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Archive for the ‘birth plan’ Category

Ah, the ‘E’ word that every makes every mother-to-be tremble in her boots.

Of course, tension and fear is not the best way to help a baby come out! Birth is complex and mysterious and beautiful, and driven by hormones. These hormones are strongly connected to your thought processes: for example, take oxytocin, aptly nick-named named the love hormone. Those feelings of warm affection, vulnerability, acceptance, enjoyment – are they present in the face of  fear? No.

We want to create a birthing situation where you have done your utmost to set fears aside and know that you are ready to be open, wide, soft, accepting and ready to welcome that baby into your arms! Closing your eyes and hoping that if you don’t look and wish hard enough things will go away is not going to improve the chances, either. Here are practical steps you can take to making yourself ready.

1. Have a dad or other close family member with you in the birthing room! That doesn’t negate a doula, and a good doula with a calming presence who can switch out coping ideas, provide warm encouragement and a wealth of options is priceless. However, as much as many women hire a doula to be your advocate, in reality there is a limit to the amount of voice that she can use in the delivery room. Yes there are appropriate times when a doula will be vocal and stand up for your rights, but we walk a fine line. Plenty of doctors, nurses and midwives are wary of a doula who is ‘pushy’, and we are well aware that a doctor or midwife who is annoyed is NOT one you want to be looking at your soft parts when a baby is coming out! Talk about feeling tense down there. Therefore, when I work with a mama, I try to foster a warm, welcoming, inclusive atmosphere in a birthing room. I may make gentle suggestions, I may successfully help make staff aware of the mama’s desires, but I will be non-confrontational. I find that this approach works best, because when hospital staff feel lovingly welcomed into the mother-doula bond in that birthing room, they are MORE likely to be flexible when it comes to birthing position/waiting the baby down/cutting the cord late etc. However, when it comes to using the scissors on a perineum, in actuality the best person to advocate for the mom (who is feeling very vulnerable and word-less at this stage) is her Birth Partner: the dad, or even another close family member. That Birth Partner should be given the authority beforehand by the mom, (almost an edict!) that even if they are queasy about birth and feel out of place, their job can be to be as involved as they want or even just stand by the mom and love and compliment and cherish her throughout the birth – but – if they see scissors, their job is to firmly say ‘No’. There is no need to be aggressive, no need to shout, but to feel confident and take this one task of standing up for the mother and own those words. The father of the baby (or another close family member) who gently but firmly reminds staff that the mother would rather tear than be cut* will usually be much more readily listened to than a doula at this one particular moment.

2. Only hire a practitioner that has a low episiotomy rate in your area, make that one of your hiring criteria! A good example of a low episiotomy rate is in the testimony of CPM Pamala Hunt in More Business of Being Born, Conversations With Ina May Gaskin, where the well experienced midwife quietly states that she has not done an episiotmy in 25 years. And this is a woman who has attended over 1,000 births. The video (also found on Netflix) is excellent to watch, if only for the part where both Ina May and Pamela speak confidently and simply about waiting for the baby to slowly crown, and how this slow back and forth progress of the head gently stretches the perineum, naturally. Truly inspiring.

For mothers who read this in Israel: when you arrive at the hospital the first thing you ask for is to please have a midwife who believes in and enjoys natural birth, or is a native English speaker, before you even hand over your forms, in the same breath as ‘Hi.’ This doesn’t ensure that you will have someone that doesn’t do episiotomies, but it does heighten the chances that you will have someone who will give you more leeway to do things your way and birth in a position other than flat on your back, or who will be gentle, or with whom you can build a good rapport! Those are all things that will help take you one more step away from the scissors.

3. Write a birth plan that will be paid attention to. A birth plan can be short and to the point, highlighting the things that are MOST important to you. Of course we are not ‘planning’ the birth, we are simply communicating to your birth team what kind of a birthing mother you are and how you wish to be treated. Here is how to write an effective birth plan. It is an important element of being heard and understood.

4. Put positive words in your mouth! As you approach the end of your pregnancy make sure that you practice the belief that you will be wide, that you will be soft and stretch, that the opening will be huge! Repeat those words to yourself, make it something that you hear/say/think so often that you believe it with all your heart. If you take a Hypnobirthing course, then that is wonderful, because those words are used on tracks which you will listen to daily. Otherwise, find a relaxation or affirming birth track you can listen to, or read ONLY encouraging stories (such as are in the first half of Ina May’s Guide to Childbirth) or write those words on a sticky note and say them to yourself ever time you look in the mirror! Say it to yourself so often that it’s written indelibly in the deepest parts of your brain. Words we practice grow physical ‘branches’ of memory in our brain, almost like deep wagon ruts in a homeward path. Make this belief your path, and as the baby’s head is moving down and out of your birth canal say to yourself that you are big and wide and soft down there, and believe it in your heart. Have your birth partner whisper those words of belief to you. Remember, it is your brain that sends messages to your body to complete functions and actions – make those communications be soft and wide and your body will respond in that direction! It is very interesting to note, that even the rate of tearing is far less with hypnobirthing mothers. Your body does respond to what you believe.

5. Don’t tell anyone you are pushing. Now that I’ve shocked you, let me explain. If this is your first baby, then it may take you 2-3 hours or more to birth the baby after you are fully dilated. If it is your second or more, then it may take much less, but it will still take some pushing. After you are fully dilated, the baby needs to slide past your cervix, and come a few inches down the birth canal to where it will slowly dilate the vaginal opening and perineum and finally the rest will follow. Slowly is good! Slowly means that there is time for the exchange of fluids necessary for your skin and muscle cells to expand and grow without tearing or bunching up and cause injury. Make it part of your birth plan to use Mother-Led-Pushing. With mother led pushing, there is no “Okay! You are at 10 cm, now give me a really big push!” No. When a mom is allowed to push as her body requires her to, (such as is usually done at a homebirth) then there is often no need to check and ascertain every time that she is at 10 cm. She will start making different noises, with little grunts at the end of contractions. Her breath will catch a little, ending in a grunt, and her body will move involuntarily as if someone were pulling on her ‘tail’. Bit by bit these signs start to become more pronounced, as the pressure builds and the ‘need’ to push become more urgent. Is okay to feel with her own fingers (or someone else can peek) and be sure that the baby’s head isn’t pressing against the opening, just to feel safe. If you feel the urge is very strong and you are pushing hard, then it is time to let everyone know. The next time you see hospital staff, state that the mother is feeling pushy during contractions, without alarm in your voice. Pushing in this way is much more gentle on the mother, and on the baby, thus possibly avoiding a situation of foetal distress and maternal exhaustion after hours of ‘purple pushing’. I am not suggesting that you birth the baby without the presence of medical staff- I’m only suggesting that there is no need to panic when 10 cm is reached. When a mother is already pushing according to her body’s direction, then she has more of a chance of continuing with Mother-Led-Pushing. Once purple pushing is begun, it is nearly impossible to go back and follow your own instincts.

It is interesting to note that with an epidural it is much more common for hospital staff to give the mother an hour to ‘wait the baby down’ after reaching 10 cm, and let her body work the baby past the cervix on the power of it’s own contractions, without purple pushing. Why not wait with un-medicated births too, before jumping to instructing hard pushes straight away?

6. Use an EPI-NO. There are plenty of devices out there to help tighten a woman up ‘down there’, and finally here is one that helps to relax you in preparation for birth. The official site for the EPI-NO gives more information and distributes to the US. In Israel, experienced midwife Ilana Shemesh is a direct distributor for the company. The reason I suggest using this product rather than perineal massage, is that there is controversy over whether or not perineal massage actually works. I have a suspicion the reason for this is that with perineal massage you have little control over the actual dilation you achieve during practice; there will only be benefit if you stretch to 10 cm. With the EPI-NO, you can see your progress, and every couple of days you will be able to stretch a little bit further, with the aim of achieving 10 cm before giving birth. I have heard a midwife criticize the tool, and the reason she disproved was that with women who used the EPI-NO, their vagina looked like a woman who had given birth two times already even if she had not. I cannot figure out how this is a negative thing – in the end, the first time mother is the one at greatest risk for an episiotomy, and after she gives birth she will have to stretch to accommodate the baby, why not have the advantage of gaining the shape of a woman who has birthed before? It is worth considering. Here is a link to a conversation between number of pregnant moms about the EPI-NO. It is also recommended to use if you have torn badly or had an episiotomy previously, to help the scar tissue learn to stretch  One more thing: If you purchase the more expensive model, you can also use it for pelvic floor strengthening exercises post birth, which is excellent.

7. Keep changing position. The baby has to move a lot, and flex her head, then make a quarter turn in the process of being born, so it makes sense that you should move your body to help your baby along! Many times a mama will seem to feel ‘stuck’ in one position, often because she was told to stay put, and when all the blood in the body is focusing on the uterus and birthing this baby, the brain lacks a little bit of decision making room. But when I ask her to listen to her body and see if it would like to change position, often times after a moment’s reflection she is emphatic that she definitely wants to assume another particular position. We so often forget to ‘listen’ to what our bodies are whispering when there is so much business and adrenalin going on in the room around us, when in fact, the actual process of birthing is going on INSIDE. That is where we really should be focused. So, right now, I am giving you permission, as the birthing mom, to take any position that your body asks you to. When told to move onto your back etc, you can firmly and quietly decline with a shake of your head. Listen closely to what your baby and your body are asking you to do; you are the ones giving birth.

Changing position regularly is especially important when having an epidural! After an epidural, the mother will often get comfortable and take a nap, and even though her position may be shifted a couple of times, she is much less mobile than a mother without an epidural. She is also pumped full of bags of fluids, to counteract the drop in blood pressure (a side effect of the epidural) which just compounds the situation – this mama is FULL of fluids. And since she is not moving, they pool on the lower half of her body. After the longer hours of pushing, this usually means that the perineum (on the lower side of her body since she is on her back) is completely saturated with fluids. It is puffy and thick, and has already stretched so much that it cannot accommodate a baby’s head, hence the need for an episiotomy to make more room. Key word for epidurals: rotissary**. Keep her turning, from side to side, to back, to supported kneeling or all fours if possible. (There must be two birth partners to actively help with these last two positions. Never let her chest drop lower than her abdomen, or the epidural could possibly flow upwards.) Turn, ever 15-20 minutes, to keep those fluids from pooling, and avoid birth path oedema!

8. Give birth in a birth pool. When immersed in the water, your tissues are soaked and warm, so they are soft and pliable. It is uncommon for a mother who gives birth in a pool to tear badly, and obviously you is not going to be given an unnecessary episiotomy underwater – which circles back to point number two. If you are birthing at home or at a Birth Center, then you have already made your caregiver choices very carefully, haven’t you!

It is important to note that yes, there are occasional situations when an episiotomy is needed. But once you’ve made choices that lessen the chances of finding yourself in that situation, you can eradicate some of that fear. Embrace the stretching, opening, widening, of your body, gently and at the perfect time, releasing your precious baby. Many of us have been there before you, and birthed with joy! You can, too.

*As a general rule, a ragged tear grows more organically back together than straight cut cells, with less pain. Also, cuts may sometimes extend beyond their bounds to become worse than a tear would have been in the first place. The cases where an episiotomy is the best option should be very rare, according to the practices of many midwives.

**Rotissary – it is an unflattering word, I know. But I find that it sticks in the mind, which means it is more likely to be followed!

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I know that many people are anti-birth-plan because you “cannot plan birth”, so I’ll just repeat it here: you are not planning the birth. You are communicating (a good thing!) to staff about what kind of birthing mother you are and what you value at your birth, and if things change, then we agree beforehand that it’s is okay! Motherhood, like birth, is full of surprises and changes that are unexpected. But it can be beautiful and oh so rewarding – just like birth.

Importantly, a birth plan doesn’t have to be a very long document, full of polite paragraphs. You can be respectful and gentle when discussing the plan with your OB before the birth, but the document that staff will glance over at your birth can be short and bullet pointed, with just the 5 most important things that you hope for at this birth.

How do you decide what those 5 things are? Write a list of everything you want (using one of those comprehensive pre-formatted examples found online) and then prioritize them numerically. Read over the entire list with your birth partner, so they are aware of all your hopes and can remember to respect the wishes such as dimming the lights and massaging your back, for you. The top 5 make it onto your list. If fear of an episiotomy will make you tense up and close your legs to giving birth, then that fear will HINDER the birthing progress and your tense muscles will make you ripe for a need to cut. If you have that fear, then the sentence “Please do not perform an episiotomy; I would rather tear than be cut” should be on your birth plan. If you do not want to be offered pain relief, then state, “Please do not offer me an epidural; if I need one, I will ask.” If you have a fear of blood, then requesting that the baby be rubbed clean and wrapped up before being given to you may be the thing you decide to prioritize.

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Then, draw a line, and under those 5 things you wish for your birth, write in detail EVERY SINGLE thing that you want done (or not done) with your baby. Leave nothing out, from skin-on-skin to letting the cord pulsate to bathing and pacifiers and immunizations – everything you want them to know is on the second half of the page! Leave nothing to chance. This is your baby, and no one else’s!

Make two copies of your birth plan. One should be on the top of any paperwork you bring with you to the birth, and the second should be taped next to the computer keyboard in the birthing room. Believe me, any medical staff who walk into that room WILL look at that keyboard, sometimes even before having a good look at the mother.

Now you have done your best to communicate, and can put your focus on letting go, and embrace birth!

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Yes I’m a doula, and I obviously I support natural birth, homebirths, breastfeeding – the whole nine yards. But that doesn’t mean that only births that go according to the perfect plan are beautiful. A beautiful, connected birth can happen no matter what the circumstances are, and sometimes that means a joyful birth for a mother who chooses an epidural, or has every complication under the sun. Sometimes the well prepared, well versed mother who had planned a natural birth, has a Cesearean birth.

I don’t talk about C-Sections much during prenatals. It is best to focus on believing in the ability of the female body to give birth easily and trust it to do so! Since I am accompanying this couple through the birth, what works best is for me to provide information as issues come up. But if you aren’t going to have a doula to support you in every eventuality, then it is a good idea to think through all eventualities and make a plan. This is not a birth plan for a Planned or Elective Cesarean Section – there are plenty of birth plans out there for planned Cesareans that are lovely, thought through, organized ahead of time with a supportive doctor. You can have classical music piped in, curtains drawn aside, births filmed. Here is one example of an Elective Cesarean Birth Plan.

This is also not a plan for a ‘Crash’ Cesarean Section. If the fetal heart-rate is dropping rapidly and the baby needs to come out NOW, then the mother will be put under general anesthetic (unless she already has an epidural) and the surgery will be done within a matter of minutes. There is no time for planning, for crafting an experience. At a Crash Cesarean Section, you are happy for medicine that can save lives. However, Crash Cesareans are the rarest kind of Cesarean Section. Usually there is time to prepare, and that takes us to the most common type of cesearean:

‘Emergency’ Cesarean Sections, in a class of their own. They are the most common type of Cesarean Section that couples experience with their first baby. Reasons are sometimes as follows:

Situation number1 – Mother is anxious about how to know when labor is really beginning, and with the first twinges of contractions she remains awake and counts every single one. She cannot or will not fall asleep, and since she is paying close attention to what she’s feeling, the level of pain she feels is at a higher level from the start. She goes into hospital, is told she’s not dilating and sent home, and ends up absolutely exhausted, dehydrated and sleep deprived by the onset of labor. An exhausted, dehydrated and sleep deprived body does not dilate well and this goes on for a very, very long labor. Dr’s decide she is not dilating enough, despite augmentation (induction) and a CS will eventually take place. Lesson: live in denial! When you are really in labor, you won’t be able to deny it anymore, you WILL know.  In the meantime eat, sleep, stay hydrated, relax. (I can’t believe I haven’t written anything about living in denial. Will do that asap.)

Situation number 2 – Baby is ill fitted in the pelvis, and does not move down. This is often because the baby is back to back, or the head is tilted at an angle that does not fit well. In this case, sometimes the mother ceases to dilate further at some point in labor, or the baby’s head simply does not descend in the pelvis. Often baby’s heart-rate does not respond well to pushing, because the fit is poor and baby is not happy with the sensations. In America this is often mis diagnosed as CPD, or Cephalo-Pelvic Disproportion. No, the baby was just in a poor position, and if the position were better the fit would have been just fine. Lesson: read up on optimal fetal positioning or see spinningbabies.com, and watch how you use your body in the weeks leading up to labor.

Situation number 3 – Dr’s have a great name for diagnosing things that they don’t understand in birth, and the term is ‘failure to progress’. They can’t explain why, there is no reason, but things aren’t happening so we might as well have a Cesarean Section.

Situation number 4 – Cord compression. This is not usually the cord around the neck, which in most cases is not a real cause for alarm. There’s a small space, a lot of cord, and it has to go somewhere. Baby is ‘breathing’ through the umbilical cord anyways, and not using air ways in the throat until after birth. Cord compression is where as the baby decends, the cord gets caught up in the way and with every contraction baby gets not quite enough oxygen. Often this can be resolved by getting mother into a different position that takes pressure off the cord or by amnio infusion (warm saline flushed inside the uterus),  but if not, and it is suggested that the cord compression will get worse during the pushing stage, then a cesearean section is required.

Situation number 5 – Failed induction. An induction has been going on for a long time, nothing is happening, baby and mother are tired, everyone wants things over and done with. Lesson: Do anything else you can before you go for a medical induction! CS rates are much higher for induction births than births that started on their own.

The Emergency Cesarean Plan

The above are a few reasons for an Emergency Cesarean Section. You know this kind of Cesarean because there is time to hang around before the surgery. Your midwife or doctor may hint at the possibitily of a C-Section, just to get you used to the idea, but tell you there is time to try a few more things first and no need to get worried yet. It will be hours before the surgery is done, because there is no immediate danger to the life of mother or child. Yet, because it is classed as ‘Emergency’, fathers are generally not allowed into the room during the surgery. In Israel, fathers are only allowed if it’s a planned Cesarean, and doulas never.

1. Ask: is my baby’s life in danger right now? If not, then there is time to suit up my husband to accompany me to surgery. I am scared. I do not agree to surgery if I have to go in by myself. *Note: if your life or your baby’s life is in immediate danger, do not argue. That is a ‘Crash Cesarean’, a whole different kind of situation. But if there is 5 minutes to spare, there is time to bother to get your husband dressed and take him with you. If you are Orthodox and husbands are not allowed for religious reasons, then insist that a female relative or doula will go in with you to hold your hand. Do not go into surgery alone.

2. Have the epidural. If it is an Emergency Cesarean Section, there is time to set things up, and there will be possibly a few more hours of labor before you get to surgery. Once a mother has given up and given into the the idea of the CS, she feels much more pain than when she has hope and fight, and that wait will feel like an eternity.

3. Dads: it is your job to make sure that mother gets to see her baby. Sometimes in the hustle and bustle of the surgery especially in Israeli hospitals, Dr’s and midwives forget to let the mother have a look in. If baby needs help breathing, as often happens (usually without mishap) at a CS, then as soon as baby is stable insist that the mother gets to be cheek to cheek with her baby, and sniff the top of her baby’s head. Take a photo of the two of them together.

4. Go with the baby. Usually the mother was looking forward to skin on skin contact and bonding right after birth – this can still be had with dad. Take the camera. Take lots of pictures and have a relative ferry the camera back and forth so the mother can see the photos of her baby still fresh and new. Follow the original birth plan for baby care already preplanned before the birth when it comes to bathing the baby, immunizations, creams and drops. There may be a need for antibiotics for the baby, about which you cannot argue.

5. Together with family members arrange to support breastfeeding from day one! A post-Cesearean Section mother cannot pick up her baby on her own for the first few days, so how is she to breastfeed? She may be feeling let down by her birth experience, but with full on support she can still realize her dreams of breastfeeding successfully. If separation from the baby is prolonged, have the nurses help her express colostrum and insist that it be given by spoon or dropper to the baby, NOT by bottle. Do not let a plastic teat touch the baby’s mouth. You want to help, not even possibly hinder by a little bit the chances this mother has at breastfeeding. Someone will have to be with the mother at all hours of the day on a rota, to bring the baby to her breast for feeding. Pester staff to send over the breastfeeding counselor for specific advice how to breastfeed a baby without hurting the mother’s tummy. I know of one family who became so endeared themselves to staff that they managed to have a female family member sleep in a chair at night by the mother’s bedside post-Cesearean Section, so that she had complete rooming-in from day one. It may officially be against the rules, but it is possible, and that baby never had any breastfeeding problems, and the mother and baby bonded beautifully, thanks to her family’s tenacity and dedication.

6. Listen to how the mother is feeling. Never, never, never say to her, “Well, at least you and the baby are alive and well! All that matters is a healthy baby. Get over it.” Yes, she knows that. She’s thought that already. She will hear that sentence a few more hundred times from well-meaning friends and family. That sentence will always shut her up effectively, but the emotions from processing the birth experience still need to come out or they will grow and cause harm inside. Let her talk. Let her feel. And nurture her with affection, affirmation, compliments, healthy food, enough sleep, and skin-on-skin time with her baby until she is through the mourning phase and the sad feelings fade on their own.

Cesarean women are Brave. Read this beautiful post by Avital Klein, a Canadian doula, who describes the sacrifice that it takes to lay down your body for your baby, how much strength it requires. That is, in the end, what every woman learns through childbirth.

If you have any more suggestions,  or experiences you could share, please do! An Emergency Cesarean Section does not need to be traumatic or horrible.  The good, the joy, the birth is still happening and both the mother and the baby can feel supported, loved, safe.

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