12. Choices

We have covered a great deal of information from learning about The Gate Control Theory, to creating a great “Birthing Tool box” to helping you relax during labor.

Now we’ll discuss your options and choices in preparing for the birth of your baby before  we move n to the topic “Labor + Birth”. Please take this time to review any information up to this point.

There are many choices available to you today in planning for the birth of your baby.  The choices you make reflects your personal values, and what you feel comfortable with.

Not everyone is comfortable with a home birth for instance, and yet for some moms-to-be that is the only way to experience the birth of their baby!  For others, a hospital environment is best guided by an obstetrician , midwife, or both.

Others seek the services of Doulas.  Even where you get your childbirth education there are choices. Such as Lamaze(R) International, Bradley(R),  Birthing From Within (R), Birthworks (R), and others.  There’s waterbirth,  Hypnobabies, and meditation with Calm Birth available to learn about and use during your pregnancy and labor as comfort and pain management techniques.

Hospital births have been the accepted norm since the late 1800′s in the USA. However there is a shift happening. Home births are on the rise because of their safety with midwives, privacy, and decreased rates of medical intervention.

The increase of childbirth medical interventions in hospitals nationally is alarming which has led to the movement of Evidence Based Practices for obstetricians to use as guides for maternal care. However, not all doctors are using these guides. As a result there is a national increase in  labor induction leading to increases in Cesarean births.

Lots of heated arguments circulate in the medical community as well as within the general public as to the justifications of medical interventions, “hospital” procedures, tests, medications used in labor, and the place of technology in childbirth, such as the use of the external fetal monitors.

Having said all that, we live in time where we can create change easier than in the past because of you. That’s right. In the era of social media we can create change. Look what happened in Egypt just a few months ago, Through social media the people of Egypt were able to rise up and throw out the ruling regime.

You are a consumer. You have rights (review the Rights of Childbearing Women), you have rights to Evidence Based Practices and you can share these with your care provider and ask questions about his/her philosophy of care based on these practices. Then decide if they are the one to manage your pregnancy and labor experience.

A lot of education is happening right now as you read this, midwives, doctors, childbirth educators, Doulas are all eagerly, yet slowly shifting the ways of maternal care in the USA.

Because a majority of births do take place in a hospital and if you are going to one to have your baby,  it is wise to be familiar with their labor and delivery procedures.  Knowing what they are gives you the opportunity to make educated decisions to reject, accept or compromise a procedure depending on your situation.

These choices range from difficult to simple. Only you and your partner can weigh the importance of the choice, your decision, how it will affect your baby, and its affect on you.

Visit this site- Birth Psychology and Read this: Psycho-Technology  and  The Procedures

Evidence Based Practices for Labor

Question for your care provider:  “Are you familiar with current Evidence Based Practices for laboring women?”

The following is from www.childbirthconnection.org:

The most recent and largest systematic review (PDF) of continuous labor support is available in full right on this website, along with a brief overview of the review. It summarizes the experiences of over 15,000 women who participated in 21 randomized controlled trials. The authors conclude:

Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labor and birth (Hodnett and colleagues 2011).

What is the best evidence about the benefits of continuous support during labor?

The review found that, in comparison with women who had continuous support, women who labored without continuous support had longer labors and were less likely to have a “spontaneous” birth (with neither cesarean section nor vacuum extraction, nor forceps). Women without support were more likely to:

• have an epidural or other “regional” analgesia to manage pain
• use any type of pain medication (including narcotics)
• give birth by cesarean section
• give birth with vacuum extraction or forceps
• give birth to a baby with a low Apgar score rating of well being 5 minutes after birth
• be dissatisfied with or negatively rate their childbirth experience (Hodnett and colleagues

The most recent systematic review looked closely at how effects of labor support varied by type of person providing labor support, and offers new knowledge (Hodnett and colleagues 2011).

Effects were strongest when the person was neither a member of the hospital staff nor a person in the woman’s social network, and was present solely to provide one-to-one supportive care. Compared with women who had no continuous support, women with companions (such as a Doula) who were neither on the hospital staff nor in the woman’s social network were:

• 28% less likely to have a cesarean section
• 31% less likely to use synthetic oxytocin to speed up labor
• 9% less likely to use any pain medication
• 34% less like to rate their childbirth experience negatively.

Support provided by a person that the woman selected from her social network (for example, her partner, husband, other family member, or friend) increased her satisfaction, but did not seem to impact her use of obstetric interventions.

Support provided by a member of the hospital staff (such as a nurse) did not seem to impact a woman’s likelihood of having a cesarean or her satisfaction. The authors note that hospital employees may have divided loyalties and other duties, and may be influenced by hospital policies, which could limit the impact of their supportive care.

From www.childbirthconnection.org

Birth  Plans
A good exercise in learning about your options, and discovering what you would like to experience during childbirth is writing a birth plan. There are pros and cons.
Visit Pregnancy Today and  Read This article on Birth Plans

Pros

• You learn about procedures, and can pretty much anticipate what procedures will be used during your labor, what you can, and can not do, such as walking the halls with an IV pole, or having intermittent fetal monitoring.

• What can you do in your labor room to make you feel comfortable, such as dimming the lights, playing music, having a Doula – visit DONA.com, etc.

• Planning how many people you want to share the birth experience with, and of course, check with your health care provider about that too, and the hospital’s policy.

• It helps you to decide what you want, and where you want to deliver. You might discover that you don’t want to deliver in a hospital, after all !  Now what? You will need to find other facilities, such as a birthing center, etc, and what their policies are.

• Start early in your pregnancy! Don’t wait until you are in the 7th month and decide you want to change from your doctor to a midwife! Yikes!

1. If you know your options, you’ll have some!

Cons

• Birth Plans can be disappointing.  Why? Because your expectations can be high, this is how you want it, and it doesn’t happen!  Use birth plans as an exercise in researching the facts, and options.  keep an open mind to events as they unfold, be flexible, and make educated choices based on what you know and have discussed with your partner, and health care provider.

• Life rarely behaves the way you expect it to, but it is full of surprises!

• Can set you up for disappointments

Nutrition

Question for your care provider: “Can I eat  in the hospital during my labor?”
One policy you’ll find in many hospitals is a diet of ice chips during labor (another hot debate)!  Why? Well, because if there is an emergency and you need to be medicated or need a Cesarean Birth  they (doctors) don’t want you to throw-up and aspirate (breathe in the contents into your lungs).

So what can you do? When you go into labor and you are at home, drink lot’s of fluid – juices, water, no caffine, etc.  Eat light – soups, sandwiches, crackers. You know, food that won’t weigh a ton and sit in your stomach.  Food you know won’t give you heartburn, or make you uncomfortable.

At some point during your labor you lose your appetite anyway.

Although, this is slowly changing if you are in the hospital during early labor. Some hospitals/doctors will allow you to eat “lightly” – jello, juice, etc. So ask!

Good nutrition is important during your pregnancy right up to labor, delivery, and after during postpartum!

You want to be healthy, have the energy when you need it,  and when your body is healing after delivery.

Medications

Question for your Care Provider: “Do you support an un-medicated birth?”

The use of medications can be helpful to you in labor. The decision to use them depends on the situation, the level of discomfort you experience, and your progress during labor. The decision to use them is totally a personal one! Your physical reaction or response to medications will also be an individual one.

Drugs should be used as a last resort after all other measures have been tried and have not been successful simply because of their potential negative effects on the labor process.

They should also be used in an emergency, when labor is lasting a long time, prolonged discomfort,  and you are overly exhausted. If you have labored a long time, for many hours ( to be determined by your doctor or midwife),  an epidural could be a good choice.  It would allow you to rest, to sleep, and regain some strength, and energy to cope better with discomfort caused by the contractions.

Drugs should never be used just because they’re available.

Drugs have side effects and yes, your baby will be affected because drugs are transfered to the baby through the placenta. How much baby will get depends on when the drug was given, the dosage, and the route the drug was given ( injection or Intravenously ).

Narcotics are usually given through the I.V. (Intravenous) and go directly into your bloodstream. The Epidural is administered through an injection in your back numbing the nerves that communicate to your belly and upper legs – the epidural does not enter the bloodstream.

Side effects will vary and also depend on the medication taken, route, dosage, and your body weight.

Once you introduce a drug into your system it alters the chemistry in your body influencing the function of hormones and your muscles.

Remember, your uterus is a muscle and it must contract for the baby to be delivered!  Drugs can interfere with the uterus’s ability to contract.  Also, if you’ve received the Epidural you will also receive “Pitocin“, the man-made drug that mimics your innate labor inducing hormone “Oxytocin” to stimulate contractions.

Narcotics:

Demerol, Nubain, Stadol, and Morphine, are the ones more commonly used in labor.  They are usually administered by an injection into your buttocks, or more commonly through an IV line which feeds directly into a vein in your arm. Thus, the drug prescribed and preferred by your doctor, enters your body through the vein and circulates throughout your vascular system, or bloodstream. You Healthcare provider also determines when, and how often you may be medicated. He or she will need to know if you have ANY allergies.

Drugs cross the placenta, so baby will be medicated also.  When the medication is given during a contraction, less of it seems to pass through the placenta because blood flow is decreased during a contraction. When the contraction is over, there is a surge of blood flow to the uterus and baby and an exchange of nutrients and oxygen takes place and baby gets what it needs. . Also, narcotics will not be given if close to delivery.  If given close to delivery, the baby will have more of the medication in its system. Narcotics work by relaxing the muscles.

When given:

• Ideally between 4cm – 7 cm.  If given too early in labor, your labor may slow down. If given too close to delivery, baby will receive more of the medication.

Side effects:

• Mother: Vomiting, nausea, drowsy, disorientated, sleepy, woozy, loss of control over contractions, dizziness, respiratory depression, dry mouth. Your reaction is totally individual. Also, your will still feel the contractions.

• Baby: Respiratory depression, decreased sucking ability, sleepy baby, trouble with breastfeeding. Note: Traces of narcotics can remain in baby’s system up to six days!

Epidurals:

Some of the medications used in epidurals are in the “caine” family.  PLEASE, if you have ever had any kind of reaction to Novocaine, which is a drug dentists use, please let your doctor know! You may not get an epidural.

Epidurals work by numbing the nerves in your body at the level where the injection of the medication was given. In the lower part of your back. There is often numbing of the legs as well. So, here the medication does not directly circulate through your bloodstream.  Baby does receive traces of the medication, but does not appear to experience the respiratory depression as associated with narcotic use.

When Given:

• Usually NOT before 4cm (depends on your doctor), and as late as 9cms (again, this is a decision made by your doctor as to how early, or late in labor you can receive one) Given too early may slow labor, and may increase the use of other medical interventions such as forceps, and vacuum deliveries.

Side effects:

• Mother: Headache, backache, low blood pressure, “spotty” distribution of medication, ringing in the ears, rare -> temporary or permanent paralysis.

• Maternal fever

• Baby: Drop in heart rate in response to low blood pressure in mother, possible subtle neurological changes.

Remember the following:

• Your baby is not able to metabolize drugs like adults can.  Baby’s organs, such as the liver, is immature and still developing. A newborn baby is not prepared to handle the by-products of drugs in its system, which is why they stay in their system for several days.

• Medications can interfere with your control over your labor experience, and the ability to work with your contractions. They also alter the ability of muscles to function properly because they are chemically relaxed. Have you ever had a muscle relaxant?  How did you feel?

• Medications can prolong labor, and epidurals may interfere with your ability to “push” in the second stage of labor.

• You will still feel the contractions with narcotics.

• You will receive Pitocin to stimulate contractions if you have received an epidural, and most likely with narcotics as well.  This is because you need contractions to deliver your baby, and the muscles are…..relaxed…..and will not function like they normally would in an unmediated state.

• Prolonged discomfort is very stressful to you and the baby, and can be alieviated by pain medication.

• Overall fatigue in labor can lead to fatigue in your muscles which will impact on your ability to “push” when the time comes, as well as the ability for your uterus to contract efficiently. Also, the diaphragm (a muscle that is necessary for breathing, located in the abdomen) may tire and compromise adequate oxygenation to you and baby. Medications, such as the epidural, could be helpful in this case, again, if all else failed, and of course depending on the situation.

Hot Debates:

• Epidurals do not increase the rate of c-sections. Studies show they do.

• Epidurals lead to maternal fever during labor

• Epidurals increase the rate of medical interventions, such as the use of forceps, etc.

• Walking epidurals.  What’s the difference? It is the dosage of medication given, and it is usually given in early labor, not in the active stage (4 -7cms). Ask your  doctor for more information, and if you will actually be able to walk with the epidural. Some hospitals view this as a safety risk.  Because you have been medicated, they will watch you closely to ensure you do not fall, or just very simply, keep you in bed.  There is a new Epidural technique that combines a spinal injection of medication WITH an epidural, using a catheter.  Ask your doctor, midwife or anesthesiologist about it.

Learn all you can! Talk to your doctor and keep an open mind.  Medication has its place when there is a medical need for it.

Nature does her best work during the process of childbirth – it comes naturally, on its own time, and it’s a normal function of a woman’s anatomy and physiology.  Birth is is an amazing event.

Induction

Question for your Care Provider: ” Why am I being induced if my health and the baby’s health is fine and I am low risk?”

Women’s lack of knowledge about the risks, benefits, and appropriate use of labor induction. www.childbirthconnection.org

• A surprising number of women don’t have accurate information about how long a normal pregnancy should last. A study of new mothers found that nearly one in four believed that a baby was full-term when it reached 34-36 weeks, and more than half believed it was safe to deliver the baby at that point. In fact, it is unsafe to deliver a baby before 39 weeks unless there is a clear medical need.

• Childbirth education classes that teach specific information about the risks, benefits, and appropriate uses of labor induction reduce the number of women having induced labor. However, attendance at childbirth education classes appears to be decreasing in the United States, and childbirth education classes are getting shorter, leaving less time to address this important topic.

• Elective induction before 41 weeks increases the chance of having a c-section if the cervix is “unripe,” especially in first-time mothers.

• Using medications or procedures to “ripen” the cervix does not decrease the chance of a c-section.

• Women in induced labor are more likely to request an epidural for pain relief than women in spontaneous labor. Epidurals introduce their own set of risks, including increased chance of instrumental vaginal delivery and fever in labor, which is often treated with antibiotics and may result in unnecessary tests and treatments for the baby and separation of the mother and baby after birth. (These and other risks are discussed in greater detail in our Labor Pain section.)

From www.childbirthconnection.org

The March of Dimes recently created a pamphlet on induction which is worth printing out if you can and then present it to your doctor. There should be a medical reason for induction.

Trust yourself and your own ability to give birth first.

Explore your options in alternative methods of relaxation such as hypnosis, and /or the other techniques discussed.  If the question to medicate or not rises, make an educated decision.  You will know what you need when the time comes. There is no right or wrong way to birth, only your way.

Knowing what your options are, you will do what is best for you when the time comes.

Lesly