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How to get what you want in the hospital

Most of the parents-to-be who hire me do so because they desire a normal childbirth but want to avoid as much of the discomfort as possible.  Only slightly second to that is the desire to have a normal birth in the hospital despite hospital policies and procedures that often run counter to a physiological birth.  A doula can help with that – by helping parents voice their desires and advocate for themselves, by providing information, and by suggesting alternatives to offered interventions.

Right after my mother became ill, I wrote a list of ideas for working with the rehab staff for maximizing her recovery.  It occurred to me that these could be adapted to hospital birth as well.  What do you think of the following list?

  • Be firm but polite.  No need to put people on the defense, but it is important to convey an attitude of confidence and also that you are convinced that a solution will be reached.
  • Say what you want.  Don’t say, “I don’t like the dr, blah blah, complain, complain, I’m mad.”  Say, “I’d like intermittent auscultation, not continuous monitoring.” Or, “We prefer to skip the bath and eye ointment.” Leave your emotions out of it.  No one cares how you feel, they just want to reach a solution and get on with the rest of their day, so get to the point.  (Nicely.)
  • Explain yourself.  Say, “It looks to me like this is what’s happening.  Does it seem that way to you?”
  • Ask and ye shall receive.  Don’t just complain or sit in your room and stew.  If you need something, ask.  “We’d like to labor in the tub for a while.”
  • Use a facility that fits the level of care you need.  A low-risk mother and baby do not need a hospital with a tertiary NICU, high c-section rate, or anything else that indicates a high-technology birth.  Use such a facility and it’s likely that you will end up with a higher-technology birth whether you need one or not.
  • Request a room that fits the level of care that you need.  Likewise, if you and your baby are low-risk, request a room with a tub, birth ball, birth stool, rope, TENS,  telemetry units, etc.  A low-risk mother can and should use water, movement, and other non-pharmaceutical pain relief methods offered in some hospitals, as well as intermittent auscultation or other monitoring that allows freedom of movement.
  • Make them feel like collaborating with you.  Say, “What can we do to solve this problem?”  When people view your problem as a shared problem, they are more motivated to find a solution.
  • Go up the chain of command.  Don’t be afraid to say, “Can I speak to your supervisor about this?”
  • Ask for the written policy.  This especially works if you are told, “We can’t.”  Often you hear, “I can’t” when what they really mean is, “I won’t” or “I’m not allowed to offer this to you.”
  • Make a new friend.  Get the name and phone number of someone that can help you with problems as they arise.  Become this person’s best buddy.  Call them as needed, remind them of your name and, if you are not the patient, who your loved one is.  Make it a point to speak to them if you see them in the hall.  Don’t let them forget you.  Be the squeaky wheel.
  • Listen.  When you have your health and your baby’s health on the line, it’s easy to get freaked out about every situation that arises, and then miss crucial information. Take a deep breath, and really think about what the other person is saying.  Not only will you hear something you need to know, but you are showing respect for the other person and hopefully gaining an ally.  You like for people to listen when you talk, right?  Remind yourself that you’re not exempt from treating others nicely just because you are having a baby.
  • Educate yourself.  No one is going to chase you down to tell you the hospital’s policies and that the staff will laugh at you behind your back because your birth plan is 6 pages longer than it needs to be.  A hospital birth class is sometimes a “how to be a good patient” class in disguise, but it does provide valuable information about how you can expect to be treated at that facility.  So does the free hospital orientation. Go to it.  If nothing else you will get an idea of what is/is not provided so you know what to pack in your birth bag.  And it should go without saying, but every parent should take a comprehensive childbirth education course like mine.  The more you understand about your baby, your body, and the process of birth, the better equipped you will be to work with your body and not against it.  Even if you’re planning to get an epidural or aren’t sure about the mythical “natural birth” – you still need to understand what you’re about to do.
  • Get some fresh air.  Most hospitals have some sort of outdoor area – a courtyard, balcony, or such – where patients can go.  (Not a smoking area though – you don’t want to be breathing secondhand smoke!)  Sometimes parents get bored or start feeling “stalled-out, stuck in their room for 12 hours.  So start walking!  For healthy, low-risk moms, a change of scenery, some fresh air, and a good walk (taken at mom’s pace and accompanied by her partner or other support person) can be just the thing for a healthy labor.
  • Ask for more time.  No, not a longer hospital stay. Ask for more time if an intervention is offered and you’re unsure about it.  You don’t have to give an answer on the spot.  Say, “We’ll call you when we decide.”  or, “Can you give us about 15 minutes alone to make a decision?”
  • Ask for less time.  Your baby is born, everyone is healthy.  Hooray!  There is no reason to stay  a full 24 or 48 hours if you don’t want to.  The showers are scary, people barge in whenever they feel like it, and Dad is sleeping on a pink plastic chair while you are uncomfortably battling postpartum sweating and chills in a room where you can’t control the thermostat.  If you are tired of being in the hospital, tell them that you’d like to get the pediatrician to discharge your baby as soon as possible so you can go home.
  • Get help if you need it.  If something isn’t right or you are unsure whether it’s normal, speak up.  Sometimes (especially if the birth was difficult) it can take a couple of visits from a lactation consultant to get breastfeeding right.  Get the help you need.  The resources are there if you seek them out.

Any more to add?  Leave a comment and tell me how you were able to get the birth you want in a hospital setting.

Group B Strep and IV antibiotics during labor

**Spoiler alert**  The Cochrane Collaboration finds that IV antibiotics during labor for GBS is not evidence-based.

While researching a different topic, I realized that I rarely address Group B Strep in my classes.

Group B Strep is a bacteria that can colonize people of any gender or age with no symptoms.  It generally lives in the urethra, vagina, or rectum.  It can be introduced into the vagina by vaginal exams, wiping back to front, or other seemingly-innocuous behavior.  Whether a woman tests positive or negative at the 36-week mark is often a matter of chance (whether the naturally-fluctuating bacterial levels are higher or lower on the day of the test) and test results at 36 weeks can be the opposite of test results taken at onset of labor.

As with any offered test, it’s an important topic and not a decision to be taken lightly. Moms considering this test should ask themselves what they would do with every possible result.  For a positive result, if the caregiver is an OB/GYN, the typical course of treatment is to give IV antibiotics starting at onset of labor

Around 0.0005% of babies will have complications from GBS.  This can range from pneumonia to meningitis and can very rarely be severe.  In contrast, risks of IV antibiotics can include:

  • allergic reaction
  • thrush (yeast infection of baby’s mouth and mom’s nipples)
  • severe bacterial infection (MRSA, c difficile, e coli infection)
  • antibiotic resistance

Other risks of IV therapy are less tangible but equally powerful.  When a laboring woman is put on an IV, she is generally confined to a bed.  She then becomes, not a woman in the process of becoming a mother, but a “patient”.  She can’t move around, so her pain level increases drastically.  The birth becomes longer and harder.  Other interventions are more likely.  The psychological effects on her labor can be devastating.  It is to every laboring woman’s benefit to avoid any intervention that keeps her unable to labor normally, and IVs are no exception.

The Cochrane Collaboration states that “This review finds that giving antibiotics is not supported by conclusive evidence.”  In other words, the scientific literature demonstrates that there is no benefit to IV antibiotics during labor.

In my class I teach the BRAIN process for informed consent or refusal of medical procedures.  If I were being offered IV antibiotics for GBS, I would use the following type decision-making process:

  • Benefit:  avoiding GBS infection in my baby
  • Risk: other serious bacterial infection, thrush (which all but kills breastfeeding), antibiotic resistance (possibly making it so that my child might not be able to take antibiotics for other illnesses in the future)
  • Alternatives: use of garlic/yogurt as suppository to raise the levels of beneficial bacteria in the vagina (no scientific evidence either way on this, but it is something I’d be personally willing to try), oral antibiotics before the birth (no evidence that this works either, but it can make caregivers feel like they’ve done something), or hibiclens wash before and during labor (this is what I’d try, personally, because it does lower bacterial levels, it’s successfully used in Europe instead of IVs, and there are little or no side effects.  The Cochrane summary states that there have not been enough studies to determine whether it actually works to reduce GBS infection in newborns. )  “nothing” is always an alternative too.
  • Intuition – Speaking as a mother, I feel uneasy with a treatment that reduces the rate of an infection that my baby has only a 0.0005% chance of getting in the  first place, but carries a much higher risk of causing my baby to get an equally serious infection later.  It’s not helping much if we avoid GBS but then have to deal with life-threatening c diff or MRSA.  From the scientific evidence, however, it’s hard to say because not much research is being done on alternatives.
  • Nothing – what if  we did nothing?  Again the chance of the baby acquiring infection is low, so doing nothing is a valid choice for moms who desire this.  A risk of refusing treatment is the feeling that one might be endangering the baby’s life, or that one is being a bad patient or will make the OB unhappy.  Additionally it should be noted that life is not without risk, and doing nothing might very occasionally result in GBS infection of the baby..  Also to be considered is that GBS infection usually manifests itself in the first 24 hours, when most babies are still in the hospital and therefore in a good position to be treated, whereas other severe bacterial infection that can occur as a result of IV antibiotics will manifest within the next few weeks.

Again, this is an example of the BRAIN thought process according to my values and priorities for my family.  Every family must make their own choices and take into consideration the risks they can live for themselves and their family, with as well as their care provider’s recommendations and the available scientific evidence.
View the Cochrane Summary here:

What does a doula do?

After a long hiatus, I’m finally able to do doula work again.  Hooray!  I love helping moms and their partners.  I love hearing moms talk about their birth goals. I love helping empower them to reach those goals.  And most of all I love seeing the look on a mom’s face when she says, “I did it!  I really did it!” after her baby is born.  As a self-confessed birth junkie, I am constantly researching ways to help laboring women be more confident, more comfortable, and more satisfied with their birth experience.  I love being able to put my skill set into practice.  I am so happy that my life has eased up enough to allow me time to resume doula work.

“Contraction” by eyeliam, Flickr Creative Commons license

What does a doula do, you might ask?  A doula is a paid labor support person who provides emotional, physical, and informational assistance to a laboring woman.  Doulas provide continuous care, “mothering the mother” as it were.  In my doula practice, I provide the following services:

  • Continuous support.  I stay with the laboring mother from the time she needs me until she is cleaned up and settled into bed and has fed her baby for the first time.  You may already know that the research shows that having a doula reduces the instance of c-section, vacuum or forceps delivery, pain medication, and negative feelings about the birth experience.  Or, stated a different way, moms who have continuous support from a doula have safer and more pleasant birth experiences.  Amazing!
  • Birth team support.  I do not take over the partner’s role, I supplement it. I am there to help the birth team come together and support the mom. Often dads in particular are hesitant, but having a doula can really take the pressure off of a partner.  If dad needs to take a breather, grab a sandwich or nap, or becomes overwhelmed by emotion (after all, it’s his baby being born, too) – I’m there to give him a break and let him come back into the birth with a stronger game.  If dad is worried about forgetting what he learned in their childbirth class, no sweat – he doesn’t have to remember every little thing, because I will.
  • Emotional support.  As a mom of 3, I understand the widely varying emotions that accompany birth.  Whether a mom is feeling sadness, anger, fear, determination, or jubilation, I am there to validate her feelings and give her a safe space in which to express herself.  (I give this same support to partners, too.)
  • Informational support.  Sometimes parents need a sounding board, a source of information about an offered intervention, or just a little bit of confidence in making a decision.  I’m there with a fairly large knowledge base, a nonjudgmental attitude, and an unbiased approach to decision-making.  I have a growing library of birth and parenting books for clients to borrow. And I’m available for questions by phone or email starting the day I’m hired.
  • Private class/workshop.  All of my doula clients receive my private childbirth class as part of my doula service.  This is a workshop for the mom and her entire birth team.  I provide handouts, show appropriate videos, answer questions, and get everyone up and moving and grooving… it’s like a really fun dress rehearsal for labor!  And it lets me get really connected with what mom wants and values most from her support team, so I can be a better doula for her particular needs.
  • Massage.  As part of making mom relaxed and happy, one of my specialties is massage… hand, foot, back, forehead… whatever it takes to make a mom comfortable.  I carry a variety of massage oils for every situation, whether a mom needs something to help her feel relaxed and blissful, or a pep-me-up to help her get up and moving.  I’ve even had training in aromatic essential oils as regards pregnancy and labor – what oils are safe to use and what oils are most effective in particular situations. This is one of my favorite types of care to give; I am always amazed by the power of simple human contact in labor.
  • Equipment.  When I go to a hospital birth, people often eye me strangely because I bring such a large bag full of… stuff.  I carry everything I think a mom might need, from birth balls to hand combs to kneeling pads for the hard floor, because, let’s face it, what works in labor can change from minute to minute and I’m going to do my best to be prepared for anything.
  • Knowledge.  As a Lamaze educator I teach a wide variety of coping strategies for labor.  I can suggest positions or movements as needed.  And I reassure parents that what they are experiencing is normal and expected for birth. Most of all, everything I recommend is based on scientific evidence, not tradition .
  • Postpartum support.  My fees include a postpartum visit if requested.  Moms have the same need for support and information postpartum that they did in birth, perhaps more as their focus has shifted from their own needs to their baby.  At this time, I assist moms as desired with postpartum comfort measures, breastfeeding, and whatever else she might require, including help with babywearing or elimination communication.   Many moms like to discuss the details of the birth (I provide a copy of my notes if requested) and I like to admire the baby.
  • Unbiased support.  When I’m at a birth, I am there just to help the mom.  I don’t work for the hospital, the doctors, the nurses, or the midwife.  My only goal is making the mom have her ideal birth however she defines it.

Other things I offer:

  • I wish this weren’t so, but occasionally a mom will feel bullied by her caregiver into interventions she doesn’t want or isn’t sure is necessary.  This is where a doula can really keep a labor on track.  Just having someone beside her can help a laboring woman find the courage to say “I want to try other options first”, “If I want _______, I’ll ask but please don’t offer it again” or even, simply “No thank you.” Or I might remind a mom who seems hesitant about a procedure that she can refuse it if she wishes.  I do not interface with the nurses or doctor, but if I know a mom is strongly against a procedure that is about to be done without her knowledge or consent, I might say to her or her partner, “It looks like they’re prepping to do _______, which was not on the birth plan. How do you feel about it now? Would you like to request an alternative (or no) procedure?”  I am a professional and try to keep interactions so, while still working 100% for the mom and her needs.
  • I do not provide any medical services or act as a monitrice.  I do have a very small amount of midwifery knowledge, but if a problem ever arose, I would use my knowledge in the Good Samaritan way and call 911 while providing basic first aid only.  That said, some moms might still feel better knowing there is another person there to help in case of the rare problem that might crop up while laboring at home.
  • Labor plans can change.  Most women are healthy and low-risk, but sometimes medical conditions can crop up and alter the birth plan.  A mom might change her mind and decide to get, or not get, an epidural.  I can roll with the changes, and I always make sure to give a mom what she needs at a given moment.  And if a cesarean becomes necessary, I can support mom through that procedure as well.
  • If there is a situation involving the baby’s medical needs, having a doula means the dad can stay with the baby while I continue to support the mom (and will keep her informed as well as I can, moment by moment, about the baby’s status.)
  • I don’t like to talk too much about this because I wish it never happened to anyone, but – loss of a baby does happen and I encourage all my clients and students to at least formulate a plan for that.  If it were to happen (and I hope and pray not) I am there to help in a sensitive and respectful way.  I would assist in whatever way required – protecting a family’s grieving space, arranging for photographs to be taken, or simply being a shoulder to cry on.  (And obviously, without saying the stupid things some people say to those who lose a child.)

And a few more notes on my doula practice:

  • I am open to all types of families, from married couples to single moms to LGBT families.  And I can help tear down the barriers that often crop up when a mom of a less-mainstream lifestyle is trying to advocate for herself with her caregivers.  Not every laboring mom is a heterosexual married woman, but ALL moms deserve a safe and pleasant birth.  (This holds true for my birth prep classes as well.)
  • I am particularly interested in assisting teenage mothers.  Teenagers are often the least able to advocate for themselves in birth; more on that topic coming in a future post. Suffice it to say that for a young mother, having someone there who is responsible only to her and who cares only that she is safe and comfortable and empowered, can make all the difference in her emotional and physical well-being.
  • I charge on a sliding scale because every woman deserves support from a doula regardless of income.

Are you pregnant?  I’d love to talk with you about how I can help you achieve your ideal healthy birth.

Push for Your Baby

Have you seen the new Lamaze campaign, Push for Your Baby? I love this quote from one of the dads: “The doula and I were working to put pressure on Cherington’s body where it would relieve the pain.” Having a trusted birth partner, whether it’s the mom’s partner or mom or doula, is SO important to helping the mom to give birth! But I digress. Anyway, watch the video and then go check out Lamaze International’s Push for Your Baby resource page.

Science and Sensibility: Henci Goer refutes elective inducion safety claims

Have you visited Science and Sensibility yet?  You should.  This excellent blog examines the scientific research being done on birth and birth interventions, to see whether current birth practices are evidence-based.  I had to share this post.  In my opinion, elective induction is (along with vaginal exams and IVs) an extremely common birth intervention.  It’s considered safe because it’s so widely done, but as with anything there are risks to offset the benefits.

Sound boring?  Ok, I’ll distill it down a little.  Researchers compared two groups of women, those who spontaneously went into labor and  those who were induced.  On the surface, the results appear to show there is no extra risk of perinatal mortality (the baby dying during labor or within a month after birth.)  Dig a little deeper and you find that the entire group of women who were induced were ultra-low risk.  The women who went into labor on their own were included in the study even though many of them had medical conditions that classified them as high or higher risk..  kidney disorders, fetal abnormality, diabetes, liver disorders, etc.  So it was a biased study intended to support a generalization that you really can’t make from this study.  Of course the babies in the electively-induced population were as healthy  – they and their moms didn’t already have problems before birth!


So what can we learn?

  • “…more women delivered via cesarean surgery in the electively induced group.”
  • “…more babies were admitted to special or intensive care nurseries after elective induction at every week through 40 weeks”
  • At every week of gestation, more mothers had an instrumental delivery (meaning by vacuum or forceps.)  This is problematic because it carries risk of injury to the baby, and does cause injury to the mother as episiotomy is required.

Ms. Goer also points out the following:  “An excess of instrumental deliveries is concerning primarily because of the increased likelihood of anal sphincter injury; however, an excess in cesarean deliveries is far more serious, carrying as it does increased likelihood of severe maternal and perinatal morbidity and mortality in both current and future pregnancies.”  Parity makes a difference.  In first-time mothers, induction can double the chance of a casearean.  However, researchers chose not to report outcomes by parity.  Hmm… wonder why?

We can see from this study how the numbers can be manipulated to show a conclusion that might not be completely valid. It makes good sense for parents to consider all the evidence and become informed decision-makers when it comes to their maternity care.  Without a really good medical reason, it’s still safest for mom and baby to let labor begin on its own.

What to Reject When You’re Expecting

Consumer Reports has written a great guide to things to avoid when you’re expecting.  They further the report by adding 10 things to do when you’re pregnant and 5 things to do before you even become pregnant.  This is great information in an easy-to-digest format.

What to Reject When You’re Expecting

My only addendum?  If your baby is persistently breech, seek out a care provider who has training and experience in vaginal breech births.  With the proper skills in attendance, vaginal breech birth is safe and doesn’t compromise a woman’s future pregnancies and births as a cesarean does.

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