Hospital Tour and Birthing "Plan"

Mike and I took the hospital tour of Yale New Haven Hospital tonight. Definitely has some nice rooms and services; very nice to see. They are also working towards a Baby-Friendly credential - something useful to know about in terms of attachment and breastfeeding. The tour reminded me, however, of how dis-empowered women are in the birthing process. As we were going along, several women asked questions and because I am now sensitive to it (learned from my awesome doula and midwife practice), I recognized the tentativeness in the language most women used (as I did before as well). Is it allowed to have the baby with you right after birth and not have all the testing right away? Does the hospital make you use this prop only for labor? Will the hospital let us waive the Vitamin K shot? As patients, we really do not understand the power we have; or the fear and guilt that providers sometimes push onto us regarding "putting your baby at risk" causes us to hand our power over to someone else who "must know better". But here's the irony; there is risk associated with EVERYTHING. It's which risk you wish to take with your body and your baby that is up to you. I firmly believe that no one should ever listen to fear-based arguments or rhetoric when making such an important decision. Get the facts, educate yourself, empower yourself and decide for yourself is the path that Mike and I chose. 

I am going to include my Birth Plan here - I wasn't sure if I would or not...Mostly because it completely exposes what a crazy, research-oriented, crunchy granola I am, but this blog is about sincerely sharing my journey to help others, so I am going to do it. I will include the content, then explain the rationale and research behind our decisions.

Misty and Mike Ginicola Birth Preferences

Introduction Content

We have chosen to strive towards a quiet, relaxed, natural birth. The following is our "ideal" birthing. We ask that you consider each of our choices and accommodate them whenever possible. We fully understand that changes may need to be made depending on special circumstances. We completely trust our providers at Women’s Health Associates to consult with us on each change and help us choose a new course of action. 

Rationale

I chose not to call our Birth Plan a "Plan". First, there is no way that you can plan all birth details like you are completely in control. Not only can you not control the details of your birth, no one else can either. The only thing you can control is communicating what you want AND controlling how you respond to whatever happens. My main philosophy towards birth is to keep it as natural as possible. I am incredibly thankful for medical interventions; but I do not want them unless I need them! All medical interventions carry a risk, so why would I want to use something that could potentially be harmful if I don't need it? I also wanted to communicate that I fully trust my provider (don't say this unless you really do and if you don't, you really need to change providers, but that is for another post!) to consult with me and my husband if there is a special circumstance that arises, to tell me what is going on, to give me all of the options and to wait for my decision and consent unless we are in a life or death situation, which, despite the movie and television dramatizations of birth, is very uncommon.

 

Pre-Admission Content

• Induction: We do not wish to use any artificial induction of labor unless it is medically indicated/ after 42 weeks.
• Labor at Home: We would like to complete all hospital forms prior to labor and to stay at home as long as possible.

Rationale

Induction: A perfectly healthy full-term baby does not normally come on their "due-date". They come anywhere from 37 to 42 weeks of gestation. But, most women are glued to that date; and since everyone asks you and the third trimester is so taxing on your body, I think we are eager to get labor going. So, a woman might ask to be induced or a well-meaning doctor may suggest induction to prevent a medical issue. But, inductions are no joke; they carry significant risks (click on the links for resources and references). At minimum, you do not get the body's natural oxytocin which helps suppress the feelings of pain, gives you that bonding and blissful feeling associated with orgasms and helps you relax so that your labor progresses quickly. So in essence, inductions are more painful and should not be used without significant medical cause. The World Health Organization has reviewed the research on inductions which provide this evidence and I have included a link to the National Health Service page on the topic so you can see how other countries handle induction. Bottom line: use all natural methods of inducing before 42 weeks and only do it if there is a CLEAR medical indication. These do not include, by the way, the ultrasound shows your baby is too big OR the ultrasound shows your fluids are low. An ultrasound is actually pretty unreliable for size estimations and amniotic fluid calculations. Other countries do NOT induce for these reasons and I believe, neither should we.

Labor at Home: If you go into the hospital too early, they will either turn you away or you might be at risk for being termed "failure to progress". This means the hospital or provider think you are taking too long to have your baby and will suggest a c-section. Some women take longer for labor; that is just a fact. Having a long labor is NOT a medical indication for a c-section. It is for the convenience of your hospital and provider, so they don't have to wait around. And just like inductions have risks, so do c-sections - there are extensive medical risks and risks to bonding and breastfeeding that are typically not mentioned. It is harder for a mom to bond because she experiences none of the oxytocin and is in shock from the surgery. Most hospitals will let you do all paperwork before getting to the hospital - make sure you ask. So literally you can labor at home until you are pretty far along, transition to the hospital with minimal stress and move through the final stages of labor.

 

Upon Admission: Content

• Nurse: We would like to have a nurse that is supportive of natural labor and understands our wishes for a more non-interventionist approach.
• Birth Support: Partner: Mike Ginicola; Doula: Debra Brackett.
• Room Environment: Misty would like a private room to bring music, dim the lights, wear her own clothes (I have a labor and birthing gown) and allow for pictures and video to be taken.

Rationale 

Nurse: If you want a natural birth, it helps to have support staff that remind you of this and do not keep asking you if you want pain medication. From what I have heard, almost every mother gets to a point in natural delivery where she basically thinks "Oh hell no, I can't do this!" I'm not sure if I will have that experience, but you are at your most vulnerable then so if someone suggests pain medication, you might want to cave. So, asking for a nurse who will "get" us is important for us. Our preference for no pain medication is not because I'm anti-medication or because I am trying to be She-Woman or SuperGirl. It's because it also contains extensive medical risks, including passing to the baby and prohibiting bonding and breastfeeding. I took lots of classes on pain management and how to transform into a relaxed, hypnotic state rather than initially depending on medication. I'll let you know how that one goes as well :)

Room Environment: Before my research, I didn't even know these were options. So happy that they are. I also bought a birthing gown which is uber-comfy and cute! These are something you can wear in hospitals and at home after and are easy to breastfeed and remove in the case that medical intervention is needed. And your ass doesn't have to hang out of the back embarrassing you further. Although, I am thinking more and more that I may be one of those moms who just rips her clothes off (especially if I am in the water for birth) and who could care less. I totally didn't picture myself there at the onset of this pregnancy, but I would not be surprised at this point.

 

During Labor: Content

• Monitoring: We prefer intermittent monitoring.
• Hydration: We ask that Misty hydrate herself with water and juice as desired. No IV/Hep Lock unless there is a special circumstance.
• Movement: We ask that Misty be allowed to move about freely.
• Labor Props: Misty would very much like the use of a birthing ball and the room with the birthing tub.
• Management of Labor: We would like to be allowed to progress free of time limits and ask that Misty not be offered pain medication.  She will ask for it if she needs it.

 

Rationale

Monitoring: It has become standard for monitoring to be continuous even in cases where it is absolutely not needed. These monitors limit your movement and keep you literally tied to the bed which can prolong your labor and make you more uncomfortable. If it's needed and indicated, of course you should use it (if they identify fetal distress). If it's not, don't. Your provider or nurse can follow you around and use a wireless one that just listens to baby's heart beat to ensure you and baby are still doing fine. 

Hydration: Some hospitals automatically put you on an IV even when you don't have Strep B (for which they give you antibiotics for at the onset of your labor) and require that you not take any fluids or snacks. If you think it's uncomfortable to have a big monitoring belt around your belly, think about having a needle in you for all of your labor. If it's not required, you can not consent to an IV and keep yourself hydrated. I chose not to eat snacks because I don't want to throw it up (something that does happen to some women), but I think it's just silly not to let a pregnant woman drink water and put her on an IV. You also can get a Hep Lock which allows you to move around if it's necessary. Key words: IF it's necessary.

Labor Props: I am likely going to try/use a birthing ball, the birthing squat bar and the birthing tub. Note on birthing tubs: for hospitals that have very few birthing tubs (like Yale), they put extensive requirements on the tub so that the person who ends up in the tub room can really use it to the most benefit. This means typically that you are on no medication, have no medical issues and are not likely to ask for an epidural as you won't be able to get out of bed after you get an epidural. 

 

During and Following Birthing: Content

• Pushing: Misty will be using positions she finds effective and using breathing and hypnosis techniques.
• Crowning: We do not want an episiotomy. If a tear were imminent, Misty would prefer to tear rather than have an episiotomy.
• Birth of our Baby: We ask that the cord be allowed to stop pulsating before clamping or cutting, and Mike, with our midwife’s help will cut it at that time. We would like to hold Wilson right away, allowing him to be treated gently and bond with his parents for a significant amount of time. We would like to allow the vernix to absorb into Wilson’s skin rather than wash it off.
• C-Section: If the event that this becomes necessary, Misty would like Mike with her at all times and for the screen to be lowered a bit so Misty can see Wilson delivered. We would also like Wilson to be given to Mike immediately. We would like to allow the vernix to absorb into Wilson’s skin rather than wash it off.
• Birth of Placenta: We decline the use of Pitocin for the active management of the third stage of labor. We fully understand the rationale, but would prefer to have the birth progress naturally, unless Misty shows signs of preeclampsia before the birth or is hemorrhaging after labor. We ask that Misty’s placenta be allowed to deliver without the use of traction.
• Postpartum: Wilson will be rooming with us; Mike or Misty will need to be with him at all times. We ask that all procedures be done in our room, preferably while he is still in skin-to-skin contact with Misty or Mike. We will decline the use of eye drops or a vitamin K shot.
• Vaccinations: Wilson will not be receiving any vaccinations in the hospital.
• Breastfeeding: We will be exclusively breastfeeding our baby and request that no bottles of any kind, pacifiers or artificial nipples be given to Wilson.
• Circumcision: Our baby, Wilson, is a boy and we will decline the surgical removal of his foreskin.
• Discharge: We would like to be discharged from the hospital with Wilson as soon as possible. We have arranged for postpartum breastfeeding support if needed. 

 

Rationale

Pushing: Research has shown that the absolute worst position you can give birth in is flat on your back with your legs up - sound familiar? This position, which is used normally in the U.S., is easiest for only one person: your doctor. Optimal birth positions as indicated by research, none of which are on your back, can make your labor easier, cut down on pressure and pain and can make it easier for your baby to emerge through the birth path. 

Crowning: The idea of a tearing or an episiotomy gave me such anxiety when I first started my pregnancy (actually earlier, if I'm being honest). Many practitioners will actually no longer do episiotomies because of the extensive research that shows medical outcomes are worse for a woman if you do an episiotomy versus allow for tearing (which may very well not happen anyway). You can prevent tears by having a good birthing position, doing kegel exercises/ strengthening your pelvic floor. Some recommend perineal massage as well. I have decided to trust my body that it can handle this birth in every way - no matter what happens and have only chosen to strengthen pelvic floor and try different birthing positions. Again, catch me after delivery for the verdict!

Delayed Cord Clamping: Allowing the placenta to do it's final job, pumping incredibly rich blood (1/3 of the babies' blood supply) into the baby following birth has been found to be linked to the best outcomes for infants and is now performed regularly in other countries. 

Vernix and Not Bathing in the Hospital: Babies are born with the world's cleanest substance on them: vernix. It's a white oily film and although you'll want to towel off blood and big chunks of vernix, research shows that this amazing substance is literally an anti-bacterial film that gets absorbed into the babies skin within a few hours. It keeps them protected from viruses and bacteria naturally. So what do we do normally in the U.S.? Wash it off with soap to make them look better. We are actually reducing the natural process of protection. Deal with the little white stuff for a few hours and your baby's immune system will thank you for it. 

Birth Bonding: It is so important that, barring a life or death experience, immediately after birth the baby is given skin-to-skin contact with the mother and the birth hormones are allowed to be expressed and the first stage of attachment can commence. This experience is blissful and relaxing for both mom and baby and is called birth bonding and it can be achieved fairly easily although you'll need to put it in your birth plan for the hospital to know it won't be business as usual. If mom cannot do skin-to skin because of a c-section or something else, then it's immediately time for the birth partner to step in and take his or her shirt off to make sure the baby has the experience and then gets to mom as soon as they can. You can find this on the links, but just so you know from here, the infant cries less (by the way, it is a myth that the baby needs to cry - they just need to breathe - it's sort of silly that we WANT our infants to cry), breastfeeds easier and immediately bonds with mom by opening their eyes, interacting and may even do the "breast-crawl" where they start seeking out the breast immediately after being born. 

Pitocin Shot and Birth of the Placenta: We found out that it is now common practice to give a shot of pitocin, which has side effects, to prevent hemorrhage, even when there is no medical indication that there will be a hemorrhage. Although fear-mongering information indicates that EVERY woman is at risk for hemorrhaging, the statistics are more likely to be about 5% of all women will have postpartum hemorrhage. There are a number of interventions that can be done at that point which will resolve the situation for the incredibly vast majority.  And when I say incredibly vast, I mean that the death rate from postpartum hemorrhage is about 8.5 per million women.  Compare that to the odds of being struck by lightening in your lifetime, which is 1 in 10,000. Interesting what we worry about! I chose to take the middle road here, if I have pre-eclampsia or my midwives feel that I am going to hemorrhage shortly after delivery, do it. If not, keep that needle away from my thigh. Make sure you check with your provider because many do this shot without telling your or getting your consent (they usually just put it in your IV without telling you).

Eye Drops: These are antibiotic ointments or drops rubbed on the baby's eyes to prevent against STDs which can be contracted from the mother. In my opinion if you have been tested for STDs, this is a stupid thing to do for a new baby who is confused and scared. You can delay or waive this procedure completely. 

Vitamin K Shots: This was historically and routinely done to encourage clotting in infants, especially when they were at high risk for a bleed, such as in circumcision or forceps delivery. This is not really indicated as such a high need anymore (nor did the research ever really support its use). There is now some research that has correlated the Vitamin K shot with jaundice and childhood cancers, so for us it was a 'add it to the list of crap we don't want - thanks!'

Vaccinations: The standard vaccination in the hospital is Hepatitis B. Babies are not at high risk for this infection. It is being instituted as a public health effort to lower the levels of adult Hepatitis B. My personal feelings are that it has not been tested enough on young babies to know if the vaccine has long-term risks. And unless you have the infection,  your baby is getting a transfusion or is particularly naughty (it's sexually transmitted), they are not getting it anytime soon. To me, it just makes more sense to wait until they are older if you want them to have this vaccine.

Breastfeeding: This was a no-brainer for me as research shows an incredible positive impact for both baby and mother. What was harder for me to embrace about breastfeeding was the cultural bias we have against it; women grow up in this culture knowing that their breasts are sexualized and are part of what causes us to feel attractive or not. Thinking of using something that we have always seen as sexual in something that we associate with a cow and fearing irreversible changes to our breasts that may impact our attractiveness (which we are told in our culture is our primary characteristic) can make us seriously question if this is "natural" at all. Also, all of the medical interventions routinely used can delay milk production or impact the baby's ability to naturally latch, making women feel like they are naturally not good at breastfeeding, when in reality it's the unnatural interventions that are to blame. In a culture where breastfeeding is the norm, you very rarely hear of problems; it's expected, natural and modeled to young girls, so they grow up with the education surrounding how to do it. The reason that we wrote this into our birth preferences is because believe it or not, some hospitals will give pacifiers or baby formula just naturally without even asking you, which will confuse the baby's latch and make it more difficult to breastfeed.  

Circumcision: This is one that Mike and I didn't agree on right away, but after Mike read the research, he came over to my non-circumcised decision. Circumcision is a cultural decision; it is not medically indicated and the American Association of Pediatrics does not advocate for a routine circumcision any longer.  Additionally, the rates of circumcision have dropped dramatically so much so that a child in this generation in the U.S. will grow up being in the majority if they are uncircumcised. Circumcision does provide some protection against STDs as the foreskin will extend contact to sexually-transmitted secretions, but I'd rather just teach my child to wear a condom. Because foreskin or not, they are still at risk. If you are going to have your son circumcised, I highly recommend watching what this will look like; you should know exactly what it is because I believe in our culture we take it for granted as a being so "normal" we forget that it is surgery on a newborn. WARNING: This link is a video of circumcision. I linked to a normal-circumcision (not by an anti-circumcision group) video because it is not meant to scare you into a decision. It's meant to make you educated on what the surgery really is. To us, there was no way that we wanted to do this to our son; Mike couldn't even watch the video it grossed him out so much. And as with any medical intervention, research does highlight some significant, albeit uncommon, risks. 

Summary

So my lessons learned from the experience of researching and writing the birth preferences? First, I learned that parenting starts before the baby is born. There are so many things to consider and research, as it seeps into your consciousness that these decisions will impact your baby, possibly for life. Second, no one, let me repeat, no one, will care about your child as much as you do. So no matter what advice you hear from anyone (including me!) or an OB/doctor recommending a procedure that you aren't sure about, QUESTION IT. I learned it's my body and my baby, meaning I have and take the responsibility for making well-educated, non-fear-based decisions. Finally, I learned those four words that give you all the power in a medical environment: "I do not consent." I've been practicing, just in case someone decides to ignore my birth preferences. At first, I was so reticient about thinking of saying that to a medical professional. After being so supported by my doula and providers, it kind of feels nice saying it like a mantra.