In My Humble Opinion…

bees

So, the world of birth is abuzz this month as ACOG (The American Congress of Obstetricians and Gynecologists) has released their newest Committee Opinion: “Approaches to Limit Interventions During Labor and Birth.”

This opinion might have left some scratching their head and saying, “Duh!” But I want to jump up and down squealing with joy! I think this is a fantastic step in the right direction from the OB/GYN leaders of America. They’re asking their members to consider: “If a pregnant Momma is low-risk, how can we keep her low-risk?”

The answer is: “Don’t intervene unless it’s medically necessary!”

I’m going to break down the recommendations and conclusions section of this Committee Opinion for you here, because there are lots of big, fancy words – and you might appreciate my attempt at a simpler translation. Also, we know that when information comes from people who wear white coats and carry stethoscopes around their necks, it sometimes carries more weight – even if we’ve already heard this same information from different sources. Just saying… In our culture, there’s a hierarchy when it comes to medical advice and opinion – evidence or bias, be damned!

So, this is not a perfect translation (and my editorial comments are included in italics) but in a nutshell here’s what the ACOG has stated in it’s Committee Opinion, Number 687 for February 2017: Approaches to Limit Interventions in Labor and Birth.

  • If a woman is between 39-41 weeks, and is in labor that’s started on its own, and has a baby that’s head down, the use of intermittent fetal monitoring and unmedicated comfort and coping techniques is a good idea. (Full-term according to ACOG. Intermittent – the fancy word that means there are breaks in between periods of monitoring.)
  • If a woman is still in early labor, she doesn’t have to come to the hospital right away as long as she and the baby are doing okay. It’d be great if she was offered frequent contact and support, as well as unmedicated comfort and coping techniques. (See what I wrote here, here and here (It’s a 3-part series!) about how to stay comfortable and pass the time of early labor at home before coming into the hospital.)
  • When women come into the hospital in early labor due to pain or exhaustion, they should be offered education and support, water to drink, encouraged to try various positions that might provide more comfort, and other unmedicated comfort and coping techniques like massage and how using the shower or sitting in warm water can be very helpful. (Hydrotherapy – the fancy word for drinking water, showering and/or sitting in the tub – are great ideas for comfort and can also help labor progress!)
  • OBs and other providers should inform those women whose water has broken at the onset of labor about any risks associated with waiting for labor to start on its own. If there are no other reasons to be concerned for the baby’s health, an informed woman can choose, and should be supported in her choice, to wait for labor to start on it’s own. The exception would be if a woman has tested positive for Group B Strep – antibiotics shouldn’t be delayed, and there may be a preference from both the provider and laboring woman to induce labor immediately, rather than wait for it to start on its own. (Many providers already use “expectant management of labor” – the fancy word for “watching and waiting,” but more providers might now be encouraged to wait before inducing immediately if water breaks at the start of labor.)
  • Evidence suggests that in addition to regular nursing care, continuous one-to-one emotional support is associated with improved outcomes for women in labor. (YAY DOULAS! And partners, and Grandmas, and BFFs and… DOULAS! You can read my post here about how a doula can be a great addition to your birth team.)
  • For women with a labor that’s progressing and a baby that’s doing well, routine breaking of the bag of waters is not necessary unless needed for internal monitoring. (Amniotomy – the fancy word for breaking the bag of waters before it has broken on its own – is often suggested as a way to “speed things up” but can be associated with more interventions and increased risk for Cesarean Birth if it doesn’t work.)
  • In order to promote intermittent monitoring, hospitals should adopt protocols and train staff on how to use hand-held Doppler monitors for low-risk women who would prefer this type of monitoring. (This one even surprised me! I thought they would suggest using the external monitoring belts less frequently, but hand-held Dopplers would be a fantastic improvement over current practice. So much easier and comfortable for laboring Mommas!)
  • Using a coping scale and the use of medicated and unmedicated coping techniques will help providers tailor interventions to meet the needs of each woman. (Some hospitals have already adopted the use of a coping scale instead of a pain scale, but this little tool can be very helpful in changing the mindset of a laboring woman from focusing on the level of pain she’s feeling to whether or not she’s coping well.)
figure-1-the-pain-intensity-scale-0-to-10-adapted-from-wong-baker-faces-pain-rating

Figure 1. The Pain Intensity Scale: 0 to 10. Adapted from “Wong-Baker Faces Pain Rating Scale”

coping

Figure 2. The Pain Coping Scale: 10 to 0, developed to assess coping during labor and birth. Adapted from “Wong-Baker Faces Pain Rating Scale”

  • As long as there are no complications and fetal monitoring is still possible, a woman should be encouraged and supported to change positions often during labor – it will make her feel more comfortable and will help move the baby into the best position for birth. (Being upright and changing positions as often as possible, for as long as possible, allows babies to make all the twists and turns necessary to be born.)
  • Women should be encouraged to use whatever kind of pushing technique she likes and is most effective. (Gone are the days of telling women to assume certain positions and hold their breath for ten seconds! Yeehah!)
  • Unless it’s medically necessary to deliver quickly, women (especially those with an epidural) can be offered a period of rest before pushing – unless she feels a strong urge to push sooner. (“Laboring down” is a really nice way to allow your body to catch up with your labor. Your contractions might have already opened your cervix all the way, but until your baby moves down into a better position for birth, pushing just because “You’re 10 cm dilated – let’s go!” might not be as effective and could lengthen the overall time of pushing, causing undue exhaustion.)

Can you see why I’m so excited about this Committee Opinion?! It aligns so beautifully with what I know to be true for women in labor. Interventions are not “bad” and can be life-saving in certain circumstances.

But if we limit the routine use of these interventions and only use them when medically necessary, we are protecting the normal physiology of birth. And this will result in better outcomes for Mommas and babies.

I am so heartened by this statement from the ACOG and excited to see the impact this will have for laboring women and birth in this country. My sincere hope is that members of ACOG will review their own personal practice based on this Committee Opinion and see where they might step back from intervening too soon or too often. I also hope that pregnant women will read this and know that they should talk with their provider about limiting the use of intervention in their own pregnancy and birth.

Knowledge is power. Be informed.

(You can access the entire ACOG Committee Opinion here in all of its medical terminology, further explanation and extensively cited form. It’s a great read, in my humble opinion…)

Happy World Doula Week!

WDW

I can’t let this week go by without a shout-out to all of the wonderful women I know personally, and professionally, who’ve taken up the call to become a doula. A doula is a woman trained to assist other women in childbirth and/or to support a new family following the birth of their baby. And this is the week we are celebrating women all over the globe who do this incredible work!

Over 20 years ago, I was working as a temporary office monkey between jobs and wondering what it was that I wanted to do with the rest of my life. Across my desk one day came the company’s monthly newsletter and on the front page was an article about “doulas.” I’d never heard of this word before, and the concept intrigued me.

A few days later as I drove home during my lunch hour, there was a story about doulas on NPR’s show, “Talk of The Nation.” I had a “driveway moment” and couldn’t get out of the car until the story was over. My curiosity was growing. 

But it wasn’t until my best friend announced her pregnancy and asked me to be at the birth that I got serious about this idea: “Maybe I should become a doula!” I’m not an overly woo-woo person, but all of these things seemed to be pointing me in the direction of birth.

After some searching, I found out that The Seattle Midwifery School (300 miles North of my home in Portland) was offering a doula training that would conclude before my friend’s due date. Everything seemed to be lining up – so I signed up. I was hooked on birth immediately, and the rest, as they say, is history.

I never went so far as to complete the work of being certified as a doula. Finding scheduled evening and weekend hours as a Childbirth Educator kept me in the world of birth and allowed me to focus on having my own family. But every now and again, I’ve had the honor of being a doula at the births of friends, neighbors, or women who had no support or financial ability to pay for a doula.

It is such a gift to be with a woman when she’s giving birth. Helping her find her inner strength and witnessing the parents and the baby lock eyes on one another for the first time – it’s one of the most awesome experiences ever (that word is so overused in our culture, but this is one area where it’s completely appropriate)!

So,thank you to all of the women who’ve answered the call to become doulas. You are very special women, indeed. You have an immense capacity for nurturance, calm, strength and advocacy. You’ve got incredible stores of flexibility, skills and knowledge and you’re somehow able to continue to do the hard work of labor support on little sleep and not a lot of food. You are the best example of how continuous physical and emotional support can make all the difference as this couple transforms into a family.

I have nothing but the utmost respect and praise for the work that doulas do in the world of birth. But don’t just take my word for it. Google “benefits of doulas” and you’ll get 359K hits in about a half of a second. There aren’t any studies that I know of that show anything other than positive results of having a doula with you in birth. If you’d like to read more about the benefits of doulas, read this article written by Rebecca Dekker on Evidence Based Birth.

Having a doula at your birth can be linked to:

  •  Reducing the incidence of c-sections      
  •  Shortening the length of labor      
  •  Reducing epidural and analgesic requests      
  •  Increasing breastfeeding initiation and continuation     
  •  Increasing mother’s satisfaction of birth experience      
  •  Reducing the incidence of postpartum mood disorders     
  •  Increasing new parents’ confidence in the care of their newborn

There’s really no downside to having a doula with you in birth or postpartum! A doula is worth her weight in gold. If you’re interested in finding a doula for your birth or for postpartum, one place you can look is the DONA International website. Other places to look would be your friends and co-workers. A lot has changed in 20 years! Many more women are using doulas in their birth and postpartum and personal recommendations can give you so much more than a website directory! Many CBEs also have referrals they can provide, if you ask.

My tips for hiring a doula: Don’t get stuck on how many births they’ve attended, or what “extras” they might provide (photography, massage, etc.) These might be wonderful additions, but I think it’s more important you feel you can hang out with this person for 24+ hours. A professional doula won’t have an agenda for what your birth “should” look like. She’ll be willing to support you, and your choices in birth. Make sure your doula and your partner can work together. If you’ve chosen well, your doula will help your partner feel like they had just the right support so they could be involved in the birth at the level they were most comfortable with.

Doulas can be an amazing support when a birth goes really well, but even more so they when a birth goes rogue. Your doula can help you remember what matters most to you in this birth experience and help you get as close to that as possible. On the other side of giving birth, you’ll share a bond with this woman forever and she’ll be an important part of the birth story you’ll remember for the rest of your life.

Doulas are amazing women and I’m happy to publicly honor them in this way! A special shout-out to Liesl & Kathie (doulas) and Beth & Marilyn (midwives) for all of the doula-ing they provided me and my husband during the birth of our four children. I mean this honestly when I say it – we couldn’t have done it without them!

If you know a doula, please take time to honor them in some special way this week!

Making Predictions During Birth – About as Magic as the 8 Ball!

Magic 8 Ball

Did you ever have a Magic 8 Ball? I did. I loved that thing. I loved being able to ask a question, any question, and have the almighty oracle predict my fate. Inside the little window floated a single die, with twenty possible answers to life’s biggest questions. Some of which included: “Signs point to yes” and “My sources say no.” When the Magic 8 Ball was certain, yes or no, then that was it. But sometimes there would be the confounding response of “Cannot predict now.” That always meant another hard shake of the ball and the search for a more straight forward answer. No matter how many times it took to get one!

I think too many of us are looking for straight forward answers to one of the biggest questions of all time. We want so badly to be able to predict what is by it’s very nature unpredictable – birth.

Today, I want to speak directly to those of us who work with pregnant and birthing couples.

Could you stop setting them up? Stop making predictions? Please, I’m begging you!

I recently had a reunion with some of my families. More than once I heard the report that someone on their birth team tried to make a prediction during their birth experience. I groaned and asked, “Why do they do that?”

One new Momma said, “so then, the nurse said to me “You’re really cooking! I bet we’ll have a baby before lunch!”

A second Momma said “the doctor came in and told me to get ready for a really long night, because he didn’t think I was going to have the baby until the next afternoon!”

Guess what really happened with these two women?

The first Momma’s labor came to a complete standstill about thirty minutes after her nurse had predicted a late morning baby. She started watching the clock and when the lunch hour came and went unceremoniously, no baby to be found even considering entering her birth canal, she became despondent and discouraged. She started to freak out that something was wrong with her body – with her baby. Given the strong connection between the mind and the body of a birthing woman, it’s no wonder all of this extra anxiety shut her body down for hours! It took an incredibly long time (and a new nurse at shift change!) before this woman’s labor started moving again. She ended up giving birth close to midnight – twelve hours longer than had been “predicted.”

The second Momma and her partner settled in for their “really long night.” But soon after she started second guessing her ability to handle the contractions that felt like they were right on top of one another. Instead of recognizing that her labor had kicked in big time and she was almost fully dilated, she thought that she was “just wimping out.” She was feeling very disappointed in herself and her ability to cope with what she’d been told by her provider was supposed to be early labor. Imagine the surprise when her husband had to run out of the room to grab someone to come catch the baby! It had only been about ninety minutes since she was last checked. So much for their marathon labor!

Birth is unpredictable. It can slow down, and appear as though it’s stopped altogether. It can speed up in the blink of an eye. The issue is not the unpredictable nature of birth, it’s our intense desire to make it predictable that’s the problem! There are way too many unique variables in every labor experience to make it impossible to predict consistently what will actually occur.

But we all still do it! Why?

Pregnant Mommas and their partners hear the due date and create an expectation that this is the day the baby will arrive, instead of recognizing their due month as closer to the reality of when the baby will actually be born.

As a Childbirth Educator, I’m guilty of it as well. I teach, as most do, textbook averages for birth. But do I explain that as a first time Momma, it’s completely within the range of normal to have a birth go super fast? Do I adequately prepare them for an ultra marathon labor experience? We all need to be more on top of this, so our students understand it is possible to have active labor begin almost immediately! And it’s also possible to be in early labor for three days before any changes in their cervix occur. As Childbirth Educators we need to provide our students with realistic expectations of the unpredictable nature of the birth process itself.

But once they’re at the hospital, too many nurses and providers think they’re doing a service for these women when they try to predict what will happen next. I know that this is not born of ignorance. These are professionals who have been at this job for a long time – decades in some cases – and they’ve seen an awful lot. The laboring woman in front of them is presenting as many have before her. The mind just wants to go there. “Here’s a pattern that I’ve seen before. So I’m going to predict what will happen next.” And in a lot of other areas of life, this might not be a bad policy. But not when we’re talking about birth.

This unpredictability of birth (and our refusal to embrace it) is what trips all of us up when it doesn’t have to. In fact, I would argue that we’re missing out on the most important aspect of birth while we’re busy trying to predict what will happen next.

As expectant couples, you go into birth with a rock solid Birth Plan that you wrote a month before your first contraction. But due to circumstances you could never have predicted, your birth has gone rogue. If you’re still clinging to the plan of your ideal birth (as opposed to participating in your real birth) you’re setting yourself up for disappointment instead of moving through your birth as it unfolds. When you’re able to adopt this attitude of flexibility, you’ll be surprised at what you’re really capable of! “Wow, this is not at all what I expected, but look at us and how we’re handling this completely unpredictable experience together!” It matters how you respond to your birth in real time, as it really happens. Not based on what you had predicted (hoped, wished, or expected) would happen.

As Childbirth Educators and Doulas, we are hurting ourselves and our couples when we try to make predictions about how we think our couples will move through their births. Let’s not prejudge how the people we work with will cope with their labors. Let’s give them all the benefit of the doubt in that they will have births that are, by nature, unpredictable. Let’s try our best to prepare them better for that reality.

As for the L&D nurses and providers who encounter these women in labor and try to make predictions about what will happen next, please understand how much that undermines a woman’s confidence in her ability to know her own body. For the woman before you, it doesn’t matter one little bit how many times you may have witnessed what she’s currently experiencing. She doesn’t need predictions from you about how much shorter or longer her birth might be. She just needs your support and your listening ear – right now. Even the least experienced laboring woman will be able to provide you with clues about what is actually happening in her body. And this is so much more valuable than what you think might be happening in her body.

I completely understand why we do this whole thing of planning and discussing averages and making predictions – all of us are wanting to avoid vulnerability. But vulnerability and birth are inseparable. They have to be. Birth without vulnerability lacks the key ingredient that’s necessary for deep and lasting transformation to occur.

All of us who work in this field should be experiencing that transformation on a regular basis. That’s why most of us got into this whole thing in the first place – the beauty, the mystery, the surprise, the unpredictable nature of birth stirs something in our soul. After each encounter, we should leave that new family feeling grateful we were once again able to witness their transformation – and be transformed ourselves at the same time. This is how we can continue to best serve our families, when we recognize the sacredness of our own work with them and strive to preserve that sacredness for our families no matter how unpredictable their birth ends up being.

There is magic in birth – it’s just not of the 8 Ball variety.

Experienced parents: Did you try and make predictions about your pregnancy, birth or parenting? Did any of them come true? Did anyone on your birth team try to make a prediction about your birth? How did his make you feel?