Interviewing a birth provider, and making the tough calls.

Recently I have had to help a client get a new provider four weeks shy of her due date, and also had a friend who is trying to conceive talk to me about options for birth providers. This got me thinking. I have this HUGE three page list of questions I give to people to give them a general idea of what ask and why, but it's too cumbersome, and too detail oriented... I thought, there has to be a way to make this simpler....

So I came up with this.

1. How can help me to achieve the kind of birth I am looking for (un-medicated, intervention-free, etc)

This question is open ended enough that you can hopefully gauge their REAL opinion on what you're hoping to do, as well as their level of comfort talking off the cuff about the topic. Stammers, and side topics are a good indication the doc you're looking at doesn't know much about it, or doesn't do it much.

2. How do you feel about doulas?

Now, obviously, I think everyone would benefit from a doula. But that's not the point of this question. Some doctors don't like doulas, and I have found that those doctors are the ones with high rates of intervention and cesarean rates. Not to mention that closed-mindedness is not helpful when it comes to healthcare providers! Some people may have had a bad experience with a doula, just like doulas sometimes have bad experiences with doctors-- the goal here is not to judge by those terms, but to gauge open-mindedness, and intervention rates.

Many doctors who straddle 'the line' of medical/natural have told clients of mine things like, 'well if that's the kind of birth you want, you would definitely be better off with a doula'. Meaning, if you're calm and under control and I don't have to worry about you, you can do whatever you want. But if you're NOT, then I just might throw the book at you. And this is not necessarily a bad thing, but can be a point of concern and warrant more questions on your part.

3. What is your cesarean section rate?

The US average (mind you we're 37th in the world when it comes to maternal and infant mortality, which is ABYSMAL) for cesarean sections is 31.8%. The World Health Organization states that there is no reason the number should be above 10-15%. Don't rest until you get the real number! They have it, or they can get it.

This can also be a good spot to segue and ask if they accept VBAC births. Even if you're not a VBAC, the answer to this question says a lot about the open-mindedness of the clinic, as well how much power the legal department has over the medical decision making.

4. What is your epidural/narcotic usage rates?

Some places give a combined stat, and some keep them separate. Either way, if it's over 60 or 70%, it's not LIKELY that the provider has seen the ebb and flow of many un-medicated deliveries, and may overreact to a situation that is normal, but 'could' be abnormal. Only someone who sees a large number of natural births will be able to adequately monitor support and gauge a mother who is un-medicated. This is where the science and the practice of medicine seem to really split. They learned about normal birth in college (theoretically), but may have not attended enough of them to be comfortable with them. Practice makes perfect-- find a practice who regularly supports natural birth, and you'll be in much better hands!

Also keep in mind that you need to have some symbiosis with ALL the providers in the group, because if you end up with the one OB who does not support the birth you are looking for, that can be a problem. Though, having been in this situation once, we did got mom through an all natural, un-medicated delivery without so much of an IV (which he was not happy about), but afterward he told us that was his first natural birth, and he was very impressed and learned a lot. So who knows... maybe we converted him. :)

Next, you need to ask about their office/hospital policies on the following things:

1. monitoring.

What kind and how often? All the studies show that too much monitoring can be really detrimental to the process of natural birth, so we like intermittent, external monitoring, or even doptone. And 'intermittent' can mean different things to different people, so be sure to ask what that entails for them. Another great question is if they have telemetry units. These report the results on radio waves, and therefore, have no cords. They can also be used underwater and in the shower. Not many places have them, but those that do are worth searching out.

Clearly, if the situation warrants a closer look, you can change your 'wish list' on monitoring, but if your office has a standard 'break the bag and insert the internal fetal monitor' policy, you may want to run screaming.

2. IV/hep lock usage

Is an IV standard? Is it possible to used a saline/heparin lock instead? Many doctors express concern over the skipping of he IV, and I can understand why. Many of the medications needed for emergency situations kept on the floor are meant to be administered directly through an IV-- so if you injected it, it could be all kinds of horrible for you, and probably wouldn't work either. So, there is a safety risk for women without IVs in unexpected situations, HOWEVER, there is no reason that a heparin lock IV start/access point isn't good enough. they can hang the saline, and literally have you connected and medicated with only a few extra moments. For most women, those extra moments are not critical, and the freedom of movement gained from not being tied to a pole, and going pee all the time is invaluable.

3. pushing positions

If they tell you supine with your legs up is best, run screaming. This has been proven time and time again to be THE WORST delivery position possible-- though, doc can see much better this way.

While many women do prefer to climb into bed to deliver, there are many options for positions even while in the bed that can help the mother use gravity, and help her use her body for leverage. Not having a choice here dictates that the doctor has not delivered in other positions often enough, and I wouldn't want to be their first case out of their comfort zone!

4. what kind of 'clock' can I expect to be put on?

Do I have 24 hours from when my water breaks until baby NEEDS to be born? 48?? In other countries women go days, and sometimes even weeks with broken waters before active labor sets in. It is not necessarily harmful at all, however, the legal-political climate in this country allows little room for situations like this. If your labor isn't 'fast enough' to beat the clock, you will be looking at pitocin at the least, and a cesarean at the most. So, the answer to this question is quite important.

5. food and drink in labor

The ACOG has recently come out in favor of food and drink in labor. A mother's blood sugar needs to be able to keep up with the marathon events happening, and allowing no food or juice is very detrimental to that process. There is really no reason to keep a mother from doing what comes natural, especially if she is hungry!

6. What are your 'standing orders'?

Standing orders are what doctors have on file at the hospital to do to get every patient ready for laboring. It often includes blood work, some monitoring, an IV, and in many cases, AROM, an internal exam, and pitocin. These orders are going to tell you a lot about how they practice, and how much patience they have for longer labors.

And lastly, ask WHY a lot, and use your gut! If you get a funny feeling, stick with it, and interview some other people. And remember-- charisma and charm are for getting the baby in there, they don't help get the baby out! Some doctors are very personable in the office, and turn out to be abrasive, short, or different in the hospital, so knowing their policies will tell you a lot about what you can expect when 'the going gets rough'.

I hope this list is helpful-- and remember to choose wisely!

Planning Your Postpartum Period

After having this conversation with almost client I've ever had, I think it's time I put it to paper. It seems most everyone is afraid of PPMD (post partum mood disorders). I can understand why, they're really scary, and who wants to be incapacitated when you have a new child to look after?

Well, here's some information that may or may nor be new to you. Postpartum mood disorders are NOT limited to depression. It can surface as any type of common mood disorder people can get when they're not postpartum as well, such as PPD, anxiety/panic disorder, OCD, PTSD, and psychosis. These diseases look and act EXACTLY the same as your standard disease by that name, except that they are linked to a 'specific onset' of childbirth, or being postpartum.

This said, they have the same treatments as standard mood disorders do. Keep in mind though, that once a mood disorder is triggered, it may stay with you for life. In may cases, the mood disorder was not caused by having a baby, but there was a strong predisposition, and childbirth was just the right circumstance to set it off. In these types of cases it is likely the symptoms would have been set off later in life, regardless.

Some of the reasons cited for PPMD are changing hormone levels, the massive physiologic stress of childbirth, and the stress associated with adapting to your family's 'new normal' once the baby is home. I can't get my hands on it, but Sarah Fields, an author on PPMD has a GREAT article on this in Mothering Magazine from May/June 2007. Other respected authors on the topic are Heather B. Armstrong, and Susan Dowd.

A great test you can take to objectively assess whether or not you have PPMD is the Edinburgh Postnatal Depression Scale. Though it is important that if you have any of the risk factors for PPMD, you discuss them with your care provider, and intervene earlier rather than later.

The risk factors for PPMD are*:
-a history of severe PMS or hormonal troubles
-family or personal history of mood disorders
-assisted fertility treatments previous to pregnancy
-prior or current perinatal loss, miscarriage,or stillbrith
-personal history of violence rape or abuse
-a complicated pregnancy or delivery, or a cesarean delivery
-early or prolonged separation from baby
-difficult infant temperament
-poor social support
-lower socioeconomic class
-single marital status or a troubled marriage
-having multiples.
*list taken from multiple sources on PPMD, and hospital handouts on the topic

The things we can do to PREVENT PPMD are as follows:
-breastfeed your baby exclusively for 9-12 months
-have a doula present at your birth
-avoid interventions at birth
-have baby on your chest and nursing right away
-do lots of kangaroo care
-eat well for you and your baby
-exercise moderately

How you can make a plan for prevention before the baby comes:
-Either have dinners by design, or a whole freezer worth of food-- not worrying about lunch and dinner takes a large burden off a new family, as well as making sure you are eating healthy food. Have healthy snacks and water on hand as well.

-Have planned visits from friends and family that break the monotony of he day, and to provide support in the immediate postpartum period.

-If overburdened by visitors, simply don your robe before answering the door. No one will stay long if you're in your robe-- it's a subtle hint that this is family time.

-Let people help you! When they ask if you need anything, have a grocery list ready or ask them to change laundry or do dishes. This is the one time in your life people are really willing to help, so please let them. It makes them feel helpful as well.

-Don't worry about acting as 'host' when people come to see your baby. They can fend for themselves. Your ONLY job is to rest, eat, nurse, and snuggle. Let the mess be messy, and DO NOT feed your guests!

-Have a calender where each day you rate how your mood was on a scale form 1-10. Make sure you fill it in at the same time of day every day. This is to help you and your partner monitor any changes or worrisome behavior. If your partner notices you are not filling it in, s/he should check in on you and why that isn't happening, as it could be a sign of emotional issues.

-Remember that the baby blues are normal, PPMD are NOT. Seek help if you feel you need it and don't wait too long.

-Continue taking your prenatal vitamins, and consider supplementing with B vitamins, folic acid, or fish oils.

-Have things on hand that are simple pleasures for mom, like favorite candles, bath salts, movies, etc, and have them all set up with easy access for a mom with one arm dedicated to holding infant to breast.

-Find a moms group and go to it.

-Find a La Leche League meeting and go to it.

-Plan time to talk to your partner about things every day, or a special night once a week where you do a special activity to stay connected through all the changes in your life.

I also think it's important not to dwell on the possibilities here, there is every likelihood that you will be fine! There are memoirs out there, written by women who have survived PPMD, and they can be great help if you do find yourself with a little more than the blues. But take care of yourself, take care of your baby, let people take care of you, and in time, things will feel right again.

A SIGN of the Times

So, here we are, back at the sign that everyone is up in arms about. Do I like it? No. Do I think it's hateful and ignorant and arrogant? Yes. But there's a deeper issue here I'd like to discuss.

The fact that the sign is UP us a victory for doulas and natural birthers everywhere. There are enough women asking for a birth of choice to upset someone who is not accustomed to giving them-- which means, we're mainstream. Of course, it's not good news that this doctor's office felt it necessary to say 'we are not like them and do not accept them', but I DO find it encouraging that our natural birth/doula/vbac movement is strong enough, and has enough interest generated by it that this office felt it necessary to say 'we're not like them'.

To be a 'them' is to be recognized as the 'other party' in a conflict, which means our side has gained enough public respect to be bothersome and common for this office. It's too bad they don't like us, progress takes time, but it does happen. Little by little the old school will be overturned, and the liberals win out. Progress is just that, what happens over time. Progress never stops, and to me, this is great sign that acknowledges our presence and prevalence in the mainstream birth communbity.

This makes me angry, but gives me hope. In 20 years, many women will either leave this office in disgust, or the sign will be taken down by a 'new management' who isn't so bothered by women's choices. You can't stop progress, not even with nifty green engraved signs in your waiting room that are full of spelling and grammatical errors.

Preparation for the big day (at war)

There have been some intense conversations going on on Facebook the last few days about the sign put up by one doctor’s office in Colorado. I am not going to address the sign exactly, other than to say ‘Thanks for letting me know so soon, so I can get a provider who has my best interests in mind’.

What I am going to talk about here, is doing your homework, and preparing yourself so that 1. You don’t have an unsupportive provider like this one, and 2. You can deal with him if the event of a last minute substitution at the hospital.

Unfortunately, there is quite a chasm in the world of maternity care, with natural childbirth acting as the polarizing factor. This includes the heated debates on the cesarean epidemic, policies on VBAC deliveries, doula care, labor medications, and much more. It seems there are thousand points to disagree on, and none that we can all say ‘okay, I can meet halfway on this one’.

In my debates over this sign, it was gently inferred by a fellow birth activist that perhaps my inexperience with all things ugly in the delivery room was the reason I was not up in arms, and that perhaps with time, I would change, and become more angry and jaded. Now, I am not taking words out of her mouth, here, nor am I going to tell you her name—but this is the impression that I got from our chatting.

I suppose to some, I am an inexperienced doula. With less than 20 births, and not one cesarean, one could assume I have had nothing but great births, but this is simply not the case. I have seen all sorts of things that have upset me to my core, sent me home crying, and swore me off my profession. It’s not always an easy job. But regardless of this, I believe the reason I can remain optimistic when birth has become such a battlefield has to do with the classes I teach, and the way I prepare my students and clients so that their births CAN be beautiful.

My birth classes are intense. I am a certified Bradley Method instructor, and I teach a pretty hard line on reality. Many of the births I attend have been my students (or come from other Bradley instructors), and therefore, they chose the right birth professional, made the right decisions, and did not allow themselves to fall victim to a terribly flawed system. Some doulas I know with 50+ births can’t do this. So I say the claim that experience makes your eyes more open, or makes you more aware of the problems at hand and what to do about them, is not a valid one.

Birth is not something that happens to my students, it is something they learn to embrace. The births I have been to have not all gone perfectly, in fact, some have gone horribly wrong. But my students are able to make good choices no matter what hand they are dealt, and are able to communicate well with their birth team, and feel confident that THEY have a choice. This said, I know many women do not have choices, and have been on a large handful of volunteer births that illustrated this for me in way that is more visceral than I can explain to you.

The system is flawed, and it seems that some of us are at war. My classes empower my students to make good choices, and not become victims in this war. The importance of being an educated consumer has never been greater, and you can’t be an educated consumer without an education. So find the BEST class you can in your area, and if you’re like me, take two. Learn about red flags, possible interventions, cesarean rates, and your provider’s comfort level. Don’t let this battle be fought in your uterus. And with my classes and me as a doula by your side, there’s very little chance this will happen to you. We may be at war, but this does not mean we can’t find peace on our big day.

Doulas and Dads

A common theme I hear about when a couple chooses to not use a doula, is that the Dad wants to have an active role in the birth of their child. I’m here to tell you that these ideas are not mutually exclusive. Doulas can actually enhance the experience of the father as well as the mother, especially when the father has taken an active role in the childbirth preparation and labor.

First let me explain to you what doulas do NOT do, which I think might be widely misunderstood. Doulas do not ‘take over’, nor do we step inbetween you and your wife, or advocate for your medical decisions with the doctor. We don't perform vaginal exams, or monopolize the birth room in any way.

Doulas do not have decision making power, are not disruptive to the process or labor, or the connection between mom and dad. A good doula will know in the interview that Dad wants to be very involved, and only step in help him when he needs it. There is nothing sweeter than watching a laboring couple love one another through contractions, needing no assistance at all.

Doulas are there to serve you both, protect your interests, and divert the power to the couple that is laboring. This means, if mom is being coached beautifully by dad, we stand back and let that happen, offering a hand to hold, a position change, or a straw to sip from as time goes on. In this sense, we can work as a team, offering two voices of reason, two hands to hold, and two levels of experience to comfort her with.

On the practical side, it is important to note that there will be at least two other people in the room during delivery, and it would be nice to have met a few of them before push time. Also practically speaking, doulas can offer dad a moment to go to the bathroom, get something to eat, or get off his feet for a few minutes, which is SUCH a blessing in the longer labors. Doulas also come with a wealth of knowledge on what positon helps what, when to walk and when to rest, and many other things that only experience can teach, which can make both parents feel more proactive and capable throughout the labor.

We can also provide a sounding board for fathers who need to make a medical decision and don’t want to decide ‘on the spot’ with the doctors and nurses watching. A doula can offer information on the risks and benefits of procedures and confirm the situation that warrants that procedure, so that Dad can decide more easily,whether he thinks this intervention is right for them.

I think the most important piece, is that we understand how hard it is to protect the one you love most when you have no control. We are there to help reframe these feelings of helplessness, and create a subtle support network to aid in decision making, and the process of labor. We can take a stressful moment and turn it into a good memory. We can reassure dads who have not seen the face of a laboring woman that ‘yes, this is normal, yes, we are doing the right thing’. As well as supporting dad throughout the labor as a significant piece of the family we have been hired to support.

I cannot speak for every doula, just for myself. But I can say that doula dads seem to walk away with a higher confidence in themselves, and are much happier in their outlook of the labor, even if it contained some less than ideal circumstances. Dads and doulas are SUCH a good team, and it would be a real shame to have to labor without either one of them.

Here is a video of Taye Diggs (very funny) talking about the birth he and his wife used a doula for.

I am published!

I was the cover story and featured article in this month's DOULA INTERNATIONAL Magazine, an industry publication for DONA International, the largest certifying body for doulas internationally. This magazine is sent to every Doula registered with DONA, which is worldwide. Since it's an industry publication, I do not have a link, but have scanned in the article for you to read. Please click on the images to make them larger and scroll down to read.

It's so nice to be recognized!

Potty Training for Babies???

I've been hearing about this for a long time now, and really regretting I didn't try this with my own son. Elimination Communication is just about the coolest thing I've ever heard of. Here's a news story to tell you more about it.

Home birth story

This is just the sweetest story! Our culture puts restrictions on so many things, and this woman's choice to overcome others' judgement and have the birth she wanted is beautiful! Enjoy!

Spinning Babies

Here is a link to a site dedicated to 'spinning babies'. This is information dedicated to fetal positioning, or the way your baby is 'poised for exit'. While most babies present in an Occiput Anterior Position with their heads down, some babies will start off in labor in a breech, transverse, or posterior position. These positions can sometimes be delivered safely, and other times not.

Either way, the ideal position for baby is OA, and is less painful and easier to
push out. Most moms are big fans of easier and less painful when it comes to birth! Babies that present in alternate positions in late pregnancy and early labor can be 'spun' or stimulated to find another position before delivery. Many times, labor will stall out, or slow down until baby is able to achieve a more ergonomic position, and sometimes, baby needs help from mom to get that way.

This is the idea behind the 'spinning babies' techniques. Babies continue to move and rotate as part of a normal, healthy labor, and changing positions can help baby to descend more quickly, and get into the best position. It is best to get a doula who is familiar with how positioning can help you with delivery BEFORE a problem appears, and lucky for you, I'm one of them. :O)

More on the dangers of Inducing Labor

Here is a very short video on the dangers of elective induction.

As we all know, babies come when they are good and ready, and NO ONE is ever pregnant forever. In the absence of a medical condition that has cause for alarm, an induction should not even be considered-- but someone forgot to tell a lot ob OBs that, and I'm hearing more and more about inductions being asked for and allowed at any point past 37 weeks, or the point of 'viability'. If baby was done cooking, it would come out, she doesn't know she's supposed to be viable yet! And if she's not, you have a preemie on your hands because of allowing non-evidence based medicine.

This is just some more information for your tool kit that I hope you never have to use!

Fetal development Progression Video

Here is a link to a short but sweet slide show on fetal development. I just love seeing the stages of baby's development as they grow... I hope you enjoy them, too!

Remember how important nutrition is to developing babies, and for mother's body to grow and change without being depleted. As always, the Brewer Diet is recommended and is the most scientifically sound. A mother who doesn't eat well will likely end up with pre-ecalmpsia, eclampsia, or toxemia, and is also more likely to suffer from excessive weight postpartum, and will notice more damage to her skin, hair, and teeth after
pregnancy that may not be repairable.

So, cheers! Eat well and happy baby growing!

From Vbac to Homebirth Midwife

What a beautiful story of endurance, and strength, and power! This was just too good not to share. It's long, but worth it. :)

My Journey to a VBAC