(Just received this from Choices In Childbirth!)
We need your help!
At midnight tomorrow, April 30th, the majority of New York City’s home birth midwives will no longer be able to practice legally. Unless immediate action is taken by the Governor and the NYS Department of Health the women that these midwives serve will be denied access to a home birth with their chosen provider and these providers will no longer be able to practice legally in NYS.
YOU MUST ACT NOW to save the home birth option for New York Women:
Call:
* 311
* Wendy Saunders, Executive Deputy Commissioner for the NY State Department of Health, appointed by Governor Paterson. 518-474-8390
* Larry Mokhiber, he Secretary of the Board of Midwifery (518-474-3817, extension 130)
And say….
With the closing of St. Vincent’s Hospital, half of the licensed, highly trained home birth midwives serving NYC have lost their Written Practice Agreement (WPA). St Vincent’s was the only Hospital in the city supportive of a woman’s right to choose a home birth and willing to sign a WPA. In the weeks since it’s announced closure, these midwives have reached out to hospitals and obstetricians all across the city looking for support, with no success. Please help us to save the homebirth option in New York.
People can also email the Governor at http://www.state.ny.us/governor/contact/GovernorContactForm.php.
April 29th, 2010
For those looking to avoid routine interventions or put off pain medication, care providers commonly recommend staying home for as long as possible. This advice is very well intended, but the birthing mom’s partner will likely be called on to help make the final call about when to go in. That responsibility can be very overwhelming if he or she is unfamiliar with the sounds and movements of labor.
As a doula, I am well acquainted with the phone call when the partner says: “The last contraction was really strong - we are heading into the hospital NOW!” At this point, I usually ask if the laboring mom can come to the phone. I want to listen to her during a contraction and assess where things seem to be. One of the benefits of having a labor support doula, or anyone that is familiar with the mechanics of labor, is that they can recognize the “signposts” of labor and have a clearer idea of when to head to the hospital or birth center.
With that in mind, this blog entry is intended to help the laboring mom’s support team identify the signposts of labor.
Stage One of labor is defined as the cervix dilating from 0-10 cm and effacing (thinning of the cervix) from 0-100%. This stage is broken down further into: early, active, and transition.
Early Labor- 0-3cm
This stage may start subtly, with minor back aches or menstrual cramp-like feelings, and is often the longest. Contractions may start pretty far apart and last only 30-45 seconds. The mother may notice more of the mucus plug passing. As this stage progresses, the contractions will start to become more regular, longer, and closer together. The cervix will start to efface (thin out) more. This leads into the next phase: active labor.
In active labor, the mother may experience:
-Mild contractions, similar to menstrual cramps. These contractions are not so strong that you cannot talk through them if you needed to.
-Lower back ache
-Excitement
-Mild diarrhea
-Anticipation
During this stage, I recommend trying to ignore labor. It is so easy to get caught up in the start of the laboring journey, but you do not want to pull out all your pain management techniques too soon and be exhausted by the time you really need them. If labor begins during the night, try to keep sleeping. If it begins during the day, alternate between resting, a gentle walk or start a “labor project” - something that can keep your mind and time occupied as labor progresses. Bake some cookies for the nursing staff - it is nice to go in and make friends with them!
For the partner, I recommend keeping the laboring woman company and encouraging her to keep eating, drinking and emptying her bladder on a regular basis. This is also a good time to start organizing the belongings that will be going to the hospital or birth center. I also recommend giving a heads-up to the doctor, midwife, doula, babysitter etc.
Active Labor 4-7cm
During this stage the contractions are becoming more regular (5-2 minutes apart) and lasting about 60 seconds. There will be more “bloody show” (a mucus discharge that is tinged pink, red or brown), which is is a sign of cervical change. You will notice a shift in the mother’s mood; she will become more introverted and will be concentrating a lot more on her breath and her contractions. She may also need more support and pain management techniques at this point.
During active labor women may experience:
-Stronger contractions
-More intense backache
-Desire to talk less
-Mood shift to more serious and introverted place
-Apprehension and feeling unsure that she can do this
-Desire for support
-More “bloody show”
During this stage, the mother might turn her focus inward and will need to rely more on her pain management techniques. It will also be more difficult for her to talk through contractions. As this labor progresses, you will start to notice the sounds and the movements becoming more “primal”. If unmedicated, the mother will start to go into a pattern of movement that she finds comforting as the contractions build. Usually this position is a forward leaning one and is often accompanied by swaying of the hips of some kind. Many mothers start to use sound to release pressure, pain and tension. The sound may be sighs or low moans. When I see or hear this type of behavior, I consider it to indicate a “turning of the corner” from early labor to a strong active labor pattern.
The partner can best support the mom by helping her concentrate on her breathing, offering counterpressure or massage, helping her change positions and continuing to give her fluids. At this point she probably does not have the desire to eat. This is a good point to head into the hospital or birth center.
Transition 8-10cm
This is typically the most intense, but quickest stage of labor. Contractions are now 60-90 seconds long and occurring every 1-3 minutes. Fortunately, most women move through this phase in approximately 10-60 minutes. If the amniotic sac has not been broken yet, it will likely break in this phase or the care provider may offer to break the bag of water. During transition, the laboring woman will really need the help, support and encouragement from her support people.
During transition women may experience:
-Very intense contractions
-Nausea and/ or vomiting
-Rectal pressure and premature urge to push as the baby descends
-Chills and hot flashes
-Mood change, irritability, hopelessness, desire to give up, and self doubt
-Heavy bloody show
-Possibly even sleeping between contractions
If these physical and emotional “signposts” are evident and a home birth is not intended, I would strongly suggest making your way to the hospital or birth center at this point.
In unmedicated births, transition has its own distinct characteristics. When a woman who had found her groove and was managing active labor well, starts to get hopeless and even irrational, I can tell we are there. She will say things like: “I don’t think I can do this anymore,” or “I think I am done now - I want to go home”. This is a pretty good sign that she is almost ready to push. Other telltale signs of transition are the laboring mother expressing that she is experiencing a lot of rectal pressure or that she has a desire to vomit. She may have nausea, or hot/cold flashes, or even fall asleep between contractions.
If the mother seems really desperate and is starting to unravel, but needs to reach full dilation, I often suggest (if her water has not broken yet) that the care provider breaks the bag. The breaking of the water intensifies the labor and can give the mother that final push toward full dilation. Please note, I don’t recommend using this tactic earlier in labor.
Once full dilation is reached, the first stage of labor is complete.
The intention of this particular blog entry is for the partner to recognize the signposts of labor in order to help determine what stage of labor the mother may be in. So I will not go further into discussing the second stage of labor – pushing - or the third stage - the delivery of the placenta - since it is assumed that most women will have the help of a birth professional involved in the labor and delivery at this point.
Exceptions
As with anything else in life, there are exceptions to the rules. The two exceptions to highlight are the case of a posterior baby or a precipitous labor.
The first one, OP or Occiput posterior, is when the baby’s occiput is toward the mother’s back. This can cause tremendous back ache since the mother is feeling the baby’s occiput push against her sacrum. In a situation like this, the mother may experience intense back pain during contractions that are timing close together and even have rectal pressure. Identifying back labor can be confusing for most, since the level of discomfort the mother is expressing, as well as the close proximity of the contractions, are associated with active labor and progressed dilation.
Typically, OP labors are longer since the baby is not pushing the cervix open with the smallest part of their head, but instead trying to use their forehead. Should a labor start out as posterior, it is good to know that the incidence of persistent occiput posterior babies at delivery is about 5.5%. So the baby is likely to rotate anteriorly.
(For more information about posterior position- please refer to “Explanation Of Fetal Positions“)
The second exception is, precipitous labor, which is a labor that from start to finish is under three hours long. In the case of precipitous births, the mother does not go through the stages of labor gradually. Instead, she feels the onset of contractions which will quickly grow in intensity and proximity. I admit, I have only seen this a few times during my doula career. It is estimated that only 2% of births are precipitous, and it is rarely the case for a first time mother.
While many mothers may read this and think: “Sign me up for a quick birth!,” a precipitous labor can be overwhelming for the mother since there is little time to rest and recover between contractions.
The mother will also need to rely on natural pain management techniques since there is no time for pain medication to be administered. On the positive side - generally speaking, when labor is happening very fast, the mother can rest assured that there is nothing wrong. Her body is working at peak performance in perfect coordination with her baby to make her labor and birth extremely efficient.
If a mother or her birthing partner suspects she is having a precipitous birth, it is advised to get help or get to the hospital as soon as possible. However, if the mother has progressed so quickly that she is already feeling the urge to push, DO NOT try to leave your home. This is when babies are born in cabs or the side of the road! Instead, call 911 for the EMT- they are well-equipped to birth babies.
“Alternative ways” to measure dilation
I can not take any credit for coming up with these alternative ways to measure dilation. My friend Kim, who has a blog, Doula Momma, wrote about these finds in one of her blog entries. I found these two methods fascinating and unusual. So here they are:
From Helping mothers give birth joyfully without fear. A doula in Israel
Measure your cervical dilation from the outside! Think about the shape of the uterus. Before labor, the muscle of the uterus is thick evenly around all sides, above, below, behind. As the cervix starts thinning and dilating, all that muscle has to go somewhere – it bunches up at that top. The top of the uterus thickens dramatically the more the cervix opens. During a contraction, at the beginning of labor, check how many fingers you can fit between the fundus (top of your bump) and the bra line – you will be able to fit 5 fingers. As the top of the fundus rises higher during labor, you will fit fewer and fewer fingers. When you can fit 3 fingers, I usually tell mothers they can think about going into hospital as they will find they are around 5cm dilated. At 1 finger, you are fully dilated. (Awesome, huh!)
Understanding the bottom line. There is something called the “bottom line,” which is a shadow that extends from the anus up towards the back along the crease of the buttocks. It begins as 1cm and lengthens to 10cm, and it’s length correlates with cervical dilation. Why not look down there before inviting a stranger to put their fingers up inside you? It makes sense to me.
Hope these tips and signposts of labor help you and your partner have a confident, good birth!
April 29th, 2010
As a Lamaze Childbirth Educator, I strongly subscribe to the Lamaze Approach to Birth. One of their key beliefs is: “Women’s confidence and ability to give birth is either enhanced or diminished by the care provider and place of birth.”
I chose to write about this topic because as a labor support doula, I have seen firsthand that certain hospitals tend to lean more toward a conservative approach than others. These more conservative hospitals may accommodate a large number of high-risk patients, and as a result, their general approach may be geared toward high-risk care regardless of the birthing mom’s needs. While many women put a heavy emphasis on choosing a care provider, they may not take into consideration what hospital or birth center the care provider is associated with.
I have interviewed a traveling Labor & Delivery Nurse that has worked at several different hospitals, as well as a mother of three that has birthed at a NYC hospital, a birth center, and at home. Both of these interviewees had wonderful perspectives on how the place of birth DOES effect your birth experience.
Rosalie Hunt is currently a Labor and Delivery Nurse at Weill Cornell on the Upper East Side of NYC. She completed the nursing program at John Hopkins five years ago and has been working in labor and delivery ever since. Her first experience out of nursing school was at Sibley Memorial, a community hospital in Washington, DC where she worked as a Labor & Delivery Nurse for 4 years. She moved to NYC and is currently working at Weill Cornell, a teaching hospital.
Right off the bat, Rosie explained to me some of the differences between a community hospital and a teaching hospital in terms of her experience as a Labor and Delivery Nurse (L & D Nurse). She explained that teaching hospitals are much larger, affiliated with a university, and they have higher level (3 & 4) NICU’s (Neonatal Intensive Care Units) as well as specialty maternal fetal medicine physicians that deal with high-risk moms. In the community hospital, the NICU level is lower, meaning that they could not take babies under 32 weeks, or twins under 34 weeks. Community hospitals are primarily designed to care for low-risk mothers.
Since community hospitals are not directly affiliated with universities, there are no residents or medical students, just the attending physicians, midwives, and nursing staff. The smaller staff allows for more intimate, direct care from the staff, especially the nurses. As a nurse, Rosie was the one that checked for dilation, and was the liaison between the laboring mother and the doctor. While at a teaching hospital, the patient may be visited and checked on by one or more residents and/or medical students, and there will be more “traffic” through the room. (Side note: I recently attended a birth at Mt Sinai here in NYC, and the doctor asked if a medical student could watch the birth. The doctor explained that this would be a good learning experience for the student, since the hospital so rarely saw unmedicated births.)
Even when deciding amongst different teaching hospitals, it is important to take a closer look at the intervention rates. They can indicate if the staff deals more often with the high-risk or low-risk patient. For example, New York’s St. Lukes/Roosevelt (which houses a birth center) tends to have lower risk women and lower intervention rates, 23% cesarean rate, compared to
New York Presbyterian Hospital (Columbia University) with a 39% cesarean rate and Weill Cornell close behind with 37%. Rosie explains that a low-risk laboring mother birthing at a “higher risk population facility” may be subject to more routine interventions intended for the high-risk woman. She also explains that with more routine interventions, such as full time EFM (external fetal monitoring), higher use of pitocin and more inductions, the nursing staff does not often have an opportunity to see unmedicated births. So for those looking to have an unmedicated birth, it may be of note that the nurses may not be used to seeing a natural birth and experiencing the sounds, movements and behavior that goes along with it. This may leave the nurse uncomfortable and not sure how to support the mother. Rosie suggests: “When looking for a place to deliver, look at your health, your pregnancy, and your philosophy and desires for birth and try to match it with a facility and practitioner where you are the norm and not the exception.”
The second interview was with Liz Fraser, a mother of three. Liz had her first baby, Liam, 4 years ago at Weill Cornell Hospital. Her second baby, Owen, was birthed 2 years ago at the Birth Center at St. Lukes/Roosevelt and her third baby, Sloane, last month at home with a midwife. Since Liz was in three very different settings for her births, I figured she can give a very personal account of what she liked and didn’t appreciate about the different settings.
Giving Birth In A Traditional Hospital Setting:
Deb: Did you find the staff was helpful and respectful of your wishes?
Liz: Once in the room, yes. But I do remember there being a reaction when I gave the birth plan to the admitting nurse.
Deb: What was the reaction?
Liz: She rolled her eyes.
Deb: Did you find the hospital protocol a hindrance to your wishes?
Liz: Luckily, I had the walkable EFM (external fetal monitor). Had it not been for that, it would have been really annoying being connected to the machine with limited movement the whole time. Our nurse also allowed us to have more than 2 people in the room [which is the norm]. Having the extra people really helped.
Deb: How was the hospital staff supportive?
Liz: The first nurse, I really liked. However, when the shift changed and the second nurse came in, the whole air of the room changed. The focus was not on me - the patient! I was just about to go into the pushing stage and she was reorganizing and straightening up the room. The attitude of the second nurse created a certain tension that had not been there before.
Deb: Can you talk about the pros of the hospital setting?
Liz: Having the immediate access to care was definitely a pro. It was my first time giving birth and I felt very confident in the care I was going to be given.
Deb: Can you talk about the cons of the hospital setting?
Liz: The potential for restriction: of movement, food, and support. I really lucked out since I had the walkable monitors, we snuck food in and I had all the people I wanted with me. I REALLY did luck out!
Giving Birth At The Birth Center
Deb: Did you find the staff was helpful and respectful of your wishes?
Liz: Yes, once we got to the Birth Center, but not in triage on the L & D floor. They didn’t really seem to care and were not very responsive. It was not until I vomited in the hallway that they seemed to pay attention to me.
Deb: Did you find the hospital protocol a hindrance to your wishes?
Liz: Yes, the whole 20 minute monitoring upstairs [in the L & D triage] was very annoying. But once we entered the Birth Center, it was like angels started to sing!
Deb: How was the hospital staff supportive?
Liz: The nurse was so helpful! It was so wonderful to have the tub filled and ready to go. There was no waiting and everything was ready for me to have my baby. I also really liked that Dr. Wong was there the whole time. She wasn’t putting any pressure on me, she was just there as things progressed.
Deb: Can you talk about the pros of the Birth Center setting?
Liz: It was not hypermedical and very casual. This helped me relax. As I said before, having the privacy and relaxed atmosphere was key for me. I spent a fair amount of labor in the huge whirlpool tub and then transitioned to the queen size bed. We could also bring in whatever food we wanted - although the smell of the food in the room didn’t really help me that much.
Deb: Can you talk about the cons of the Birth Center setting?
Liz: There were none!
Giving Birth At Home
Deb: What was your experience like giving birth at home?
Liz: It was nice not to have to go anywhere. That was really key for me. I figured, I am not getting medication, so what is the point of going anywhere. It also felt good not to have any routine medical procedures done. Cara, the midwife, unobtrusively checked the baby’s heart rate with the doppler scope. Other then that she just observed and gave me space to have my baby. I was not even aware of her medical supplies and instruments tucked away to the side
Deb: Can you talk about the pros of your home birth?
Liz: The experience itself as a whole, was very positive. I didn’t do this as a statement - it was just something I did. I liked being in my space with my people and then afterward, everyone [the midwife, and the doula- me!] left and we went on with our lives.
Deb: Can you talk about the cons of your home birth?
Liz: I didn’t think about the advantages the hospital and birth center provided. I was catered to in recovery from the staff. They had ice packs available at my request. I also had 24 hours between giving birth and going home. I forgot how nice it was to have the nurse’s support afterward. If the baby started crying, the nurse took care of him. At home, I didn’t allow myself the recovery time.
Deb: Any final thoughts you want to share?
Liz: Really think had about what kind of environment and experience you want and figure out what setting is going to provide you with that vision.
I couldn’t agree more with the two lovely ladies I interviewed. Take the time to figure out what you, as a mother, want out of your birthing experience. If the place, staff and care provider you choose does not approve of or have confidence in your birth preferences, you will be fighting an uphill battle. With so many options available, please take the time to think about what is best for you, your family and your baby.
April 15th, 2010
