I attended Andrea’s birth almost 5 years ago. I think this was the third birth in which I took the role of a doula - I was just a doula in training. Andrea had given birth naturally to her first child (almost 10 pounds if I remember correctly) and was well on her way to repeating the experience.
She was doing remarkably well, positioning her body in ways that felt productive and comfortable (well, as comfortable as one could be while moving through transition). When she reached full dilation and had the spontaneous urge to push, she was positioned on her hands and knees. For her, this seemed like the easiest, most natural way to push her baby out. To my horror, the doctor would not allow her to deliver her baby in this position. The doctor wanted her on her back. Andrea pleaded with the doctor not to make her turn around and get on her back. The doctor wouldn’t budge. So Andrea ended up flipping over onto her back - and pushing her 10 pound baby out in 7 minutes! She tore horribly. To this day, I believe Andrea pushed her baby out so quickly just to spite her doctor.
The moral of this story is that there are many positions in which to birth a baby. And research has shown that birthing on the back, although the most common - is NOT the ideal way to facilitate a baby fitting through the pelvis and birth canal. In all fairness, Andrea’s doctor (who was the resident on call, not Andrea’s intended doctor) probably insisted that she birth on her back because she didn’t know how to “catch” a baby in any other position. The supine position is the most convenient for the doctor and is these days the one student doctors are primarily taught. However in my experience, when a woman has been given total freedom to take a birthing position of her choice, she has NEVER chosen to go on her back. The mothers I have seen have chosen to be on all-fours, side-lying, in a partial squat, kneeling, sitting on a birth stool or upright in a seated position. Art from many cultures throughout history shows that women have used both upright and gravity-neutral positions (such as side-lying or hands-and-knees) to give birth to their babies. Until doctors began using forceps in the 17th century, women were rarely shown giving birth in supine positions (lying on the back) The most ideal position for a woman would allow for optimal opening of the pelvic outlet, use the advantage of gravity and offer a smooth path for the baby’s descent through the birth canal. When a mother births in the lithotomy (flat-on-back) or C-position (resting on tailbone with body curled in the shape of a C) she reduces the space in the outlet of her pelvis, making it a tigher fit for the baby. The sacrum gets pushed into the birth canal, thus diminishing the space for baby to move through, and preventing the rectal space from stretching. This will, in effect, lengthen her second stage of labor (pushing). Also, the baby has to work against gravity as it heads upwards over the tailbone and under the pubic bone.
It is also not uncommon for a woman to hear that her pelvis is too small for the baby to fit through. This is called cephalo-pelvic disproportion (CPD). It does happen - but rarely. It may be that due to the baby’s size a woman needs to take a number of positions in order to push the baby out. Pioneer doula Penny Simkins explains in The Labor Progress Handbook, “Many suspected cases of CPD actually involve fetuses who are subtly malpositioned (asynclitic, deflexed, occiput transverse or posterior), who will fit well through the pelvis once the malposition has been resolved. The shape of the woman’s pelvis is also a consideration. The woman may need to try pushing in a variety of positions to find the ones that optimize descent. Resolving problems of position or fit often requires extra time. Many large fetal heads will mold and fit safely through the pelvis, but molding takes time.” It is important to allow a mother to experiment with different positions to see what is the most effective for her and her baby, especially if her baby is suspected to be large.
Over the last few weeks I have received so many inquiries about doulas. What is a doula? What does a doula do? How much do they cost? How do you interview a doula? So, I thought I would try to answer these questions to the best of my ability.
The word ‘doula’ is derived from Greek and means ‘woman of service’. (In my opinion this sounds a little negative - I prefer ‘labor assistant’!) There are two different types of doulas: labor support and postpartum care. Postpartum doulas are also considered ‘mother’s helpers’. They help mother the mother after her birth, perhaps showing her some newborn procedures, helping establish a schedule for mom and baby, and doing basic chores like cleaning the house, food shopping, and laundry. (I chose to be a labor support doula. I figure I am not that good at cleaning my own house or doing laundry, and to be honest taking a trip to Fairway is a low point in my weekly routine - so my skills are best used to help mom during labor.)
Labor support doulas are usually hired by the couple, although some hospitals provide them free of charge to offer nonjudgmental emotional and physical support. They are also equipped to help answer many questions about the labor and birth process and medical interventions. While most doulas are not trained medical assistants and do not perform medical procedures, they have quite a bit of knowledge that may assist the couple when making decisions about the path of their labor and birth. Personally, I never make a decision for the couple, but rather provide answers to their questions and both pros and cons of any options that are presented. This way, when the couple has to make a decision, they are doing it from a place of knowledge, not fear.
There are currently two principle groups that certify doulas: ALACE (Assocation of Labor Assistants and Childbirth Educators) and DONA (Doula Organization of North America). I was certified through DONA. Both groups firmly believe in the importance of consistent, continuous support throughout labor and in respecting the couple no matter how they choose to birth.
I am often asked by concerned mothers who want to have an epidural if that is likely to be ok with a doula. The answer may vary from person to person, but most doulas believe that they are there to assist in the best birth experience a mother can have through her own vision and wishes. I firmly believe that each woman needs to birth how she feels is best for her and her family. The experience of birth has a lasting and profound effect on a woman, and the doula is there to help ensure that it is empowering and satisfying.
Once you have found a doula who you think you would like to work with, what is the next step? I would suggest a ‘meet and greet’. This is an opportunity for the mother and her partner to sit and chat with the doula and inquire about her style, beliefs, price, availability, back-up support, etc.
Here are a few questions that may be useful:
1. What is your philosophy on childbirth? Do you only attend and support women that are intending to do a natural birth? Are you open to the use of pain medication?
2. What are some of the non-pharmaceuticals pain methods that you use?
3. How do we determine when you join us? Do you come to our house at the beginning of labor? Or do you meet us at the hospital or birthing center?
4. Have you worked with my doctor, practice, midwife or at the birthing center or hospital where I will be giving birth?
5. How many births have you attended?
6. What kind of training do you have?
7. Do you have a back-up doula in case you are not available when we need you?
8. What is your cost?
9. Do you have references we can check?
10. How many times before the labor do we meet? Do you help us with our birth plan?
One of the most common questions I encounter is the cost of doulas. There is a range based on several factors - where you live, for instance. A doula in NYC will probably cost more than outside the metro area. Experience is another determining factor. At this time the average range for a doula with a fair amount of experience, which I would say is at least 25 births under her belt, is $1500-$2500. I have heard of very seasoned doulas who have attended hundreds of births charging upwards of $4000. If these numbers sound outrageous, you could also consider finding a doula who is in training and would probably only ask you to cover her expenses - taxi fare and food. Some doulas even work on a sliding scale. But keep in mind when digesting this figure that the doula is making a commitment to you to be on call and available for three weeks prior to your due date up until you have your baby. It is possible that your doula will be on call for you for a whole month!
The statement from ACOG and the subsequent resolutions from the AMA are very likely due at least in part to the increased attention from the media on home birth, brought to the forefront by the film “The Business of Being Born” and its producer Ricki Lake. I have seen the film multiple times and think it is a very responsible, well-done documentary on the subject of home birth. The overall message is that home birth is a safe option for a low-risk woman who has a trained, certified midwife in attendance for medical assistance.
The midwifery model of care is based on the concept that pregnancy and birth are normal life processes - not pathological medical conditions. However midwives are trained medical experts. They monitor the mother and the baby throughout labor with a dopplerscope, come equipped with oxygen and resuscitation skills, and bring Pitocin in the event that it is necessary. They are also at the ready to make a call to transport the woman to a medical facility should she need more advanced medical attention. But unlike many medical professionals within hospital walls, they allow the birthing mother a great deal more choice - for instance the position she wishes to take to birth her baby - with fewer restrictions.
Other eye-opening statistics indicate that though the US has the most expensive births, the maternal and infant mortality rates are on the rise. According to Mother Magazine, US infant mortality rates continue to rank it below 30 other countries. Twenty-two percent of all pregnancies are induced, and most worrisome of all, in the last four years the maternal mortality rate has risen above 10 per 100,000 for the first time since 1977. These statistics can not be blamed on home birth since only 1% of US women are birthing in their homes.
Home birth is not a choice for everyone. Several states in the US have made a home birth attended by a direct-entry midwife illegal. These states include Alabama, North Carolina, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maryland, Missouri, South Dakota and Wyoming. One of the concerns of home birth advocates is that the AMA is trying to persuade individual state legislators to see home birth as harmful to the baby, equating it as child abuse, for which the woman may be criminally prosecuted.
I have never been one to closely follow celebrity gossip. In fact, I am embarrassingly behind the times - stuck somewhere in the late 90’s when Julia Roberts, Meg Ryan and Friends were big. But I can’t deny the influence celebrities have on society. They are the American equivalent of the British Royal Family. Recently, the biggest Hollywood trend is pregnancy and babies. (I have even been called up by VH1 looking for the scoop on “hot Hollywood mamas” only to disappoint the producer when I told him the mega stars have not passed our threshold.)
With this uprise in celebrity births there is a bit more scrutiny on how the precious little off-spring of the Hollywood elite come into the world. And, it stands to reason that like everything else, how Tinseltown gives birth will have an impact on Jane Q. Public. There seem to be two emerging camps of thought: A return to the home for birth or an early trip to the ER for a planned cesarean birth.
On one hand we have people like Ricki Lake, who has used her celebrity status to open the eyes of many to the possibility and safety of a home birth with her film The Business of Being Born. I recently spoke with one midwife who said she has never been this busy. That movie really boosted business! After a little digging, I was thrilled to find out that many well-known celebs have recently opted for a home birth with a midwife. Demi Moore, Cindy Crawford, and Davina McCall have all given birth at home three times. Nelly Furtado, Lucy Lawless, Ani DiFranco, and Pamela Anderson are also amongst those who chose a home birth. Pamela Anderson is quoted as saying “I gave birth at home both times, naturally, with a midwife, in water, with nothing.’
We live in a society where our heroes are actors and rock stars - fame is valued, many would argue, more highly than education. I’m not prepared to debunk the importance of the cool factor in our role models. But I do think it’s important to bear in mind that when it comes to life and death decisions, jumping on any bandwagon being driven by pop culture is ill-advised. Who will empower you? What will inspire you? And what is informing your decisions?
Very few occasions in life have the expectations and anticipation that compare to those of pregnancy - the whole pregnancy is called ‘expecting’! So of course, the onset of labor is going to be a big deal - but maybe it shouldn’t. I am not saying that you shouldn’t be excited about finally meeting your baby and starting this new phase in your life, but at times over -excitement can lead to downright exhaustion.
When I teach a childbirth education class or am working with a couple as their doula, I advise them that when they suspect labor is starting they should notify the important people that are involved: Their doula, doctor, babysitter, etc. - just to give them the heads-up. And then ignore the situation. Put the watch away- don’t time the contractions. Early labor can take many hours or even days. I guarantee you will know when things have shifted to where they need more attention. If it is nighttime, try to sleep. If it is daytime, alternate between rest and doing a ‘birth project’. (A birth project is anything that is distracting that you like to do. Some women I know have started baking projects or crossword puzzles or just gone for a walk.) A good indication that labor is shifting is that the mother can no longer focus on her birth project, and the cookies she started earlier are burning in the oven!
The reason I give this is advice is that if she doesn’t rest, a woman will focus solely on the early contractions and will start to pull out all the tricks she has to deal with labor - and not have any energy for later in labor. I was having an in-depth conversation with a friend who is currently pregnant with her second child about the length and exhaustion of her first labor. (Granted, her baby was posterior which explains the lengthiness of the experience.) But one thing she recognizes is that she jumped the gun a bit on ‘dealing with her labor’, and by the time it got really difficult she had already exhausted herself.
For a woman giving birth for the first time, it’s hard to know how to pace herself for an experience she has not yet had. Over the years as a doula, I’ve had the benefit of seeing many births - and now I’m better at knowing when it’s really time for mom to gear up for labor. But I remember several years back, when I was just starting out as a doula, when I too was drawn into the excitement of early labor. I was called into my client’s birth, and she explained that her contractions were rather intense and she felt she was ready for me. I thought it was pretty early on for her to be so far along in her labor, but being a novice I didn’t really question the situation, and I didn’t know the emotional signposts to look for to indicate where in labor she was really at. When I arrived, she was bouncing on her birth ball with a big smile across her face and doing her “breathing”. Needless to say, we were miles away from the more active part of labor. But we breathed, we walked and we rocked - and ultimately by the time she really needed her energy reserves, she was pretty tired. (Just to give you the ending to this client’s birth story, she went on to have a beautiful baby girl and all was well.) Had we ignored her labor for a bit longer, she might have had a bit more energy, hydration and stamina for her marathon labor.
So I guess what I am trying to say is do less. Let your body and baby give you the signals - you’ll know when you need to put a little more energy into your labor. Until then, continue to nourish, hydrate and rest until you just can’t ignore your new arrival.
I was talking to one of the students yesterday about freedom of movement during labor. She was concerned that as soon as she arrived at the hospital she would be hooked up to the EFM and would not have the freedom to move about as she would like. She asked what I thought about that.
Well, if you are on full-time EFM, it is true that your movement options will be limited. This is because in certain positions, like on all-fours or sitting/leaning on the birth ball, the fetal heart rate isn’t as easily picked up by the monitor. As an alternative to full-time EFM, you can ask your doctor to do intermittent monitoring which will allow you to walk the halls, take a shower or bath, or what ever else you want to do, monitoring at times between these activities.
A few years ago, I attended Monica’s first birth. Her baby was slightly posterior and her labor was not progressing very well. So, knowing that we needed to shift her baby in her pelvis, we turned on the salsa music and got her booty shaking! It was actually a lot of fun - her mom even joined us in dancing around the room! Although, the hospital staff didn’t quite know what to make of this spontaneous dance party. And, the dancing and movement was quite effective. After many songs and different moves, her baby did shift into a better position and she was able to have a vaginal birth.
When I was at The Farm Midwifery Center this past fall, I remember Joanna, one of the legendary midwives, saying that moving during labor reduces the length of your labor by 25%. What woman would not want those results? Ina May Gaskin, one of the founding members of The Farm, encourages women to “find their inner monkey” while birthing. A primate would not labor on her back in stillness. She would move. She would rock. She would sway. She would create mobility to allow her baby to descend and rotate deeper into her pelvis and work its way out of her body. So why not follow her example? Birth is birth!
There are so many reasons supporting the importance of open movement during labor. I encourage all pregnant women and those thinking about becoming pregnant to investigate this option with their care providers. If mom is ok and baby is ok, why not move and groove as your body and baby wants to?
I came across this video on YouTube. I encourage all expectant moms to take 3 minutes and 3 seconds out of their day to watch it.
What I think is really scary about this video is how much truth is revealed about the practices of birth in our society. The video demonstrates the many ways a mother is pressured and frightened into accepting a variety of different interventions that may or may not be necessary, but have become commonplace in today’s births. The message seems to be clear: If the mother doesn’t accept these interventions, she is doing something wrong and it will hurt her baby. I have heard, on occasion, nurses and doctors saying, “We need to have full-time external fetal monitoring to make sure your baby is ok.” When in fact, there is evidence supporting the contrary, that full time EFM can lead to unnecessary cesarean birth. Or statements like “If you don’t take your epidural now, you may not be able to get it later.” Or “You can’t push your baby out, there is not enough room, your baby is too big”. All of these statements - that were probably not made with malicious intent - diminish a woman’s confidence that she is capable of birthing her own child without a cascade of interventions.
Hopefully at some point this trend will change, and birth will become an opportunity for a woman to feel supported and empowered by her choices - not scared.
The cervix is opened by the baby’s head pushing against it with each contraction. You can visualize this action by picturing the cervix as a turtle neck sweater through which the head is slowly emerging. Ideally, to push the cervix open most effectively, the baby’s chin is flexed, and the smallest part of the baby’s head (the occiput) presents first. However, sometimes the baby’s occiput is facing backwards or is posterior, so it does not emerge first.
Posterior Position
• Occiput Posterior (OP)
• Right Occiput Posterior (ROP)
• Left Occiput Posterior (LOP)
The baby presenting in a posterior position can lead to a host of issues. For one, dilation and progression usually take longer, and some women get “stuck” at a certain point in dilation. The mother may experience intense back pain, since the baby’s skull is pressed up against her sacrum. She may also experience the urge to urinate during each contraction, because the baby’s forehead is pushed up against her bladder.
At times it is it difficult to rotate a baby out of the posterior position, especially if the baby has entangled itself in the cord. There are yoga poses that are encouraged and discouraged during the last trimester to help the baby move into the ideal birthing position.
Specific yoga poses to omit from the 3rd trimester practice are:
• Legs up the wall
• Supta Baddha Konasana (at the end of class)
• Supported bridge for a long period of time
It is advisable to do any “belly down” pose like child’s pose, cat/cow, body circles and a brief downward facing dog. (Please exclude downward dog if the baby was once in a breech position and has finally turned head down.) I also encourage women to sit on a birth (exercise) ball or sit upright or leaning forward in chairs. If the mother has access to a pool, swimming is a fantastic activity for the last trimester since the mother is belly down for a prolonged period of time, and immersing the body in water can help reduce swelling.
During the last trimester I encourage the mothers to spend as little time on their backs as they can. This includes asking them to check in with the way they recline at home as well as in the yoga studio. It is so easy (and desirable!) to come home and drop back into the couch or comfy chair. They should avoid doing so, however, since it creates a hammock-like shape for the back and invites the baby to settle into a spine-to-back position.
Another reason that the baby may present posteriorly is that the mother’s uterine ligaments and pelvic floor muscles are tight and somewhat twisted, preventing her baby from settling into a good position. Luckily, many poses we do in prenatal yoga encourage the pelvic and uterine ligaments to gently open and relax. Exercises that relax and tone the pelvic floor muscles are also included in class.
Specific asanas for preparing the pelvis for labor and delivery:
If the baby is malpositioned and the mother is aware of what side the baby is laying on, she can help correct this by arranging her body to encourage the baby to shift during savasana or while asleep. If the baby is OP, the mother should use “pure side lying” as opposed to semi-prone. The mother should lie on the side towards which the occiput is already facing, with the baby’s back toward the bed.
If the mother would prefer to rest in a semi-prone position, she needs to lie on the side in which the baby’s occiput and back are facing towards the ceiling. For example, if the baby is ROP, the mother would be on her left side in a semi-prone position and on her right side for “pure side lying”.
Breech Position
• Breech
o Footling breech
o Frank breech
o Complete breech
o Kneeling breech
Another issue some mothers face is the baby being in a breech position. This could mean the baby is standing straight up in the womb (footling breech), presenting butt first (frank breech), sitting cross- legged in the womb (complete breech) or the baby is kneeling inside (kneeling breech). Either way, very few doctors will deliver a breech baby vaginally. If a mother finds out her baby is breech, she is often anxious to help turn the baby around. Luckily, there are some yoga poses that can assist with this.
Poses to help turn a breech baby:
• Prolonged inversion like downward dog
• “Butt up” child’s pose
• Supported bridge pose
• Right angle handstand at the wall ***advanced practitioners only
• AVOID squatting, as it opens the outlet of the pelvis and invites the baby to wedge itself deeper down.
Beyond these specific yoga poses, acupuncture has been known to help. Also, you can try placing ice at the fundus since the baby will likely move away from the cold. Or, place music or light down at the pelvic opening since babies will go toward sound and light.
In general, mothers should be mindful of the baby’s position as she nears her due date and tailor her practice accordingly. Yoga can have a powerful effect on these last few weeks and days of pregnancy!
Labor is probably not the time to request a huge steak dinner, but it is a good idea to continue to nourish your body. Not eating during labor may reduce your energy, increase your fatigue and decrease your ability to deal with stress. Can you imagine laboring for 15 hours and then pushing your baby out having had only ice chips the whole time?
Hospitals began restricting food and fluids about 50 years ago, when women often gave birth under general anesthesia without their airway protected. The doctors were concerned that the women would vomit and aspirate while under the anesthesia. Even though it is extremely rare that general anesthesia would be used in a modern-day labor and delivery situation, this old protocol is still enforced in many hospitals.
Moreover, women who ate rated their overall labor experience as significantly better than that of women who were only allowed to drink water, according to a study presented in poster form at the annual meeting of the Society for Gynecologic Investigation“.
So what do you eat? A while back, I was reading Midwifery Today and found a short article about “The Midwife’s Pitocin”. This particular midwife recommends that her clients make a bowl of oatmeal, honey and nuts during labor and graze on it as they desire. If you break down the ingredients, you will find the perfect balance of complex carbohydrates, protein and natural sugar. Imagine that you are about to run a marathon – surely you would fuel your body with healthy supportive food! Why not for labor? I have been recommending this concoction to my doula clients, and it seems give them lasting stamina.
If you are birthing at a birthing center or at home, you can continue to eat when you like. But what can you do if you are birthing at a hospital? The oatmeal will probably not be welcome at the hospital, but you can try to get some in your body before you head in. First check in with your hospital and care provider and see what their guidelines are. For low risk women, some hospitals have recently opened up the option of consuming clear fluids, broths and juices. If you are restricted to ice chips, bring along a sports drink that has electrolytes and some sugar, and mix that in with your ice chips. But be sure to avoid the overly sugary drinks, as they may cause nausea.
Some women are concerned that eating during labor will cause them to vomit. But according to the same study referenced earlier, “Vomiting was not more common among women allowed to eat light foods, 18% of whom vomited once and 17% of whom vomited more than once, compared with 17% and 17% of women in the water-only cohort.” In fact, vomiting is a sign of transition and can actually help push the baby deeper down into the birth canal.
Here is a “light menu” that may be appealing to the laboring mom. You are more likely to have a desire for food early in labor. Whenever you choose to eat, don’t force yourself to eat anything you don’t want to.
True story: I had the misfortune of bad timing the other day in the bathroom at the UWS Loews Theater, overhearing a brief conversation between two very pregnant women. The conversation went something like this:
“When are you due?”
“March 20th, but I’m having my c-section on the 18th.”
“I’m having a c-section on the 23rd. Why are you having a c-section?”
“Well, at 37 weeks, the baby was already 7 pounds 13 ounces and my doctor said ‘I wouldn’t put you through labor with a baby that big’.”
I left after that. Shocked by what I heard, I headed back to the theater and proclaime
