The Fear of the Unknown: Should I have a birth plan?

As a new doula, there are of course things that surprise me and things that I expected.  One thing I love about birth is that it is unpredictable.  You can’t decide how long your labor will be, how long you will push (if at all), what emotions will come up, what you will need.

Of the few patterns that I have noticed, this one keeps repeating:  I keep hearing from mothers that for their first birth experience they didn’t want to know too much, they didn’t want to become afraid.  I can totally sympathize.  If I had become pregnant a few years ago, I would have probably had similar reactions.  However, what I’ve learned so far, is that this is counter-productive.  As a mother and a woman you of course care about how your birth experience is- not just that it has minimal pain, but that it is satisfying, successful, a moment you want to remember.  When what this means to you isn’t clearly defined, you are leaving things to chance, and therefore almost ensuring that you will not have the experience you desire.

I am reading Natural Hospital Birth right now, and my favorite morsel of wisdom I’ve acquired so far is the idea of a birth plan.

Birth plans are fairly controversial.  Doctors feel that women get too attached to their birth plan, don’t allow for the unpredictability of birth, and they are left to defend their choices and decisions in the care they give moms.  Mothers feel that it is useless because birth is so unpredictable.  But what this author suggests is that you should get attached to your birth plan.  It is your birth, and if you don’t know what you want, you’ll be at the mercy of what all the people around you want- and no one can know your body quite the same as you!

Flexible is often a euphemism for vague….To the call of flexibility I say ‘Let the hospitals be flexible! I am standing proud and firm for what I want!’  Wouldn’t it be great if doctors were urged to be flexible to accommodate to the birthing women instead of the other way around?  Doctors could be trained to be flexible in delivery positions, to be as capable of catching a baby when the mother is on her hands and knees as when she is lying on her back in bed.  That’s how flexibility could serve birthing women.”

Gabriel suggests that being attached to your birthing plan increases your chances of knowing what you want, and that it should allow for emergencies.  Make it detailed. Know how you will respond if certain complications arise.  Answer questions like:
– do I want any drugs?

-what do I want the room to be like (dim lighting, specific music, who will be there?)

-Do I want to delay cutting the cord?

– what circumstances do I believe warrant an intervention (dystocia, failure to progress, baby not descending, my own exhaustion, uterine infection, problems with the placenta etc)?

– under what circumstances do I believe I am still capable of birthing without intervention (any of the ones listed above, malpositioned baby, etc)

Make sure to be respectful and positive in your language.  Your care providers do not want to feel that their expertise is being dismissed, but rather that you have a philosophy you’d like supported.  For example  instead of saying “I do not want pitocin” say “I want to start labor naturally, even if my water breaks beforehand, or labor slows down periodically”.

“A good birth plan is like a good financial plan: strongly structured, yet also able to handle the unexpected”

There are two things every woman should address in her birth plan, because these are two of the things you can control about your labor: how labor will begin and freedom to choose your own position giving birth. What position you give birth in  can be a huge factor in how much pain you feel and length of labor.  Whether you start your own labor or not is an excellent predictor of whether or not you will have a natural birth or not.

You might be thinking: What if it doesn’t go the way I want to?  Won’t I be disappointed?

” Here’s the risk: Getting attached to your birth plan means that you will feel disappointed if you don’t get what you’ve decided you want.  But feeling disappointment can be healthy and life enhancing.  Not getting what we want in life is disappointing.  Isn’t is always better to strive and fall short than never strive at all?  Since when has it become unacceptable to feel sadness, disappointment or anger?

Repressing strong emotions like disappointment is a normal reflex in North American and some parts of western Europe.  Not coincidentally, these are the same places where most often repress pan in childbirth. 

Getting attached to your birth plan, like getting attached to anything or anyone in your life, makes you vulnerable.  You are indeed risking, not getting what you want.  The alternative is virtually ensuring that you don’t get what you want by leaving events to chance.”

She suggests that you imagine your ideal birth- the one free of fear or danger or complications.  And then take out the parts that are necessary for your care providers and give them each this simplified and specific plan. Make sure to include all parts of labor relevant.

Read more here: http://www.amazon.com/Natural-Hospital-Birth-Best-Worlds/dp/1558327185

Here’s an example of what I think is a great birth plan!

And remember mamas, it’s your birth, and only you know how to have your baby best!

(photo credit: http://thatwifeblog.com/pregnancybirth/)

Red Raspberry Leaf Tea: Good for Fertility, Pregnancy AND Post Partum

I have long known the benefits of quality red raspberry leaf tea when I’ve had cramps.  I also knew that for pregnant women it helps, especially in labor.  What I didn’t know was that it helps fertility as well.

Read this brief and helpful blog for more info.  And check out http://www.mountainroseherbs.com/ to buy some of the herb (just boil for tea!)

Have You Thought About Your Umbilical Cord?

Fascinating blog about the umbilical cord and what happens to it after birth!

Remember in a hospital they will clamp and cut it right away.  This is something to consider if you’re delivering in a hospital setting.  Your baby gets oxygen from both the cord and it’s lungs breathing air for the first time.  As the baby no longer needs it, the cord stops pulsing on its own.  Watch this photo chronicling of it!

Nurturing Heart Birth Services

This video is incredibly simply and clear about the benefits of waiting a few minutes before cutting the cord to allow the placenta blood to get to the baby:

Youtube: Petty Simkin on keeping Cord intact

Here are a few studies that explain evidence for this practice:
Anthro Doula: Wait to Cut the Umbilical Cord Study Says

A few extra thoughts from a home birth midwife: Erin Midwife.com
It makes logical sense that allowing the infant to learn to breathe with it’s new lungs while also still receiving oxygen from the umbilical cord.  This is especially the case if the infant requires resuscitation.  Investigate the following info:

What is Pitocin and what is Oxytocin?

Pitocin and Oxytocin: What they do and why



What is Pitocin?

It is a synthetic version of Oxytocin, the body’s natural hormone that stimulates uterine contraction and milk production.  The synthetic version is put directly into the bloodstream but cannot be released into the brain as natural oxytocin is.

What are the benefits of natural Oxytocin vs synthetic?

This hormone is released naturally by a woman’s body at certain specific points in life: labor, orgasm, breast-feeding and even in small amounts when in the presence of other women. For this reason it is called the love hormone.  It is what causes a bonding response.  

It also strengthens the contractions of the uterus.  It comes from the Greek word for “quick birth”.  It causes the contractions to be strong and effective.

When it is natural and not synthetic it is released into the brain as well.  This has the effects of:
– increasing pain threshold
– drowsiness
– relaxation and calmness
– aiding in bonding with child after birth

When Pitocin is used, the contractions are strengthened without the body’s pain relief being activated.  This results in a much more painful labor.  


How and when is Oxytocin released in the body/brain?

The parasympathetic nervous system is the system in the body that releases Oxytocin and calms you down.  One of the reasons why yoga is so effective at stress relief is because it has been shown to activate the parasympathetic nervous system.

When a mother is relaxed, and Oxytocin is being released in her system, it causes the lower uterine muscles and cervix to relax and allow room for the baby while strengthening the upper uterine muscles to expel the baby through the birth canal.  

When a mother is tense, it causes the reverse effect.  Her upper uterine muscles loosen and lower tighten.  Blood flow is diverted from the uterus to other parts of the body because her “fight or flight” response has been turned on.  When this happens and the muscles are continuing to push the baby while the cervix has closed up, labor pain is greatly increased.  We are seeing this more and more in laboring women as they enter a stressful birthing environment and are given synthetic hormones to increase and augment their labors.  Causing much more pain in their process.  

Things that can increase stress and activate the sympathetic nervous system are: bright lights, strangers in the room or anyone who causes discomfort to the mother, words of fear, fear of their partner, threats or time limits imposed on the mother, cold temperatures, being restricted to the bed, monitors, emotional pressure, repeated vaginal exams etc.  

Research suggests that use of Pitocin is one of the main factors in our increased cesarean rate. Use of pitocin, especially during a normal labor, increases your risks of needing further medical intervention and ultimately cesarean.

What is in Pitocin?

Other than the drug itself, pitocin contains a preservative called chlorobutanol.  This is a derivative of chloroform.  It keeps the drug in your body for up to 10 days.  It has been known to cause cardiac tension and should not be in the system with too much additional fluids.  However, epidurals are almost always prescribed with pitocin because the unnatural contractions are now that much more painful.  In order to keep your blood pressure from dropping patients are given a lot of fluid in an IV.  (Thereby increasing your risks of side effects from the pitocin and fetal distress and an emergency cesarean.)

Concerns have been raised that using artifical oxytocin, which does not cross the blood/brain barrier but does cross the placenta, may be part of the cause of the rise in autism in the US. New research suggests that treating autistic children with pitocin (direct injection into the brain) is having positive responses.  This implies that we are causing a deprivation of their naturally occuring oxytocin during labor and birth- the peak time for the presence of oxytocin.  By interfering with the natural cocktail of hormones that are present during labor and birth.  It’s estiamted that only about 4% of births medically require pitocin.  That means that something like 75% of women are getting pitocin unecessarily.  (A lot of this has to do with estimated due dates and not allowing pregnancies to reach 42 weeks, and the fear of big babies- But that’s for another blog!)


Should I induce labor with pitocin?

There are a list of reasons for inducing labor that are legitimate and where the risks may be outweighed by the potential benefits. These include things like preclampsia,  if the baby has had their first bowel movement prior to the water breaking and/or prior to being born, being two weeks past the due date (greater than 42 weeks). Remember there are many other ways to induce labor without pitocin (prostangladins in semen, nipple stimulation..)

“As with all obstetric conveniences, there is growing evidence that the decision to induce for non-medically necessary reasons increases risks of interventions and complications, including, but not limited to: a longer labor compared to spontaneous labor, artificial rupture of membranes, significant discomfort, epidural anesthesia or increased need of other types of analgesia, maternal fever, hypotension, prolonged second stage of labor, operative vaginal birth, episiotomy, vacuum or forceps assisted vaginal birth, fetal heart changes, shoulder dystocia (where the baby’s shoulder gets stuck behind the mother’s pelvic bones), babies born with low birth weight, need for birth by cesarean section, need for admission to the Neonatal Intensive Care Unit (NICU), jaundice that required treatment and a lengthened hospital stay (Simpson and Thorman 135) (Amis 18) (Romano and Lothian 96). “Medical induction of labor also nearly doubled the risk of overall cases of amniotic-fluid embolism, and the association was stronger for fatal cases” (Kramer et al 1444). Because due dates are not an exact science, and there can be up to a two week error window for the actual due date, a medically induced baby at 38 weeks can actually only be 36 weeks old. This is one of the reasons that babies born after elective induction can have poor outcomes such as low birth weight or jaundice requiring treatment. They were accidentally born before they have reached full maturity, which is defined as reaching 37 completed weeks (Amis 8). 

Besides, adverse maternal outcomes, such as cesarean sections, there are other reasons that might warrant waiting for spontaneous onset of labor, such as the addition of escalating health care expenditures, including additional supply and labor costs, added lengths of hospital stay, and increased neonatal and maternal morbidity and mortality. Delivery with spontaneous onset of labor is significantly lower than the cost of delivering following induction, particularly those ending in a cesarean birth (Wilson 212). There is also the chance that the mother may have to an intravenous line and continuous electronic fetal heart monitoring. In many settings, the mother must stay in bed or very close to the bed, and this does not allow the mother to walk freely or change positions in response to labor contractions, possibly slowing the progress of labor. The mother may be unable to take advantage of a soothing tub bath or a warm shower to ease the pain of labor contractions. Artificially induced contractions often peak sooner and remain intense longer than natural contractions, increasing the mother’s need for pain medication (Amis 8). The afore mentioned natural interventions all help the mother to have an “easier” labor and to help the labor progress along at a natural rate. A tub bath or a warm shower can be relaxing to the mother and may even help with pain distraction. Being artificially induced removes the ability to utilize these techniques, which can lead to an increased need for pain relief in the form of medications. 

When it comes to the increased cost that is associated with elective induction of labor, Romano writes that women with induced labors were twice as likely to end up having their baby by cesarean delivery and in addition to this, their baby was more likely to need to be admitted to the Neonatal Intensive Care Unit (NICU). These factors resulted in a significantly high increase in the average cost of labor (53)”



Resources:

Dysnfunctional Labor and Myometrial Lactic Acidosis
To induce or not to induce?

Amis, D. “Care practice #1: labor begins on its own.” Journal of Perinatal Education 16.3 (June 2007): 16-20. CINAHL with Full Text. EBSCO. 7 Mar. 2009 .

Amis, D. “Care practices that promote normal birth #1: labor begins on it own… including commentary by Gaskin IM.” Journal of Perinatal Education 13.2 (Mar. 2004): 6-10. CINAHL with Full Text. EBSCO. 7 Mar. 2009 .

“ICEA position statement and review: induction of labor.” International Journal of Childbirth Education 18.1 (Mar. 2003): 31-40. CINAHL with Full Text. EBSCO. 7 Mar. 2009 .

Kramer, MS, et al. “Amniotic-fluid embolism and medical induction of labour: a retrospective, population-based cohort study.” Lancet 368.9545 (21 Oct. 2006): 1444- 1448. CINAHL with Full Text. EBSCO. 7 Mar. 2009 .

Lothian, JA. “Saying “no” to induction.” Journal of Perinatal Education 15.2 (Mar. 2006): 43-45. CINAHL with Full Text. EBSCO. 7 Mar. 2009.

Moran, DE and Kallam,GB The Gift of Motherhood: Your Personal Journey Through Prepared Childbirth. Customized Communications, Inc: Arlington. 2008.

Romano, AM. “Research summaries for normal birth.” Journal of Perinatal Education 15.1 (2006 Winter 2006): 52-55. CINAHL with Full Text. EBSCO. 7 Mar. 2009 .

Romano, AM, and JA Lothian.. “Promoting, protecting, and supporting normal birth: a look at the evidence.” JOGNN: Journal of Obstetric, Gynecologic, & Neonatal Nursing 37.1 (2008 Jan-Feb 2008): 94-105. CINAHL with Full Text. EBSCO. 7 Mar. 2009 .

Simpson, KR, and KE Thorman.. “Obstetric “conveniences”: elective induction of labor, cesarean birth on demand, and other potentially unnecessary interventions.” Journal of Perinatal & Neonatal Nursing 19.2 (Apr. 2005): 134-144. CINAHL with Full Text. EBSCO. 7 Mar. 2009 .

Waldenström, U, et al. “A negative birth experience: prevalence and risk factors in a national sample.” Birth: Issues in Perinatal Care 31.1 (Mar. 2004): 17-27. CINAHL with Full Text. EBSCO. 7 Mar. 2009 .

Wilson, BL. “Assessing the effects of age, gestation, socioeconomic status, and ethnicity on labor inductions.” Journal of Nursing Scholarship 39.3 (Sep. 2007): 208-213. CINAHL with Full Text. EBSCO. 7 Mar. 2009 .

Risks of Pitocin, according to  the FDA:

“Oxytocin is distributed throughout the extracellular fluid. Small amounts of the drug probably reach the fetal circulation.”

This is the FDA website for Pitocin.

Precautions

General

  1. All patients receiving intravenous oxytocin must be under continuous observation by trained personnel who have a thorough knowledge of the drug and are qualified to identify complications. A physician qualified to manage any complications should be immediately available. Electronic fetal monitoring provides the best means for early detection of overdosage (see OVERDOSAGE section). However, it must be borne in mind that only intrauterine pressure recording can accurately measure the intrauterine pressure during contractions. A fetal scalp electrode provides a more dependable recording of the fetal heart rate than any external monitoring system.
  2. When properly administered, oxytocin should stimulate uterine contractions comparable to those seen in normal labor. Overstimulation of the uterus by improper administration can be hazardous to both mother and fetus. Even with proper administration and adequate supervision, hypertonic contractions can occur in patients whose uteri are hypersensitive to oxytocin. This fact must be considered by the physician in exercising his judgment regarding patient selection.
  3. Except in unusual circumstances, oxytocin should not be administered in the following conditions: fetal distress, hydramnios, partial placenta previa, prematurity, borderline cephalopelvic disproportion, and any condition in which there is a predisposition for uterine rupture, such as previous major surgery on the cervix or uterus including cesarean section, overdistention of the uterus, grand multiparity, or past history of uterine sepsis or of traumatic delivery. Because of the variability of the combinations of factors which may be present in the conditions listed above, the definition of “unusual circumstances” must be left to the judgment of the physician. The decision can be made only by carefully weighing the potential benefits which oxytocin can provide in a given case against rare but definite potential for the drug to produce hypertonicity or tetanic spasm.
  4. Maternal deaths due to hypertensive episodes, subarachnoid hemorrhage, rupture of the uterus, and fetal deaths due to various causes have been reported associated with the use of parenteral oxytocic drugs for induction of labor or for augmentation in the first and second stages of labor.
  5. Oxytocin has been shown to have an intrinsic antidiuretic effect, acting to increase water reabsorption from the glomerular filtrate. Consideration should, therefore, be given to the possibility of water intoxication, particularly when oxytocin is administered continuously by infusion and the patient is receiving fluids by mouth.
  6. When oxytocin is used for induction or reinforcement of already existent labor, patients should be carefully selected. Pelvic adequacy must be considered and maternal and fetal conditions evaluated before use of the drug.

Carcinogenesis, Mutagenesis, Impairment of Fertility

There are no animal or human studies on the carcinogenicity and mutagenicity of this drug, nor is there any information on its effect on fertility.

Pregnancy

Teratogenic Effects
Animal reproduction studies have not been conducted with oxytocin. There are no known indications for use in the first trimester of pregnancy other than in relation to spontaneous or induced abortion. Based on the wide experience with this drug and its chemical structure and pharmacological properties, it would not be expected to present a risk of fetal abnormalities when used as indicated.
Nonteratogenic Effects
See ADVERSE REACTIONS in the fetus or neonate.

Labor and Delivery

See INDICATIONS AND USAGE section.

Adverse Reactions

The following adverse reactions have been reported in the mother:

Anaphylactic reaction Premature ventricular contractions
Postpartum hemorrhage Pelvic hematoma
Cardiac arrhythmia Subarachnoid hemorrhage
Fatal afibrinogenemia Hypertensive episodes
Nausea Rupture of the uterus
Vomiting

Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.
The possibility of increased blood loss and afibrinogenemia should be kept in mind when administering the drug.
Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been reported.

The following adverse reactions have been reported in the fetus or neonate:

Due to induced uterine motility: Due to use of oxytocin in the mother:
 Bradycardia  Low Apgar scores at five minutes
 Premature ventricular contractions and other arrhythmias  Neonatal jaundice
 Permanent CNS or brain damage  Neonatal retinal hemorrhage
 Fetal death
 Neonatal seizures have been reported with the use of Pitocin.


Pop The Pills For Post-Partum Depression

I know, I know, consuming your placenta seems incredibly hippie and way too crunchy for you.  I get it.  I do.  BUT take a moment and think about it. Though I will admit there is not much (if any) in the way of randomized placebo research on placenta encapsulation or placenta indigestion postpartum, here are the list of benefits I have accumulated from various sources (books, websites, and personal stories):

  • Fights off Postpartum Depression
  • Can stop hemorrhage postpartum.
  • May increase breast milk supply.
  • May increase energy and fight fatigue postpartum.
  • Decrease likelihood of iron deficiency.
  • Decrease likelihood of sleep disorders or insomnia.

Placenta Benefits: Placenta for Healing.

San Diego Birth Network- could placentas actually give you more breast milk?

Two Doulas on a Mission: Placenta Info and Benefits. 

InJoyable Birth: Battling fatigue with placenta.

Colorado Springs PBi news report: Dealing with Post Partum Depression with placenta.

The Nest Chicago: Accupuncture and Chinese Medicine for PPD.

Taking it home from the hospital may be tricky, but not impossible.  If you plan to take home your placenta for encapsulation or to bury it, make sure to discuss this with your care provider and assign this job to someone before labor so they are able to retrieve it for you.
And don’t forget to consider delaying cord clamping to allow all of that precious blood (about 1/3 of the newborn’s blood ) to be pumped out of the placenta and into your newborn, as well as allowing the baby to continue to receive oxygen while learning to use their lungs for the first time!
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