a
C-section getting educated about what is involved and what your options are
will be beneficial. Talk to your care provider about the possibility of a
C-section and what their procedures are. Ask any questions you have, share
any of your concerns, and your partner’s concerns. If you do this beforehand,
and something doesn’t go as planned, and you end up meeting your baby via
cesarean you will be so much better off going into this knowing what to expect
and knowing what your options are. In an emergency scenario, your doctor
may not be able to fully explain the procedure and answer all of your
questions. Over 25% of C-sections are with low-risk pregnancies (Osterman,
2014), a lot of these are women who went into labor planning not to have a
C-section.
One big reason, and the most common reason, for an unplanned C-section is
that your labor is not progressing. You should be well versed in the
interventions, both artificial and natural, that can be applied in this case. There
are some interventions that increase your risk for a cesarean section. Some
other reasons for an unplanned C-section include:
Your baby’s heart rate will be monitored during labor and if your doctor is
concerned that your baby is not getting enough oxygen, they may suggest a
C-section.
If there is a problem with the umbilical cord, which could happen if the
umbilical cord slips through your cervix ahead of your baby, this is called a
prolapsed umbilical cord. If the cord is compressed by the uterus during
contractions or is compressed as your baby comes through, and is cutting off
the oxygen supply to your baby, this could create the need for a C-section.
In the case of a placental abruption, which means your placenta starts to
separate from your uterine wall, an emergency C-section is done. A placental
abruption can compromise your baby’s oxygen supply, and that is why it is
considered an emergency.
You can see that there are some things that can be out of your control and
create the need for a cesarean section. Even if you are planning the most
natural birth possible, it is a good idea to know about C-sections just as some
emergency preparation if it were to come up.
Vaginal Birth After Cesarean (VBAC)
VBAC stands for vaginal birth after cesarean. In the past it was assumed once
you had one cesarean section, every subsequent birth would also need to be
via cesarean. A VBAC is not recommended if you had a uterine rupture during
a previous pregnancy or if you had a classical incision in a C-section. A
classical incision is a vertical incision in the upper part of your uterus and this
carries a higher risk of uterine rupture than the more commonly used low
transverse uterine incision. A uterine rupture can occur when your uterus tears
along a scar from a previous C-section, and this requires an emergency
C-section.
Today VBAC is becoming more popular. The majority of women who have
had a cesarean are a candidate for a VBAC. Of women who plan for a VBAC,
about 60-80% are successful (American Congress of Obstetricians and
Gynecologists, 2010).
If you are planning a VBAC the first and most important step is to work with
a doctor or midwife who is supportive of your decision and make sure they are
100% on board with your birth plan. Also, make sure to discuss your plan B in
the event a cesarean becomes necessary. There are a few things you can do to
increase your chances of a successful vaginal delivery.
If you are planning a VBAC take into consideration any interventions that
could increase your risk for a cesarean. Interventions are discussed in detail in
Chapter 8. A study of over 6,000 women attempting a VBAC did find that
induction of labor before 40 weeks in women with one prior cesarean delivery
is associated with an increased risk of failed VBAC, and required a cesarean
delivery (Lappen J.R., 2015).
To increase your success of having a VBAC you want to stack the odds in your
favor as much as possible. The more things you can do to decrease your risk
of having a C-section, the better. First you definitely want to be working with a
doctor or midwife who is supportive of VBACs. There is some research that
shows inducing labor increases the risk of a failed cesarean, so the preference
would be to go into labor naturally without an induction. Getting a doula
could be a huge asset for you during your labor and birth as studies show
having a doula decreases your risk of having a cesarean (Hodnett E.D., 2012).
Chapter 9: Natural Birth
Natural birth is defined as childbirth without routine medical interventions,
particularly anesthesia.
Let’s take a look at what the natural birth process looks like from beginning to
end, without interventions. Our understanding of this process, the hormones
involved, and how they impact labor and birth is constantly improving. We do
not know exactly how everything works but our overall understanding of the
uninterrupted birth process may help explain why some moms choose a
natural birth.
As your baby and your body get ready to go into labor your placenta triggers
an increase in prostaglandins that soften the cervix to prepare it for effacing
and dilating. Your levels of estrogen rise and the levels of progesterone
decrease which makes the uterus more sensitive to oxytocin. During labor and
birth oxytocin is the driving force of your contractions. In cases of a labor
with interventions, Pitocin is commonly used to both start labor and progress
labor, and this is a synthetic version of oxytocin. Your labor will progress best
in an environment where you feel safe and relaxed. In the wild most animals
retreat to a quiet safe place to give birth. If there is any sign of danger their
bodies will literally halt the birth so they can react to the threat and find safety.
Humans operate the same way. Part of having a natural birth is being in an
environment where you feel safe and supported to allow your body to do what
it needs to do. Oxytocin is the hormone primarily responsible for causing your
contractions, and the levels of oxytocin will be highest when you are in a safe
environment. It is really this symphony of everything working together in sync
that starts your labor naturally, when both you and your baby are ready.
As part of the natural labor process, in the first stage of labor when your
cervix is dilating and effacing, your body produces a hormone called
beta-endorphin. Beta-endorphin is a stress hormone, and it is released under
conditions of duress. This hormone acts as an opiate or painkiller. It also
suppresses the immune system, which is thought to be important in preventing
your immune system from acting against your baby, who has different genetic
make-up from you. When you are in labor and high levels of beta-endorphin
are released this is going to reduce the levels of oxytocin being released, which
can slow down your contractions. While this may seem counterproductive to
birth, this keeps labor at a pace where you are able to experience the positive
effects and relief from beta endorphins, and at a pace where your body can
handle the stress. Beta-endorphin is similar to morphine. This applies to more
than the pain relief aspect of it, and beta endorphins induce feelings of
pleasure and euphoria. The high levels being released during birth help you
enter an altered state of consciousness. This might sound a little out there, and
what this basically means is that you are on a high, similar to being high on a
drug, but without any of the negative side effects. You will sometimes hear
birth educators or practitioners talk about a birthing mother being in labor
land. This is used to describe this sort of meditative state where you are zoned
out of what is going on around you and focused on what is going on internally
with your baby and your body.
At the end of the first stage of labor your cervix is fully dilated at 10
centimeters and you enter the transition phase which is taking you into the
second, or pushing stage of labor. This is where your fight-or-flight hormones
come in, which are classified as catecholamines. These include adrenaline, also
called epinephrine, and noradrenaline, also known as norepinephrine. These
hormones are secreted from your adrenal gland in response to stress, and they
get your body ready for a fight-or-flight response. While these hormones can
slow things down a bit in the first stage of labor, they act differently in the
second stage just before your baby is born. Right before the moment of birth
there is a sudden increase in catecholamines, especially noradrenaline, and this
works with oxytocin, which activates the fetal ejection reflex. Stereotypically
when this happens you are going to get a sudden rush of energy, you will be
upright and alert, your mouth will be dry, and your breathing will be shallow.
You could express fear, anger, or excitement, and the rush of these fight or
flight hormones is going to cause several very strong contractions, which are
designed to birth your baby quickly and easily. These hormones will also act to
help your baby during birth by protecting them against the effects of hypoxia,
which is a lack of oxygen, because when your uterus contracts oxygen flow is
temporarily restricted. After the birth, your levels of catecholamines drop
sharply which will help your body release more oxytocin.
Once your baby is born you will immediately get skin to skin. Oxytocin is
continuing to be released which is going to continue contractions, which will
be much milder than the ones you experienced during birth. The purpose of
the continued contractions is to push the placenta out of your uterus, close off
the blood vessels that were attached to it, and start shrinking your uterus. This
process is important to prevent postpartum hemorrhage, which is heavy
bleeding and can be a serious complication.
All of the hormones you are producing during birth are also being transferred
to your baby. Immediately following birth both you and your baby are going to
have really high levels of oxytocin and this is going to help promote bonding.
The fight or flight hormones are going to make your baby alert for their first
contact with you. The skin to skin contact after birth is going to soothe your
little one and help to lower those levels of adrenaline and noradrenaline.
One of the first things that happens naturally after birth is that your baby
instinctively wants to latch on to breastfeed. If a newborn is placed on your
abdomen after birth they will use all of their senses (sight, touch, taste, smell,
and sound) to instinctively crawl up to your breast and latch on. Babies come
pre wired to breastfeed and birth hormones have a lot to do with the process
of your body producing milk and the breastfeeding relationship. The hormone
most associated with breastfeeding is prolactin, and it is also known as the
mothering hormone. Throughout your pregnancy you be producing higher
than normal levels of prolactin but production of milk is inhibited until the
third stage of labor when you birth the placenta. Your level of prolactin
decreases during labor, increases at the end of your labor, then peaks at birth.
This hormone is going to help with breastfeeding, not just by physically
helping you to produce milk, but it also fosters nurturance from you to your
baby and that will overall help your breastfeeding relationship. Another factor
that will help breastfeeding is a peak in your levels of beta-endorphin about 20
minutes after birth; this also ends up in your breast milk and fosters some
dependency between you and your baby. Oxytocin also plays a part to help
promote the letdown reflex, which is the reflex that causes milk, or initially
colostrum, to be released, and this is going to help signal your body to produce
milk.
You can see that labor and birth is a really complex process with a lot of
moving parts. Although we are constantly improving our understanding of
how everything works with a natural labor, we do not fully know the effects of
everything going on.
There are some expecting moms who are at a high-risk and their doctor or
midwife would not recommend a natural birth or they may recommend some
interventions or procedures. You will need to be working with your care
provider to decide which course of action is going to be the best one for you
to take and weigh the benefits and risks of your specific situation. The bottom
line is that you have choices. You do not have to make a choice between
having your baby in a bathtub at home or in a hospital with a C-section. Your
birth is not a black and white choice between two opposing options. You have
an infinite number of options and there are a lot of shades of grey where you
can combine the tools, techniques, and procedures you think will be best for
you and your baby and really craft the birth experience you want.
For more information on natural birth you can listen to episode 40 of the
Pregnancy Podcast at PregnancyPodcast.com/episode40.
Chapter 10: Water Birth
There are legends of women in different cultures laboring in water dating back
quite a ways but there isn’t documentation of anyone actually giving birth in
water until 1803 in France. Then it wasn’t until the 1980’s that the popularity
of water births began growing in Western cultures, and today it is becoming
increasingly popular. Proponents of water birth claim that it is beneficial in
management of discomfort from contractions, that it promotes relaxation, and
that it eases stress for your baby during birth. Critics of the practice raise
concerns about the safety of water birth, risks associated with respiratory
issues for your baby, and the risk of infection for both you and your baby.
Water birth may be an option for you if you are planning a natural labor and
are considered low-risk. You will need to be planning on having your baby at a
venue that accommodates water birth, with a care provider who is supportive
of the practice, and who has experience attending water births. While more
hospitals are beginning to offer this as an option, the majority of water births
are taking place in homes or at birth centers, under the care of a midwife.
During a water birth you are partially immersed in a tub of warm water. The
temperature of the water is about body temperature. Generally the tub is larger
than a standard bathtub and is either a built-in tub or a portable inflatable
pool. You will be naked from the waist down in a tub during labor. Some
women choose to wear a sports bra and some women prefer not to wear
anything, ultimately whatever you are most comfortable in. Your partner may
be able to join you in the tub if that would assist you. Even if you are not sure
if you will want your partner in the tub, they should have swimwear on hand
just in case.
Immersion in water could be helpful in the first stage of labor even if you are
not planning to birth your baby, or go through the second stage of labor in the
tub. In a tub of warm water you are free to move around in different positions
and may find some relief from the buoyancy of water. If you do choose to
have an underwater birth and be immersed in water for the second stage of
labor you should know that it is common for babies born in water to take a
little bit longer to get their color.
Your labor is going to progress best when you are comfortable. Your needs
and the positions you choose will evolve as your labor progresses. It is possible
you find being in a tub wonderful in the beginning and at some point decide
you prefer to be on dry land. Give yourself some wiggle room to change your
plans if needed and if at any point a tub isn’t working for you, get out and try
something else. You can always get back in.
One of the most common questions about water birth is whether your baby
could drown under water. The first thing you should know is that your baby’s
oxygen supply is coming through the umbilical cord. Your baby’s oxygen
supply is monitored by their heart rate, which would slow down in the event
they were not getting enough oxygen from the placenta. Your care provider
will be intermittently monitoring your baby’s heart rate with a hand held
waterproof Doppler. There is a complex chain reaction that takes place once a
baby is born that initiates their first breath of air. Once your baby is born you
or your care provider would be gently lifting them out of the water where they
would take their first breath of air, and you wouldn’t leave them in the water
for any extended period of time.
A review of 12 trials, including over 3,200 women found that being immersed
in water for the first stage of labor was associated with a significant reduction
in the rates of epidural or other types of anesthesia and the first stage of labor
was about a half of an hour shorter. There was no difference in the rates of
assisted vaginal deliveries, cesarean sections, use of Pitocin, perineal trauma, or
maternal infection. There were also no differences in neonatal outcomes for
Apgar scores of less than seven at five minutes, neonatal unit admissions, or
neonatal infection rates. Of the three trials that compared water immersion
during the second stage with no immersion, one trial showed a significantly
higher level of satisfaction with the birth experience. This review did note that
a lack of data for some comparisons prevented robust conclusions and further
research is needed (Cluett, 2009). Another study found that water births had
shorter second and third stages of labor compared to vaginal deliveries on dry
land, both with and without an epidural (Mollamahmutoğlu L., 2012).
An Italian study of 2,625 water births found shorter labor duration, a net
reduction in episiotomy rate, and a marked drop in requests for pain relievers.
The study mentions that during the birth of the baby, fecal matter is released
into the birth pool water, contaminating it with microorganisms. Despite this,
water birthing was found to be safe for the neonate and did not carry a higher
risk of neonatal infection when compared with conventional vaginal delivery
(Thöni A., 2010).
As is the case with so many pregnancy and birth procedures there is no
perfectly controlled study that gives us a solid answer as to whether water birth
is safe and effective. Two major authorities on pregnancy and birth, the
American Academy of Pediatrics and the American Congress of Obstetricians
and Gynecologists both agree on the official opinion issued on water births.
Both organizations state that immersion in water during the first stage of labor
may be associated with decreased pain or use of anesthesia and decreased
duration of labor. They go on to state there is no evidence that immersion in
water during the first stage of labor otherwise improves perinatal outcomes,
and it should not prevent or inhibit other elements of care. The safety and
efficacy of immersion in water during the second stage of labor have not been
established, and immersion in water during the second stage of labor has not
been associated with maternal or fetal benefit. Given these facts and case
reports of rare but serious adverse effects in the newborn, the practice of
immersion in the second stage of labor (underwater delivery) should be
considered an experimental procedure that only should be performed within
the context of an appropriately designed clinical trial with informed consent
(American Academy of Pediatrics, 2014) (American Congress of Obstetricians
and Gynecologists & The American Academy of Pediatrics, 2014).
The American College of Nurse Midwives has issued an official statement in
support of water birth and states that labor and birth in water can be safely
offered to women with uncomplicated pregnancies and should be made
available by qualified maternity care providers. Labor and birth in water may
be particularly useful for women who prefer physiological childbirth and wish
to avoid use of pharmacological pain relief methods (American College of
Nurse Midwives, 2014).
If you are interested in a water birth you will want to discuss your options with
your care provider and make sure you are a good candidate given the specifics
of your pregnancy and any possible risk factors. If water birth is not an option,
because your care provider has concerns, or the policy of the hospital does not
allow it, you may still be able to take advantage of some of the therapeutic
aspects of water. You can take a warm bath in the early stages of labor at
home. Once you are in labor at the hospital a shower may be soothing. You
may even be able to take a plastic chair in the shower and sit on it backwards
to get the shower on your back, which could be helpful and relaxing.
For more information on water birth you can listen to episode 45 of the
Pregnancy Podcast at PregnancyPodcast.com/episode45.
Chapter 11: The Placenta and Umbilical Cord
When an egg is fertilized and the egg implants into your uterine wall the
placenta starts forming. The placenta is an organ with a highly specialized
purpose, and that is to support the normal growth and development of your
baby. Oxygen and nutrients are transferred from you to your baby. Carbon
dioxide and other waste products are transferred from your baby through the
placenta and to your blood supply. Beginning around week 20 of your
pregnancy, antibodies pass through the placenta to help protect your baby in
utero. The antibodies being passed to your little one will help protect them
during the first few months of their life and are the building blocks for their
immune system. You already know that hormones rule everything during your
pregnancy; your placenta plays a big role in secreting hormones that are crucial
for your baby. This includes hCG, commonly known as the pregnancy
hormone. HCG controls a lot and is also the indicator that turns your
pregnancy test positive. The placenta secretes estrogen and progesterone and a
few other hormones that are essential for your baby’s development and your
body during your pregnancy. Lastly, your placenta acts as a reservoir of blood
for your little one. You can see that the placenta is a pretty amazing organ,
your baby would not be able to survive without it.
The placenta is attached on one side to your uterus, and is connected to your
baby by the umbilical cord. The umbilical cord is your baby’s lifeline. At birth
this will be about 20 inches, or 50-70 centimeters long, and .75 inches or 2
centimeters in diameter. The cord contains the umbilical vein, and two
umbilical arteries. The umbilical vein carries nutrient rich, oxygenated blood
from the placenta to your baby and the umbilical arteries carry deoxygenated,
nutrient-depleted blood from your baby to the placenta.
Delayed Cord Clamping
When your baby is born blood will continue to flow between the placenta and
your baby through the umbilical cord for a few minutes following birth. The
net blood volume transferred to your baby during this time is called a placental
transfusion. This transfer can give your baby about a fifth of their blood
volume at birth, and this may make a difference to their health. This additional
supply of blood provides extra iron, which can help guard against anemia in
the first year of life, and it is enriched with immunoglobulins and stem cells.
Placental transfusion drains the blood left in the placenta, which may help the
placenta separate from the womb and may reduce overall blood loss at birth
for you.
At some point after your baby is born, a clamp is put on the umbilical cord
and the cord is cut. Once the cord is clamped, no blood is flowing so the
timing between clamping it and cutting it is insignificant and usually cutting is
done immediately after clamping it. The umbilical cord has no nerve endings
so it is painless and neither you nor your little one will feel anything when this
happens. The big question is when to do this. Do you clamp and cut the cord
immediately or wait 3 minutes, or do you want to wait until the cord stops
pulsating, which is closer to 10 minutes?
To cover all of your options there is something called a lotus birth, and this is
where the cord is not cut at all. This means that your baby remains attached to
the placenta until the cord naturally separates, and this usually happens
somewhere between 3 and 10 days after birth. During this time the placenta is
stored in a bag or container and must be carried around with your baby. The
term lotus birth was coined in 1974 after Claire Lotus Day observed that
chimpanzees do not sever the umbilical cord of their babies. This is not the
most common practice but some mother’s do it. If this is something you are
considering you would definitely want to make sure that you are not exposing
your little one to a risk of infection and talk to your care provider about the
best way to minimize that risk.
The World Health Organization (WHO) recommends late cord clamping,
which is performed approximately 1–3 minutes after birth. The WHO does
not recommend early umbilical cord clamping, which would be less than one
minute after birth, unless the there is an emergency where your baby needs to
be moved immediately (World Health Organization, 2014).
The American Congress of Obstetricians and Gynecologists (ACOG) notes a
study that found full term infants receive a transfer of approximately 80 ml of
blood from the placenta in the first minute, and a total of 100 ml within three
minutes. ACOG notes that systematic reviews of other studies have suggested
that clamping the umbilical cord in all births should be delayed for at least
30–60 seconds. The reasoning behind the recommendation to delay is based
on the benefits including; increased blood volume, reduced need for blood
transfusion, decreased incidence of intracranial hemorrhage in preterm infants,
this is bleeding in the skull, and decreased frequency of iron deficiency anemia
in term infants. In addition, a longer duration of placental transfusion after
birth may be beneficial because this blood is enriched with immunoglobulins
and stem cells, which provide the potential for improved organ repair and
rebuilding after injury from disorders caused by preterm birth (American
Congress of Obstetricians and Gynecologists Committee on Obstetric
Practice, 2012).
Clearly there is a lot of evidence to support delayed clamping. How did the
practice of clamping the cord immediately after birth ever start in the first
place? This became pretty standard practice in the 1960’s because it was
thought to reduce the likelihood of postpartum maternal hemorrhage. The key
word here is thought. Although more research needs to be done to know the
effect of delayed cord clamping on maternal outcomes, immediate clamping
does not reduce hemorrhaging. A review of 15 randomized trials involving a
total of 3,911 women and infant pairs showed no significant difference in
postpartum hemorrhage rates when early and late cord clamping (generally
between one and three minutes) were compared. There were, however, some
potentially important advantages of delayed cord clamping in healthy term
infants, such as higher birth weight, early hemoglobin concentration, and
increased iron reserves up to six months after birth. The study notes that these
benefits need to be balanced against a small additional risk of jaundice in
newborns, which requires phototherapy (McDonald S.J., 2013).
The main instance where immediate clamping would be necessary is in an
emergency when you or your baby are in danger. As long as you and baby are
doing well after birth, your care provider may delay clamping the cord.
Delayed cord clamping is not just for mothers who are having vaginal births
with full term babies. This practice can still be applied if you are having a
C-section or if your baby is premature.
There is still a transfer of blood that takes place after a cesarean birth and
delayed cord clamping can still be beneficial. An approach your care provider
may employ if you are having a C-section is to milk the umbilical cord. This is
exactly what it sounds like, the cord is squeezed from the placenta towards
your baby to help transfer blood between the two. In a C-section where time
and speed are a concern, milking the cord may allow more of a transfer of
blood.
Delayed clamping can be even more critical in a premature baby. There is a
review of 15 randomized controlled trials with 738 babies born prematurely
between 24 and 36 weeks' gestation by cesarean section or vaginal birth. These
studies compared babies where the cord was clamped within a few seconds of
the birth with those whose cords were clamped after a delay of at least 30
seconds. The maximum delay in cord clamping was 3 minutes. Providing
babies with additional blood through delayed cord clamping or milking the
cord before clamping helped the babies to adjust to their new surroundings.
Fewer babies needed transfusions for anemia, the risk of bleeding in the brain
(intraventricular hemorrhage) was reduced, and the risk of a severe infection in
the bowel (necrotizing enterocolitis) was reduced. Further studies are needed
comparing the two methods of milking the cord or allowing it to transfer
blood on its own, to deliver placental blood to babies to see which has the
most benefit (Rabe H., 2012).
There is clear evidence that delaying cord clamping can be beneficial to both
you and your baby. If this is something you want to do, the first thing is to ask
your doctor or midwife what their practice or policy is. If they have a policy of
clamping at one minute but you want to wait three minutes you need to make
sure your wishes are known. Perhaps you are comfortable with your care
provider clamping it at one minute. Or some women prefer to wait until the
cord stops pulsating on its own and this usually is closer to 10 minutes.
For more information on delayed cord clamping you can listen to episode 26
of the Pregnancy Podcast at PregnancyPodcast.com/episode26.
Placenta Encapsulation
After the birth of your little boy or girl is the third stage of labor, and this stage
involves the placenta detaching from your uterine wall and it will come out the
same way your baby did. Once your baby is born should the placenta be
discarded or could it be useful in helping you adapt and thrive in the
postpartum period? Consumption of placenta by a mom after birth has been a
taboo subject and has been gaining popularity in recent years. The thought of
eating your placenta might gross you out at first but once you hear about some
of the amazing benefits women claim it has you might be willing to consider it.
Human placentophagy is the technical term for eating your placenta. This can
be either raw or altered by cooking, drying, or steeping it in liquid.
The list of potential benefits of placentophagy is pretty impressive and
includes replenishing depleted iron, increasing energy, lessening the amount of
postnatal bleeding, increasing milk production, balancing out hormones, and
helping your uterus return to its pre-pregnancy state.
One of the biggest reported benefits of this list is balancing out hormones,
which theoretically should help with the baby blues and/or postpartum
depression. You have major drops in hormone levels following birth. If you
have made it through your first trimester you know firsthand how hormones
can make your moods swing all over the place and make you an emotional
mess. Combine this with sleep deprivation, the physical stress after having a
baby, your body healing, possibly dealing with breastfeeding challenges, and
the stress of taking care of a newborn and you have the perfect storm to be
bummed out after having your little one. The postpartum period is quite an
adjustment as you are navigating being a new parent and your body is healing.
If it is possible that consuming your placenta in some way could help you
adjust it is definitely worth looking into.
There is no perfect placebo controlled study to give us black and white
benefits or risks of consuming your placenta. Without a study showing a large
group of women who ate their placenta, compared to a group who was given a
placebo, the only evidence we have is anecdotal. The evidence we do have
access to is a growing number of women who will rave on and on about how
their experience with placenta encapsulation or eating their placenta raw was
amazing. Just as no studies exist to prove any of the benefits, there are no
studies that show that there is zero risk in consuming an organ that has acted
as a filter to absorb and protect your developing baby from toxins and
pollutants. Most of the time any conversation about placenta encapsulation is
dominated with stories of how amazing it is, and many women feel it was an
excellent choice. There has been some concern raised about the safety of
ingesting your placenta.
If you really want to dig into the science side of this debate a computerized
search of all of the big scientific journals from 1950 to 2014 for anything
published in the scientific or medical community of placentophagy
summarizes the findings of a total of 49 articles. The findings noted that
overall the health benefits and risks of placentophagy require further
investigation. As to risks, the placenta is not sterile and one function of the
placenta is to protect the fetus from harmful exposure to substances. As a
consequence, elements including selenium, cadmium, mercury, and lead, as
well as bacteria have been identified in post-term placental tissues. There have
been some studies on animals, such as rats, consuming placenta immediately
after birth, but overall the results are inconclusive. From a scientific
standpoint, more research is needed to determine whether benefits can be
replicated in other populations with sound research methodology (Coyle C.,
2014).
One resource, often cited as evidence of the benefits of placenta
encapsulation, was a survey done by UNLV researchers who surveyed 189
women who ate their placenta, most of them in capsules. Overall, 96% of the
women said they had a “positive” or “very positive” experience consuming
their placenta, and 98% said they would do it again. About 57% of women in
UNLV’s study reported no negative effects from ingesting placenta. The most
commonly reported negative experience revolved around the pill's taste and
the "ick" factor of consuming placenta. As reported by the participants in the
survey, the top positive effects were improved mood, increased energy, and
improved lactation. The top negative side effects were unpleasant burping,
headaches, and an unappealing taste or smell (Takahashi, 2013).
One recurring theme is the possibility that consuming placenta has positive
effects due to the placebo effect. Obviously the reason anyone would
encapsulate their placenta is because they perceive multiple postpartum health
benefits. These are benefits drawn from the media, friends, family, doulas,
midwives, and even doctors.
It would be easy to assume you can do whatever you want with your placenta,
but that may not be the case. You need to check with your state and the
hospital or birth center where you are planning to have your baby to make sure
that you can remove your placenta. This shouldn’t be an issue at most birth
centers and it is becoming more and more common for hospitals to allow you
to take your placenta home, or have someone else take it to prepare it. Some
hospitals label the placenta as medical waste and deem it hazardous to release
it to a patient to take home. This may be partly for liability reasons. If you
want your placenta after birth, check the policies of your care provider, talk to
your doctor or midwife, and make sure it is an option.
There are many different ways that you could consume your placenta. Since
the placenta is an organ, it should be treated just the same way meat would as
far as safety goes. If you are planning to eat it raw it should be stored in the
fridge and consumed within 3 days. You can also freeze it for up to six
months. The most common way of eating your placenta raw is to put it in a
smoothie. Another option is to cook it. A quick Google search will bring up
recipes covering everything from lasagna to pizza and sandwiches. People get
pretty creative with placenta recipes. Some moms prefer the raw method to
cooking or drying the placenta because they believe that nutrients are lost
during the steaming or cooking process. If all of this sounds off putting to you
there is another option, which is much easier for many women to stomach,
and that is placenta encapsulation. This is the most common, and perhaps the
most socially accepted, method used.
Once your placenta is out, it should be refrigerated until it is treated and
processed to be encapsulated. Typically, the person who is taking care of the
encapsulation for you will pick up your placenta and the first step in the
process is to drain and clean it. The next step will vary depending on the
method being used to encapsulate your placenta. According to the traditional
Chinese medicine method, it is steamed with herbs. Traditionally this includes
lemongrass, ginger, and spicy green pepper. The other option is the raw
method, which skips the step of steaming it with herbs. If you are into raw
foods and eat a raw food diet, this option may be more aligned with your
lifestyle. The next steps are the same regardless of the method being used. The
placenta is sliced very thinly and put in a dehydrator. Once the placenta is
dehydrated, it is ground up and put into gel capsules. There are different types
of gel capsules and if it is important for you to have vegetarian or vegan
capsules, or if you want to know your options on this be sure to ask about it.
This entire process takes between 1-3 days and once the capsules are done
they are delivered to you and you can start taking them right away. You will
want to store them in a cool dry place and probably take a few capsules a
couple of times a day. Depending on your total supply, you should have pills
for about a month, and you would want to take these within 6-12 months max.
There is no standard on dosage. Talk with your care provider and the person
who will be encapsulating your placenta to figure out what will be best for you.
It is possible to DIY placenta encapsulation if you want to get really hands on.
If you are considering this keep in mind that you will probably have your
hands pretty full, especially in the first few days. Most moms who choose to
have their placenta encapsulated will outsource it to a doula or midwife who
specializes in the process.
The last option available to you is to have a tincture made from your placenta.
This is a good option to stretch out the length of time you can use it. A small
portion of your placenta is added to over 100 proof alcohol and ferments for 6
weeks. There are women who do this and save it to take later as a mood
stabilizer during their menstrual cycle to help with PMS or even much later in
life when they are going through menopause. We aren’t going to get into the
possible pros and cons of taking this after your postpartum period but if this is
something you may want to consider talk to your encapsulation specialist
about it.
There are several organizations that offer a training program and a certification
for placenta encapsulation. This includes the Association for Placenta
Preparation Arts, PlacentaBenefits.info (PBi), and the International Placenta
and Postpartum Association. There is no nationally accredited certification
program. If you are looking into multiple providers of this service it may be
worth it to ask if they have any type of certification and how many clients they
have done it for. If placenta encapsulation is something you are considering
look into it and talk to some specialists, or even ask around to find out if
anyone you know has an experience with it. If you aren’t sure whether or not
you want to do this contact a placenta specialist and ask them any questions
you have to make a decision about it.
For more information on placenta encapsulation you can listen to episode 28
of the Pregnancy Podcast at PregnancyPodcast.com/episode28.
Cord Blood Banking
Cord blood contains hematopoietic stem cells that can form red blood cells,
white blood cells, and platelets. The ability to differentiate into these types of
blood cells can make cord blood helpful in treating blood and immune system
related genetic diseases, cancers, and blood disorders. You can collect a sample
of cord blood right after your baby is born and then have it stored in a cord
blood bank to potentially be used at a later date.
The first clinically documented use of cord blood stem cells was in the
successful treatment of a six-year-old boy afflicted by Fanconi anemia in 1988.
Since then, cord blood has become increasingly recognized as a source of stem
cells that could be used in stem cell therapy. There is a fairly long list of
illnesses (nearly 80) that may be treated with cord blood. This includes many
types of cancers, bone marrow failure syndromes, blood disorders, metabolic
disorders, immunodeficiency, and some other diseases like osteoporosis. Take
note that these are not common, and your little one has a very small chance of
having any of these illnesses. If you have a family history of any disorders or
diseases it may be worth talk to your care provider about whether cord blood
banking could potentially help treat the condition, in the event your baby, or
someone else in your family has it.
While cord blood banking is often marketed as biological insurance, you
cannot assume that your baby would be able to use their own cord blood.
Often, children who develop an immunological disorder are unable to use
their own cord blood for transplant because their blood also contains the same
genetic defect. This is common with leukemia, which is a cancer and the
largest use of cord blood stem cells.
A cord blood bank is a facility that stores umbilical cord blood for future use.
When you store your baby’s cord blood at a private bank it is stored solely for
the potential use by your baby or your family. There are no accurate estimates
of the likelihood of children who need their own stored cord blood stem cells
in the future. Private banks do charge a fairly high fee, typically around $2,000
USD for the collection, and around $200 USD a year for storage. This could
vary from one company to the next, but this is a good ballpark figure of what
you can expect to spend. There is some controversy in the medical community
about private for-profit cord blood banks, and whether physicians, employees,
and consultants of private banks have potential conflicts of interest in
recruiting patients because of their own financial gain.
If you choose to store your baby’s cord blood at a public bank, it works very
much like a blood bank, and you don’t own the cord blood donated. Public
cord blood banks accept donations from anyone, they discard donations that
don’t meet their quality control standards, and they use national registries to
find recipients for their samples. Some of the public cord blood banks are
programs funded by the National Heart Lung and Blood Institute, the
National Marrow Donor Program, the American Red Cross, or academic
programs based in not-for-profit organizations. Samples sent to a public bank
are tested for chromosomal abnormalities and infectious diseases and if
abnormalities are identified, you will be notified. It is important to note that
cord blood banked in a public program may not be accessible for future
private use. It is also a possibility your donation could be life saving for
someone else. Public banks generally do not charge any fees.
Since patients who need cord blood frequently need more cells than a single
collection would have provided, public banks frequently combine multiple
samples together when preparing the treatment for a single patient. If
someone needs a cord blood transplant as an adult, they will need an even
larger sample because their body is larger than a child. Many cord blood
samples may be too small to be used for transplantation because they don't
contain enough stem cells. A private bank will store a sample, even if it is too
small, because you are paying them for that service. Public banks will discard
any samples that do not collect enough usable cells. The percentage of public
bank donations discarded as medical waste is often cited to be between 60%
and 80%. Some of this is due to contamination that can occur during
collection or complications arising from shipping, but this is mostly due to the
collection not collecting enough usable cells.
You can see a few reasons why public cord banks are more widely accepted in
the medical community. Overall the attitude is that private banks have lower
quality control and lower medical usefulness of using a patient's own cord
blood. Matches are almost always likely to be better in a public bank rather
than a private bank. The American Academy of Pediatrics states that cord
blood donation should be discouraged when cord blood stored in a bank is to
be directed for later personal or family use, because most conditions that
might be helped by cord blood stem cells already exist in the infant’s cord
blood. The cord blood stem cell collection program should not alter routine
practice for the timing of umbilical cord clamping (American Academy of
Pediatrics, 2007). The American Medical Association recommends that private
banking should be considered in the unusual circumstance when there exists a
family predisposition to a condition in which umbilical cord stem cells are
therapeutically indicated. However, because of its cost, limited likelihood of
use, and inaccessibility to others, private banking should not be recommended
to low-risk families (American Medical Association, 2008).
If you choose to use a cord blood bank, the way most companies work is you
sign up with them, complete some paperwork, and they send you a collection
kit, which you take with you to the delivery. Cord blood collection happens
after the umbilical cord has been cut and your care provider or a nurse collects
the sample from the end of the cord that was attached to your baby. This is
usually done within ten minutes of giving birth. After the collection a medical
courier picks up the cord blood and delivers it to the cord blood bank.
An adequate cord blood collection requires at least 50-75 ml in order to ensure
that there will be enough cells to be used for transplantation. Keep in mind
about 80 ml of blood is transferred from the placenta to your baby in the first
minute after birth, and this amount increases to about 100 ml within three
minutes. You can see that there could be a conflict if you want to both delay
cord clamping and bank cord blood. The placenta contains approximately 200
ml of blood, although that doesn’t mean that exactly 200 ml of blood could be
extracted from it.
The short answer is that delaying clamping and cord blood banking are not
mutually exclusive, you can potentially do both, but the delay should be brief.
According to the American Academy of Pediatrics, if you are banking cord
blood, you can delay cord clamping, as long as the delay is brief – no more
than a minute or two (American Academy of Pediatrics, 2007). The American
Congress of Obstetricians and Gynecologists (ACOG) states that it is possible
to delay clamping and collect enough cord blood to bank it. ACOG states that
only about 50 milliliters (ml) of blood is necessary for cord blood storage,
which is just a portion of the approximately 200 ml of blood contained in the
placenta and umbilical cord. If you choose to delay the cord clamping by 1
minute, around 80 ml of this blood is transferred to your baby, leaving more
than enough to be stored in a cord blood bank. Even if you delay clamping by
3 minutes, only around 100 ml will have gone into your baby. They
recommend that you probably don’t want to wait to clamp the umbilical cord
for much longer than 3 minutes to ensure you’ll have enough for cord blood
storage (American Congress of Obstetricians and Gynecologists, 2015;
Australian Institute of Health and Welfare, 2013).
If you are considering cord blood banking, and want to delay cord clamping,
you should talk to your doctor or midwife, since they will likely be the person
actually taking the sample. Ask them for a specific time frame and for their
opinion on delaying clamping and whether they feel that you can still get an
adequate sample size after a delay of whatever the length of time is that you
want to delay clamping and cutting your baby’s cord.
For more information on cord blood banking you can listen to episode 27 of
the Pregnancy Podcast at PregnancyPodcast.com/episode27.
The Third Stage of Labor
The third stage of labor starts after your baby is born and ends with birthing
the placenta. Once your beautiful baby is born your uterus continues to
contract and shrink, and your placenta will detach from your uterine wall. The
blood vessels are then closed off and the placenta is pushed out.
The main complications that can arise during the third stage of labor are
postpartum hemorrhage, a retained placenta, and uterine inversion.
Postpartum hemorrhage is the number one cause of maternal mortality. In
general, postpartum hemorrhage occurs when a mother loses over 500 ml of
blood in a vaginal birth or 1,000 ml of blood in a cesarean birth. These figures
may vary between countries and there is no universal measurement. Care
providers can only estimate the amount of blood lost, they cannot accurately
measure it. Postpartum hemorrhage is more common in low-income countries
where access to care is limited. Over the last few decades, rates of postpartum
hemorrhage have been on the rise in developed countries and unfortunately
researchers have not been able to pinpoint the cause of this.
A retained placenta occurs when the placenta does not detach from the uterine
wall. The risks involved with this include hemorrhage and infection. The
amount of time your care provider is comfortable waiting for your placenta to
be delivered without interventions will vary, and can range from 30 minutes to
2 hours.
Uterine inversion occurs when the placenta does not detach from the uterine
wall and as it is pushed out it draws the uterus with it, turning the organ inside
out.
It is a high priority of your doctor or midwife to make sure that your third
stage of labor goes smoothly, and the placenta is delivered without
complications. You have two main choices when it comes to how to birth your
placenta; expectant management or active management. Advocates of
expectant management argue that the natural process your body goes through
promotes normal separation and birth of the placenta and minimizes
complications. Proponents of an active approach argue that that active
management is quicker and results in fewer complications.
Expectant management, sometimes also called physiological, means that the
cord is not clamped early, no medications are administered, and there is no
pulling on the umbilical cord. Advocates of this method argue that any
interference with the natural cascade of hormones that occurs immediately
following birth has impacts on both you and your baby. In general, mothers
who are planning a natural birth opt for expectant management, which is more
in line with their ideology on birth.
Active management usually involves early cord clamping, administration of
medication, and gently pulling the umbilical cord.
It is also possible to have a combination of these two methods, sometimes
referred to as mixed management, where some but not all of the methods of
active management are employed.
A review of seven studies involving over 8,000 women found that active
management of the third stage reduced the risk of hemorrhage greater than
1000 ml at the time of birth, but adverse effects were identified. The review
concluded that given the concerns about early cord clamping and the potential
adverse effects of some medications, it is critical to look at the individual
components of third stage management (Begley CM, 2015).
A look into the individual components of active management will give you a
better idea of what methods you would like to use or avoid during the third
stage of labor.
There is quite a bit of evidence to support delayed cord clamping and this
topic is covered in depth in the beginning of this chapter.
The medications given during active management of the third stage of labor
are classified as uterotonic agents. These drugs increase contractions and are
given either orally, through an IV, or with a shot. There are four main types of
uterotonics; oxytocin, carbetocin, ergot derivatives and prostaglandins.
Oxytocin is your body’s natural hormone to create contractions, and there are
also synthetic versions of this. Carbetocin is available in the U.K. and Canada,
but not in the United States. Ergot derivatives include Syntometrine, a
combination of oxytocin and ergometrine. Prostaglandins include misoprostol,
which is marketed under the brand name, Cytotec.
A review of six trials involving over 9,300 women compared Syntometrine, a
combination of oxytocin and ergometrine, with Syntocinon, which is oxytocin
only. The review found that the combination drug was associated with fewer
instances of postpartum hemorrhage but had more side effects, notably
vomiting, nausea and hypertension (McDonald SJ, 2004).
A review of 72 trials involving over 52,000 women examined the use of
prostaglandins, specifically misoprostol, which is taken orally. When
misoprostol was used compared to no other drugs it did lower the risk for
postpartum hemorrhage and blood transfusions. Compared to other
uterotonics, misoprostol had higher rates of severe postpartum hemorrhage
and use of additional uterotonics, but fewer blood transfusions. The review
also found that misoprostol is associated with significant increases in shivering
and a temperature of 100.4º Fahrenheit, or 38º Celsius, compared with both a
placebo and other uterotonics. Overall, misoprostol is not as effective as
oxytocin, and it has more side effects (Tunçalp Ö, 2012). In areas where access
to medical care is limited an oral medication, like misoprostol, may have more
application.
A review of 20 trials involving over 10,800 women found that oxytocin
reduced the rates of postpartum hemorrhage. When compared to ergot
alkaloids, oxytocin was more effective and had fewer side effects. There was
also no benefit found in combining oxytocin with ergometrine, the
combination drug known as Syntometrine. There was no evidence suggesting
that retained placentas were more common with use of oxytocin (Westhoff G,
2013).
If you are planning to have a uterotonic administered during the third stage of
labor it may be helpful to discuss your options with your care provider and
discuss the risks and benefits of the different medications available.
Your care provider can also use controlled cord traction, and apply traction to
the cord by gently pulling it to assist in the delivery of the placenta. They may
also put pressure on your uterus to help it contract. There is a method to this,
and any care provider performing controlled cord traction should be skilled in
the technique.
A review of three trials involving over 27,000 focused on controlled cord
traction and found that there was no difference in the risk of blood loss over
1,000 ml but that it did reduce blood loss of more than 500 ml. There were no
clear differences in use of additional uterotonics, blood transfusion, maternal
death, operative procedures, nor maternal satisfaction (Hofmeyr GJ, 2015).
When you are figuring out what methods you want to use or avoid during the
third stage of labor talk to your doctor or midwife and find out what their
policy and recommendation is. From there you can discuss your options and
any concerns to figure out what route you want to take.
For more information on the third stage of labor you can listen to episode 48
of the Pregnancy Podcast at PregnancyPodcast.com/episode48.
Chapter 12: Breastfeeding
Breastfeeding is arguably the best thing you can do for baby. There is no
formula that comes close to mimicking breast milk. Your milk contains every
vitamin, mineral, and nutritional element your baby needs. It contains living
cells to inhibit the growth of bacteria and viruses. Babies who are breastfed are
at a lower risk for ear infections, intestinal upsets, respiratory problems,
allergies, dental problems, and their immune system will be stronger.
Breastfeeding produces prolactin and oxytocin, which are hormones that
foster a connection to your baby and help you recover from birth. The best
way to get breastfeeding off to a great start is to be skin to skin with your baby.
For more information on breastfeeding you can listen to episode 10 of the
Pregnancy Podcast at PregnancyPodcast.com/episode10.
To get tips on preparing for breastfeeding you can listen to episode 29 of the
Pregnancy Podcast at PregnancyPodcast.com/episode29.
Colostrum
During your pregnancy your body starts producing colostrum. This first milk
has immunological properties. Most importantly, colostrum contains high
concentrations of secretory immunoglobulin A. This is an anti-infective agent
that coats their intestines to protect against the passage of germs and foreign
proteins that could create allergic sensitivities. Another ingredient in colostrum
is pancreatic secretory trypsin inhibitor, which protects and repairs the infant’s
intestine. It may not seem like very much but at birth your baby’s stomach is
the size of a marble. Colostrum is nature’s perfect food until your milk comes
in.
Formula
Today most hospitals and care providers are extremely supportive of
breastfeeding and will have a lactation consultant on staff that can come by for
a visit after your baby is born. Take advantage of this resource to help you get
off to a great start. If you do not want to supplement with formula do not
hesitate to let your care provider know. If you are planning to supplement with
formula from the start and you want to know what formula your baby will be
getting ask your care provider what the hospital provides and you can always
bring your own with you if things like organic or non GMO ingredients are
important to you.
For more information on infant formula you can listen to episode 33 of the
Pregnancy Podcast at PregnancyPodcast.com/episode33.
Pacifiers
Whether or not you choose to give your baby a pacifier is entirely up to you.
While it may seem obvious to give your baby a pacifier, some parents choose
not to do it. The only reason you would include anything about pacifiers in
your birth plan is if you do not want to use them, in which case you may want
to make sure the hospital or birth center does not give one to your baby.
There are both pros and cons to pacifiers and by understanding both sides you
can decide whether giving your baby a pacifier is the right move for you.
Pacifiers are designed to pacify your baby. At one point or another you have
seen a mom give a fussy baby a pacifier, which can immediately calm them
down. Babies start building their strong sucking reflex in the womb. This is
needed for breastfeeding and nutrition but it also has a calming effect and
many babies find it soothing.
Let’s start with the pros. A crying baby can be stressful and it can be a
challenge to run through a list of things to try and soothe them. Often, giving
them a pacifier will instantly calm them down. A pacifier can also serve as a
good distraction when you are visiting the pediatrician or want to do
something your baby doesn’t enjoy like clipping or filing their nails. A pacifier
can be helpful in settling your baby to sleep. On a flight a pacifier may help
your little one equalize their ears during air pressure changes during takeoff
and landing. Giving your baby a pacifier may even decrease the risk of SIDS.
You can see there are a lot of times when having a pacifier can be handy, and a
lot of parents would consider them to be a necessity.
There are also cons to giving your baby a pacifier. Early pacifier use could
interfere with breastfeeding. Your baby could become dependent on a pacifier,
which could be troublesome if they need it to go to sleep, then wake up crying
when it falls out of their mouth during the night. If your baby uses a pacifier it
could increase their risk of middle ear infections. It is worth noting that the
risk of middle ear infections is lowest in the first six months, which is also the
time your baby will be most interested in a pacifier. If your baby ends up using
a pacifier long term it could create dental issues with the development of their
mouth and the alignment of their teeth.
Some practitioners refer to using a pacifier as nonnutritive sucking, as opposed
to nutritive sucking while breastfeeding or drinking from a bottle. A review
from the American Medical Association did not find pacifiers to be
detrimental to breastfeeding outcomes but overall it did find that early use of
pacifiers could be associated with decreased exclusive breastfeeding, and the
duration of breastfeeding (O’Connor N.R., 2009). If you are breastfeeding, you
can wait to offer a pacifier to your baby until breastfeeding is well established
and they are at least 3 or 4 weeks old. The first few weeks are also very
important to establishing your milk supply and the more often you are
breastfeeding the better. Using a pacifier could substitute some times that you
would be putting your baby to your breast to soothe them.
There is some evidence that pacifiers lower the risk of sudden infant death
syndrome (SIDS). The American Academy of Pediatrics recommends parents
consider offering a pacifier at naptime and bedtime. Although the mechanism
is yet unclear, studies show a protective effect on the use of a pacifier and the
instances of SIDS (American Academy of Pediatrics, 2011).
There are reasons to both offer your baby a pacifier and reasons not to use
one. If you prefer not to use a pacifier or would like to wait to introduce one
make sure your care provider and the venue where you are giving birth is
aware of your preference.
Chapter 13: Procedures after birth
There are a lot of procedures that can happen to your baby shortly after birth.
Whether these procedures occur and when depends on where you give birth
and what you and your care provider have planned. While a number of
procedures have become routine, that does not always mean that they are
mandatory. You have options when it comes to what procedures are done on
your baby and whether or not you choose to opt in, delay, or opt out of these.
Skin to Skin
No matter what type of birth you have, the most important thing is that you
get skin to skin with your baby as soon as possible. Skin to skin means that
your baby is not swaddled or clothed and their bare skin is placed belly down
against your bare chest. A blanket is then put over you and your baby to keep
both of you warm. The first hour after birth your baby will be pretty alert,
enjoy every second with that little one. If you do choose to opt in to some
procedures many of them can be performed while your baby is on your chest.
Kangaroo care is a term for skin to skin contact that was initially developed for
preterm babies. Today, kangaroo care is practiced in many neonatal intensive
care units around the world with successful results. The World Health
Organization has developed a set of guidelines involving other
recommendations, in addition to skin to skin contact, called Kangaroo Mother
Care.
From an evolutionary perspective skin to skin contact was necessary for the
survival of a newborn. According to mammalian neuroscience, intimate
contact evokes neurobehavioral actions needed to fulfill basic biological needs.
This time may represent a psycho physiologically sensitive period for
programming future physiology and behavior. It wasn’t until births began
taking place in hospitals that mothers and newborns were separated,
completely or by clothing, after birth.
There is good evidence that normal term newborns who are placed skin to
skin with their mothers immediately after birth make the transition from fetal
to newborn life with greater respiratory, temperature, and glucose stability and
significantly less crying indicating decreased stress. Mothers who hold their
newborns skin to skin after birth have increased maternal behaviors, show
more confidence in caring for their babies and breastfeed for longer durations.
Being skin to skin protects your newborn from the well documented negative
effects of separation, supports optimal brain development and facilitates
attachment, which promotes your infant's self-regulation over time. Normal
babies are born with the instinctive skill and motivation to breastfeed and are
able to find the breast and self-attach without assistance when skin to skin.
When your newborn is placed skin to skin with you, nine observable behaviors
can be seen that lead to the first breastfeeding, usually within the first hour
after birth (Moore E.R., 2012).
Skin to skin not only applies to moms, there are benefits for dads and partners
being skin to skin with a baby as well. Your partner can be especially helpful
with skin to skin contact in cases of a cesarean where mom may not be able to
hold their baby immediately or with multiples. This contact with your partner
will help regulate your baby’s temperature, keep them calm, and promote
bonding. Skin to skin contact extends through the first few weeks and is
advised even after you are home with your baby.
The evidence to support immediate skin to skin contact is becoming more
available all over the world. A study in Russia found that skin to skin contact
positively influenced mother-infant interaction one year later when compared
with routines involving separation of mother and infant (Bystrova, 2009). A
study in India found that skin to skin contact improved physical growth of low
birth weight infants (Gathwala G., 2010). There is overwhelming evidence that
supports the benefits of skin to skin contact to both parents and babies.
Immediate skin to skin contact is critical.
Vitamin K
Babies naturally have low levels of vitamin K at birth. A shot of vitamin K
reduces the chance of vitamin K deficiency bleeding which happens in a small
number of babies, and can be fatal. There are three types of this complication
classified by when it occurs. Early, within 24 hours, and classical, within the
first week, affects between 1 in 60 to 1 in 250 newborns. Late, within the first
six months, is more rare and affects between 1 in 14,000 to 1 in 250,000
infants. Infants who do not receive a vitamin K shot at birth are 81 times more
likely to develop vitamin K deficiency bleeding (Centers for Disease Control
and Prevention, 2014).
The good news is that vitamin K deficiency bleeding can be prevented with a
shot of vitamin K. The shot is given in your baby’s thigh and it is stored in the
muscle and released over a period of time and is designed to provide vitamin
K until your baby is producing enough on their own. Since the early 1960s this
has become standard procedure at all hospitals and birth centers. The shot is
usually done within the first six hours after birth. This is a procedure that can
be done while your baby is on your chest.
One risk factor for vitamin K deficiency is exclusively breastfeeding. Babies
who are fed formula have higher levels of Vitamin K. By about six months of
age your baby will be producing a sufficient amount of vitamin K on their
own.
The only reason to include vitamin K in your birth plan is if you are opting out
of the procedure or delaying it. If you have any questions or concerns about
the safety of the shot, discuss them with your care provider to make sure you
are making the best decision for your baby.
For more information on vitamin K you can listen to episode 47 of the
Pregnancy Podcast at PregnancyPodcast.com/episode47.
Erythromycin
Ophthalmia neonatorum (ON) is conjunctivitis, or pink eye, that is contracted
at birth. This eye infection is primarily caused by two sexually transmitted
infections, gonorrhea and chlamydia. If you have either of these infections it
can infect your newborn with ON. Untreated, ON can cause permanent eye
damage or blindness. Many women who are infected with gonorrhea or
chlamydia do not show any signs of infection and it has become standard
practice to test for this in pregnancy.
It has become routine procedure for erythromycin eye ointment to be placed
on your baby’s eyes within 24 hours after birth. In the United States many
states require by law that newborns are given erythromycin. The eye ointment
can make your baby’s vision temporarily blurry and it will wear away within 24
hours.
Some parents choose to opt out of this procedure, if their state allows it, if the
mother does not have gonorrhea or chlamydia, and if they are in a
monogamous relationship with one partner who is not infected. If you think
erythromycin is a procedure you would like to decline, talk to your care
provider about all of the risks, and find out if declining it is an option for you,
and whether it is mandated by your state.
For more information on erythromycin you can listen to episode 47 of the
Pregnancy Podcast at PregnancyPodcast.com/episode47.
Part Three: Guide to Writing Your Birth Plan
Chapter 14: Step-by-step Guide
You start creating your birth plan the minute you start educating yourself
about labor and birth. This is going to be a work in progress throughout your
pregnancy and it may change as you go. To be on the safe side you are going
to want to have your birth plan done by week 36, but you can always make
changes to it. You may find that you are even changing your priorities during
labor depending on how your birth unfolds. You will want a few printed
copies packed in your birth center or hospital bag, or on hand for a home
birth. More importantly, you, your partner, your doula, and your care provider
need to know what is included in your birth plan so you can all work together
to create the birth experience you have been planning for.
By this point you are really knowledgeable about everything that can happen
during birth and should have a solid idea of how you envision your birth. As
you have been reading this book you have already completed some of the
steps in the checklist below. Below is a step-by-step guide to creating your
birth plan.
1. Get educated. Education about birth comes from reading resources
like this book, listening to the Pregnancy Podcast, doing your own
online research, and talking to your care provider.
2. Decide what is important and make a list. Get out a pen and paper, or
a new Word document and start writing down the things that are
important to you and that you know you want to include in your plan.
3. Find out what the policies are of your care provider or venue and
make note as to whether they are in line with your wishes.
4. Create your first draft. Once you know the policies and routine
procedures that will affect you birth you can compare these to your list
and see what is in sync and what isn’t. If you have a preference that is
in line with your care provider’s routine practice you may be able to
take it out of your birth plan. On the other hand, if you wish to do
something that is outside of your care provider’s routine practice you
will want to leave it in your birth plan to make sure they know your
preference. You can use the template in the next section as a guide.
5. Check for conflicts. Read through your draft birth plan and see if
everything makes sense and if there are any conflicts. For example,
you may not be able to avoid IV fluids if you are choosing to have
your labor induced with Pitocin. Make sure everything in your plan
works together.
6. Discuss it with your partner. Have your partner take a look at it and
ask them if it makes sense or if you are leaving anything out.
7. Discuss it with your care provider. You will be working with your
doctor or midwife throughout your entire pregnancy. If you aren’t
100% clear on anything about your birth, now is the time to bring it
up. Make sure your care provider is clear on what you want and that
they are supportive of your wishes.
8. Final edits, make it short. Read through your birth plan and cut it
down to one page. You could go longer if you feel it is really necessary
but the shorter the better. One page is ideal. Ask yourself whether
every item must be included. If a routine procedure is in line with
what you want you can probably take it out of your birth plan. Focus
on the things that are really important to you. Once you have a
concise plan that you are happy with print it out.
9. Know it inside and out. You need to know exactly what is in your
birth plan and be confident in your decisions so you know how you
expect things to go down during your birth. This is also true for your
partner. They need to know your birth plan well so in the event they
need to speak up and advocate for you they can. If you are working
with a doula also make sure they have a copy and will be supportive of
your choices and know exactly what is important to you.
10. Pack it in your hospital or birth center bag, or have it on hand for your
home birth. You should have a few copies printed out and make sure
that the when you first see a nurse, midwife, or doctor they know that
you have a birth plan so they can plan your care accordingly.
Part Four: Template and Samples
The birth plan template is available as a PDF at:
PregnancyPodcast.com/bptemplate
To access the document you will need to enter the password: YBP09temp26
This template includes everything you could include in your birth plan for a
variety of births. Please feel free to delete, add, and customize it as you see fit.
Birth Plan Template
Dear [Hospital Staff, Birth Center Staff, Your Doctor, Your Midwife, Your
Doula],
I appreciate you being here to support me through the birth of my first child!
I am so thankful to have your support during the birth of my baby!
I have spent a lot of time researching the evidence for all of the decisions
listed here, and I feel confident in the choices I have made.
I have put a lot of time and energy into researching all of the evidence for my
choices, and I feel confident in my birth wishes.
I thank you for respecting my wishes, especially if they fall outside of the usual
procedure.
Thank you for supporting my wishes, especially if they do not align with your
routine procedures.
I have been preparing and planning for a VBAC and am confident in this
choice. I would like to exhaust all options for a successful vaginal birth before
resorting to a C-section.
I have been preparing and planning for a natural birth and would like to avoid
all interventions.
I would like to be paired up with a nurse who supports natural childbirth.
I have been preparing and planning for a [home/birth center] birth and would
like to avoid a transfer to a hospital providing myself and my baby are doing
well.
I have been preparing and planning for a water birth I would like to labor in
water.
I would like to give birth to my baby [in water/on dry land].
I have been preparing for a [home/birth center] birth. If I am in the hospital, it
is because I required some intervention that was unavailable.
I have been preparing and planning for a cesarean section
Environment:
The following people will be present during my labor and birth: [partner,
doula, sister, brother, best friend, mother, father, photographer, etc.]
I value my privacy and would like to limit the number of staff members
present to as few as possible.
It is my intent to give birth in a calm and relaxed environment.
I would like to keep the environment dimly lit, please dim or turn off any
lighting when not needed.
I would like to keep my environment as quiet as possible with soft voices and
minimal sound.
I would like to play [music, meditations, etc.] during my labor.
I would like to use essential oils and aromatherapy during my labor.
In labor:
I am not intent on delivering in a particular position or in a particular place.
Please encourage me to try different things to see what works best.
It is my preference to labor in an upright position as much as possible, please
encourage me to stay off of my back.
It is my preference to be as mobile as possible during my labor, please
encourage me to try different positions.
I would like to include a [birthing ball, squatting bar, a birthing stool, etc.] for
my labor. Please encourage me to utilize different props.
I prefer to avoid routine procedures (continuous EFM, IV, epidural, Pitocin
augmentation, etc.) unless clearly necessary for a safe birth.
I am prepared to be flexible on the use of interventions if a medical necessity
arises.
Barring a major medical emergency, I ask that you please discuss with me any
and all interventions, allowing me the opportunity to give informed consent to
any procedure you suggest.
I am comfortable inducing labor anytime after [41/42] weeks via [any method
you feel is appropriate, sweeping the membranes, synthetic
prostaglandins—misoprostol or dinoprostone, a mechanical dilator—balloon
or laminaria, or rupturing the membranes].
I prefer to avoid inducing labor via [any method, sweeping the membranes,
synthetic prostaglandins—misoprostol or dinoprostone, a mechanical
dilator—balloon or laminaria, or rupturing the membranes].
I prefer to wait until at least [41/42] weeks to induce labor.
I am planning to be monitored using [external/internal] continuous electronic
fetal monitoring.
I would like any monitoring to be intermittent.
I would like to have intermittent monitoring done via auscultation.
I would like to avoid internal continuous monitoring.
I would like to be monitored with a telemetry unit if possible to allow for the
most mobility.
I am comfortable being given IV fluids throughout my labor.
I prefer to avoid IV fluids throughout my labor if possible.
I prefer a hep-lock in place of IV fluids.
In the event IV fluids are administered, it is important to me that you take the
24-hour birth weight of our baby into consideration to measure their weight
gain.
I am group B strep positive and am planning on being given antibiotics during
my labor. [Please note that I am allergic to penicillin.]
I am planning to have an [epidural/spinal] to assist with managing my
contractions.
I would like [to have an epidural/spinal as soon as possible, or to hold off on
having an epidural/spinal until I am at least 4/5/6/7 centimeters.]
I would like to keep the medication in my epidural to a minimum so that I may
maintain some feeling.
I would like to use patient controlled medication so that I may be in control of
the dosage.
Please do not offer an epidural or any medication, unless I request it.
I am comfortable using Pitocin to augment my labor.
I prefer not use Pitocin or any other method of augmentation.
Please do not perform an episiotomy unless necessary to prevent a
second/third/fourth degree tear, or if medically necessary for an assisted
delivery.
I would like to avoid an episiotomy if possible.
Please use [perineal massage, a warm compress, lubricant, or guided pushing]
to prevent tearing or an episiotomy.
In the event an episiotomy becomes necessary it is my preference to use a
[midline/median] incision.
If an assisted delivery becomes necessary I prefer to use [a ventouse suction
cup/forceps].
I would like to avoid an assisted delivery.
In the event a hospital transfer is necessary for a non-emergency reason, I
would like to be transferred to [hospital name].
Please lower the screen just before delivery so I may see the birth of my baby.
My partner would like to catch our baby when [he/she/they] are born.
It is important to me to utilize all other resources before a cesarean section.
In the event all other options are exhausted and a cesarean becomes necessary,
I would like my partner present for the procedure.
In the event of a cesarean I would like the incision to be stitched up in two
layers.
After the birth:
Please delay clamping of my baby’s umbilical cord [for a minimum of 1/3/10
minutes/until it stops pulsating].
Please do not cut my baby’s umbilical cord, I am planning a lotus birth.
My partner would like the opportunity to cut our baby’s umbilical cord.
Please allow for the placenta to be delivered naturally and I request that you do
not rush this process.
I am comfortable with active management for the third stage of labor.
I request no routine uterotonics to assist in the delivery of the placenta.
Please do not use [Pitocin/Carbetocin/Syntometrine/Cytotec].
Please do not apply controlled traction on the umbilical cord.
I am planning to keep and take my placenta home with me.
Someone will be picking up my placenta to prepare it for encapsulation.
I will be banking my baby’s cord blood, after a delay of [1/2/3/10] minutes.
For my baby:
It is very important to me to be skin to skin with my baby immediately
following birth.
Please perform any procedures or evaluations of my baby while they are on my
chest.
In the event I am unable to be skin to skin with my baby immediately after
birth please put my baby skin to skin with my partner.
I would like to breastfeed my baby as soon as possible after birth.
Please do not give my baby any infant formula.
In the event I decide to supplement with formula I have a specific brand I
would like to use with me.
Please do not give my baby a pacifier.
I do not wish to give my baby a vitamin K shot.
Please delay the shot of vitamin K for [6/7/8+] hours.
I do not wish to give my baby erythromycin.
Please delay erythromycin for [1/12/24+] hours.
I [tested positive for gonorrhea/chlamydia and] would like erythromycin
administered to my baby.
Thank you!
Thank you for taking good care of my baby and me!
I appreciate your support and care!
Your name
Sample Home Birth Plan
Dear Sara Smith, CNM,
I appreciate you being here to support me through the birth of my daughter! I
have spent a lot of time researching the evidence for all of the decisions listed
here, and I feel confident in the choices I have made. I have been preparing
and planning for a home birth and would like to avoid a transfer to a hospital
providing my baby and myself are doing well.
Environment:
The following people will be present during my labor and birth: my partner,
Shannon, and my doula Caitlin. It is my intent to give birth in a calm and
relaxed environment with dim lighting and soft voices.
In labor:
It is my preference to labor in an upright position as much as possible, please
encourage me to stay off of my back. I would like to include a birthing ball and
a birthing stool for my labor. Please use perineal massage, a warm compress,
lubricant, and guided pushing to prevent tearing. My partner would like to
catch our baby when she is born.
After the birth:
I would like to delay clamping of my baby’s umbilical cord until it stops
pulsating.
Please allow for the placenta to be delivered naturally and I request that you do
not rush this process. Julia, from Julia’s Birth Care, will be picking up my
placenta to prepare it for encapsulation.
For my baby:
It is very important to me to be skin to skin with my baby immediately
following birth and I would like to breastfeed my baby as soon as possible. I
appreciate you giving my partner and I as much alone time with our new baby
as possible.
Thank you for taking good care of my baby and me!
Joan
Sample Birth Center Birth Plan
Dear Birth Center Staff,
I am so thankful to have your support during the birth of my baby! I have put
a lot of time and energy into researching all of the evidence for my choices,
and I feel confident in my birth wishes. I have been preparing for a birth
center birth and would like to avoid a transfer to a hospital providing my baby
and myself are doing well. I thank you for respecting my wishes.
Environment:
My partner, Robert, and best friend and photographer, Alli, will be present
during my labor and birth. It is my intent to give birth in a calm and relaxed
environment. I would like to keep the environment dimly lit, with soft voices
and minimal sound.
In labor:
It is my preference to labor in an upright position, please encourage me to stay
off of my back. I would like to include a birthing ball for my labor.
To help prevent tearing, please use perineal massage, a warm compress,
lubricant, and guided pushing.
My partner, Robert, would like to catch our baby when he is born.
In the event a hospital transfer is necessary for a non-emergency reason, I
would like to be transferred to Sharp Hospital. Please coordinate my care with
Dr. William Erickson.
After the birth:
Please delay clamping of my baby’s umbilical cord for 10 minutes or until it
stops pulsating.
Please allow for the placenta to be delivered naturally and I request that you do
not rush this process.
Mary, from Living Tree Birth Services, will be picking up my placenta.
For my baby:
It is very important to me to be skin to skin with my baby immediately
following birth. Please perform any procedures or evaluations of my baby
while they are on my chest.
I would like to breastfeed my baby as soon as possible after birth.
Please delay the shot of vitamin K and erythromycin eye ointment for 6 hours.
Sample Hospital Birth Plan – Plan B to Home or Birth Center
Dear Hospital Staff,
I am so thankful to have your support during the birth of my baby! I would
like to be paired up with a nurse who supports natural childbirth. I have been
preparing for a home birth, and if I am in the hospital, it is because I required
some intervention that was unavailable.
Environment:
The following people will be present during my labor and birth: my partner,
Steven, my doula, Evelyn, and my mother, Sarah.
It is my intent to give birth in a calm and relaxed environment. I would like to
keep the environment dimly lit, please dim or turn off any lighting when not
needed.
In labor:
I would like to include a squatting bar and a birthing stool for my labor.
I prefer to avoid routine procedures (continuous EFM, IV, epidural, Pitocin
augmentation, etc.) unless clearly necessary for a safe birth. I am prepared to
be flexible on the use of interventions if a medical necessity arises. Barring a
major medical emergency, I ask that you please discuss with me any and all
interventions, allowing me the opportunity to give informed consent to any
procedure you suggest.
If continuous monitoring becomes necessary, I would like to be monitored
with a telemetry unit if possible.
In the event IV fluids are administered, it is important to me that you take the
24-hour birth weight of our baby into consideration to measure their weight
gain.
Please do not perform an episiotomy, unless necessary to prevent a third or
fourth degree tear, or if medically necessary for an assisted delivery. If an
assisted delivery becomes necessary I prefer to use a ventouse suction cup.
In the event all other options are exhausted and a cesarean becomes necessary,
I would like my partner present for the procedure.
After the birth:
Please delay clamping of my baby’s umbilical cord for a minimum of 3
minutes.
Please allow for the placenta to be delivered naturally and I request that you do
not rush this process. If active management becomes necessary, please do not
use Cytotec.
For my baby:
It is very important to me to be skin to skin with my baby immediately
following birth. Please perform any procedures or evaluations of my baby
while they are on my chest. In the event I am unable to be skin to skin with
my baby immediately after birth please put my baby skin to skin with my
partner.
I would like to breastfeed my baby as soon as possible after birth. Please do
not give my baby any infant formula or a pacifier.
I appreciate your support and care!
Flora
Sample Hospital Birth Plan – Without Interventions
Dear Hospital Staff,
I appreciate you being here to support me through the birth of my daughter! I
have spent a lot of time researching the evidence for all of the decisions listed
here, and I feel confident in the choices I have made. I have been preparing
and planning for a natural birth and would like to avoid all interventions.
Please pair me up with a nurse who supports natural childbirth.
Environment:
My husband John, and sister Kate will be present during my labor and birth. I
value my privacy and would like to limit the number of staff members present
to as few as possible.
It is my intent to give birth in a calm and relaxed environment. Please dim or
turn off any lighting when not needed. I would like to play music and
incorporate aromatherapy during my labor.
In labor:
It is my preference to labor in an upright position as much as possible. Please
encourage me to stay off of my back and try different positions.
I prefer to avoid routine procedures (continuous EFM, IV, epidural, Pitocin
augmentation, etc.) unless clearly necessary for a safe birth. Barring a major
medical emergency, I ask that you please discuss with me any and all
interventions, allowing me the opportunity to give informed consent to any
procedure you suggest.
Please do not offer an epidural or any medication, unless I request it.
To help prevent tearing, please use perineal massage, a warm compress,
lubricant, or guided pushing.
It is important to me to utilize all other resources before a cesarean section. In
the event all other options are exhausted and a cesarean becomes necessary, I
would like my husband present for the procedure, and for you to lower the
screen so I may see my daughter when she is born.
After the birth:
Please delay clamping of my baby’s umbilical cord until it stops pulsating. My
husband would like the opportunity to cut our baby’s umbilical cord.
Please allow for the placenta to be delivered naturally and I request that you do
not rush this process.
For my baby:
It is very important to me to be skin to skin with my baby immediately
following birth. Please perform any procedures or evaluations of my baby
while they are on my chest.
I would like to breastfeed as soon as possible after birth. In the event I decide
to supplement with formula I have a specific brand I would like to use with
me.
Please delay the shot of vitamin K and erythromycin eye ointment for 6 hours.
Thank you for taking good care of my baby and me!
Kara
Sample Hospital Birth Plan – With Interventions
Dear Hospital Staff,
I appreciate you being here to support me through the birth of my first child! I
have spent a lot of time researching the evidence for all of the decisions listed
here, and I feel confident in the choices I have made. Thank you for
supporting my wishes.
Environment:
My partner, Mike, will be present during my labor and birth. It is my intent to
give birth in a calm and relaxed environment. Please dim or turn off any
lighting when not needed and use soft voices and minimal sound.
In labor:
It is my preference to labor in an upright position as much as possible, please
encourage me to stay off of my back.
I am prepared to be flexible on the use of interventions if a medical necessity
arises.
I am comfortable inducing labor anytime after 42 weeks via any method you
feel is appropriate.
I am comfortable being given IV fluids throughout my labor.
I would like to have an epidural as soon as possible and I am comfortable
using Pitocin to augment my labor.
In the event all other options are exhausted and a cesarean becomes necessary,
I would like my partner present for the procedure.
After the birth:
Please delay clamping of my baby’s umbilical cord for a minimum of 3
minutes.
I am comfortable with active management for the third stage of labor.
For my baby:
It is very important to me to be skin to skin with my baby immediately
following birth and in the event I am unable to be skin to skin with my baby
immediately after birth please put my baby skin to skin with my partner.
I would like to breastfeed my baby as soon as possible after birth.
Thank you for taking good care of my baby and me!
Sample Cesarean Section Birth Plan
Dear Hospital Staff,
I am so thankful to have your support during the birth of my baby! I have
spent a lot of time researching the evidence for all of the decisions listed here,
and I feel confident in the choices I have made. Thank you for supporting my
wishes, especially if they do not align with your routine procedures. I have
been preparing and planning for a cesarean section
Environment:
My partner, Brian, will be present during my birth.
It is my intent to give birth in a calm and relaxed environment. Please use low
voices during the procedure.
During birth:
Please lower the screen just before delivery so I may see the birth of my baby.
We have chosen not to find out the sex of our baby and I would like my
partner to announce the sex when he or she is born.
After the birth:
Please delay clamping of my baby’s umbilical cord for a minimum of 3
minutes.
For my baby:
It is very important to me to be skin to skin with my baby immediately
following birth. If possible, please perform any procedures or evaluations of
my baby while they are on my chest. In the event I am unable to be skin to
skin with my baby immediately after birth please put my baby skin to skin with
my partner.
I would like to breastfeed my baby as soon as possible. In the event I decide to
supplement with formula I have a specific brand I would like to use with me.
Please delay erythromycin for 24 hours.
Thank you for taking good care of my baby and me!
Melissa
Additional Resources
PregnancyPodcast.com
The home base where you can get access to all of the Pregnancy Podcast
episodes and links to additional resources, research, and studies.
Pregnancy Podcast
A podcast dedicated to all things pregnancy, birth, and being a new parent. A
new episode is released every Sunday about a specific topic on pregnancy,
birth, and being a new parent. Every Wednesday Vanessa answers a question
from a listener with a short Q&A episode. You can find the Pregnancy
Podcast on iTunes, Stitcher, and Google Play or listen to episodes directly on
the website at PregnancyPodcast.com.
Pregnancy Podcast Community on Facebook
Connect with other expecting parents and ask questions specifically to what
you are going through during pregnancy and what you are planning for your
birth.
40 Weeks
A short podcast episode for each week of pregnancy. Find out what is going
on with your body, how your baby is growing, plus get a weekly tip for dad, all
in less than five minutes. You can find the podcast on iTunes, Stitcher, and
Google Play or listen to episodes directly on the website at
PregnancyPodcast.com/week. You can sign up with your email address to get
a link to each week in your inbox according to your due date.
Vanessa Merten
The author of Your Birth Plan and host of the Pregnancy Podcast is
committed to helping expecting parents navigate pregnancy, birth, and being a
new parent. As always you can contact Vanessa through the Pregnancy
podcast website or send her an email at [email protected]
All About Breastfeeding
Lori Isenstadt is a powerhouse of knowledge when it comes to everything
Breastfeeding. She has many certifications in the maternity field, has worked as
a childbirth educator, postpartum and birth doula, she has written several
books, and for the last 20 years has worked as an International Board Certified
Lactation Consultant. She is a pro on all things breastfeeding, she runs a
private practice where she helps moms and babies with breastfeeding, and is
the proud host of the All About Breastfeeding Podcast at
AllAboutBreastfeeding.biz
La Leche League
An international organization dedicated to helping mothers worldwide to
breastfeed through mother-to-mother support, encouragement, information,
and education, and to promote a better understanding of breastfeeding as an
important element in the healthy development of the baby and mother. The
Womanly Art of Breastfeeding is the best selling guide to everything you need
to know on breastfeeding. This book covers everything from preparing during
pregnancy to troubleshooting. For more about La Leche League you can visit
LLLI.org
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