Pregnant in 2017? ACOG Recommends…

veronica2

As a doula, getting the latest recommendations on birth updated is almost like Christmas morning. And if you are pregnant in 2017, you probably want to be aware of the latest recommendations by the American Congress of Obstetricians and Gynecologists (ACOG). Whether you are attempting a natural birth in the hospital, or maybe you aren’t sure exactly what you want to do, there are some important points that would be good for you to know. And as we all know, knowledge is power. And what pregnant woman couldn’t use an extra boost of power?

You can read the entire position paper they put out here, or simply read on to get an overview of some of the key points.

These new recommendations consist of a more hands-off approach when it comes to some things (like fetal monitoring and pushing approaches), and they include and reaffirm their past position on things such as eating and drinking during labor (Yes, of course it’s good for you!)

And you know what else is good for you? Continuous support. Although this is not “new” news. This document specifically mentions doulas several times and numerous citations are used to note the mounting evidence that continuous labor support is associated with a myriad of positive outcomes such as:

  • Fewer operative assisted birth such as forceps or vacuum extractions
  • Less need for epidurals and analgesia
  • Fewer cesarean births
  • Shorter labors
  • Higher 5 minutes Apgar scores
  • Fewer reports of dissatisfaction with the experience of labor

So what else might be important for you to know now?

Laboring at home until active labor is encouraged and beneficial

In recent years the definition of active labor has changed to mean until 5- 6 cm of dilation. But that means little to moms who are laboring at home without being checked by a care provider. So the bottom line is, be prepared to labor at home…for quite awhile. It is perfectly normal for a first time mom to be in early labor for 24 hours, or more. Early labor (the latent phase) is a very important part of the labor process that should not be downplayed, in my opinion. A lot is still going on for a laboring woman, both physically and mentally. Research shows that for low-risk, healthy women, interventions are more likely to be avoided if they are admitted once they reach active labor. So it’s important to understand a lot of labor will be happening outside the hospital, and it’s important to have a good plan. I always educate my clients on the process of early labor, what to look for, help them come up with some ideas as to how to spend it, and I help their partners understand they will have a very important role during this time period.

Intermittent monitoring is appropriate for low-risk labors

Woohoo! ACOG finally affirms that for low-risk labors, intermittent monitoring (as opposed to being tethered to a machine by 2 elastic straps the entire time) is appropriate, and sometimes even more beneficial. The opinion clearly states that studies have shown that continuous monitoring has not reduced perinatal death or cerebral palsy for low-risk pregnancies, and has in fact increased cesarean and instrument assisted births. So couple that with the desire to want to move about freely and change positions at will, which naturally will aid in the descent of the baby and the progress of labor, and it becomes quite logical that for low-risk labors, intermittent monitoring is way more beneficial. But you will need to discuss this before “labor day” with your provider, and make sure the hospital you will be attending has this as a true option. Then on labor day, you will need to remind them that this is important for you.

Water breaks before labor starts? You have choices, and equally good options

When a woman experiences PROM (premature rupture of membranes), this means the water breaks and labor doesn’t begin immediately. When this happens, according to the newest findings, “approximately 77–79% of women will go into labor spontaneously within 12 hours, and 95% will start labor spontaneously within 24–28 hours” (ACOG, Feburary 2017). There are 2 types of management in this case. Expectant management is a “hand’s off” approach where conditions are monitored but treatment is withheld until symptoms appear or parameters change. Active management is where induction is started shortly after the rupture of the membranes “to move things along”.

“For informed women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for a period of time may be appropriately offered and supported”

-Committee Opinion: Approaches to Limit Intervention During Labor and Birth, ACOG, February 2017

Current best practices shows outcomes are the same, whether active or expectant management is used in low-risk pregnancies. So this is another good talk to have ahead of time with your provider. Make sure if you think you might want to wait it out at home, they are comfortable with assessing you, and then letting you do your thing until somethings changes, or you change your mind.

And speaking of water breaking…

Your water will break, at some point before or during, or even after labor (for babies born in the caul). This is a hard fact. ACOG is now recognizing what research has shown for years- that AROM (artificial rupture of membranes) has little benefit to the labor as a whole, and may actually do more harm than good in terms of increasing the risk of infection, causing a malpositioned baby, or in extreme cases it can cause cord prolapse or placental abruption, both which will lead to an emergency cesarean. Expectant mothers should know it’s perfectly normal for waters to release when they are ready, and that there is no need to rush the process.Unless, of course, there is an obvious medical necessity.

Keep Calm and Drink On

The reasoning behind the “no eating or drinking during labor” (at a hospital) rule is primarily to avoid aspiration should an emergency ensue later.  Current findings show current anesthesia techniques (meaning epidurals) are associated with a low incidence of aspiration, and ACOG has stated now that hydrating yourself with fluids is preferable to IV hydration. So bring lots of coconut water, herbal teas, bone broth, juices, whatever appeals to you! They have alluded to the fact that since aspiration risks are so low, eating would in effect help keep a laboring mom’s strength up for the marathon of labor, but they have yet to officially change their stance regarding food and are continuing their “ongoing review” on it. We’ll have to give them more time to catch up on this one.

Push it Real Good

The “purple pushing” or Valsalva (closed glottis) pushing technique is being compared to an instinctual, open glottis pushing which is often accompanied with vocalizations of many varieties (and wow, have I heard it all!) in this recent finding. Studies show that there is minimal difference when it comes to the duration of the second stage, no difference in overall outcomes (meaning cesarean, instrument assisted, APGAR scores, etc.). There is a slight shortening of the pushing phase (depending on the study), between 5 and 10 minutes, when using the Valsalva technique, but there is also increased incidence of “abnormal urodynamics” (hello, pelvic floor, how I miss you so). Also, women are now (finally!) being encouraged to “labor down”, meaning give baby some time to move further down on his own and to following their own instincts as to when to start to push. This is a good thing because you are working WITH your body, when it’s ready. Just because you hit 10 cm. does not necessarily mean baby is down low enough to make pushing warranted or very effective…and no one wants an exhausted mama by the time baby is low enough.

Regardless of what you choose for YOUR birth, having evidence based information can help you make better choices. And it’s important is that these are your choices, what you feel is best for you and your family. Documents such as the one just put out by ACOG make wonderful talking points with your care provider. They tend to like that kind of evidence based stuff, they’re funny like that. And believe it or not some of them who have been practicing for a long time may or may not be up to speed with the latest recommendations. So here’s your chance to share with them.

Share on mamas, share on!

What This Doula Wants You to Know

 

 

evelyn3

Doulas are for everyone. At least, this one is. Doulas are not only for the earthy-crunchy, squat-in-a-field-by-the-river, no-medication-whatsoever Moms.  I believe everyone could benefit from some intensive support, no matter what your preference, plan, or non-plan is.

After all, birth is a monumental, incredible, life-changing experience, whether you think of it that way or not. And who wouldn’t want some degree of support while going through a monumental, life-changing experience?  But – believe it or not – some people don’t hire a doula. Which is absolutely okay. There are many mothers, sisters, friends, even partners out in the world who are up for the challenge and make incredible birth companions.

But pregnancy and birth is not always a straight line. It (sometimes) has it’s twists and turns, and  (sometimes) that’s when having a trained professional- someone who has been down this well worn path many, many times before, and has seen an endless number of variations of this dance- is invaluable.

But whether you hire a doula or not, my nervous, excited, ever-so-hopeful and determined mama…..there are a few things I really want to share with you.

  • Please, take a great deal of care and time when choosing your birth provider. Your provider is one of the most important decisions you will make in this process. He or she has a significant impact on the outcome of your birth. Please, talk to them open and honestly early on. Listen to what they say, and how they say it. Listen to the tone of voice they use, look at their facial expressions. Then listen for what they don’t say. Don’t be afraid to share everything you are concerned or curious about, or to ask anything, even the hard questions. Then notice how you feel when you are talking with them. Do you feel calm and at ease? Supported? Dismissed? Like they are truly listening? If you don’t get a good feeling and it doesn’t feel like a good match look into meeting another provider. You have the ability and the power to do so! It needs to be a good fit for you both! You need to feel completely comfortable in this relationship. There are all types out there. Just because this person was incredible with your good friend, or cousin, or cousin’s sister, doesn’t mean it’s the right fit for you!!! Go with your gut.
  • Providers are human beings too. They have similar clinical training across the board, but all have their unique personalities. They bring to the table (and to your birth) with them their own “baggage”. They have opinions and history and past experiences that are going to impact they way they practice today. That doesn’t make them good or bad, only human! Again, find one that makes you feel comfortable! For example, if you are seeking a  VBAC and they seem on the fence about it early on, they are not going to suddenly change their mind halfway through YOUR pregnancy and become a huge advocate and push for it! You might wish that, but it’s not going to happen. So again, find the right fit, early on, or move on and keep looking. It’s a lot easier to find a compatible provider at week 15 than it is at week 36. Or, be prepared to constantly advocate for yourself every step of the way.
  • Remember to think outside the box. There are other places to give birth. Such as at home, with a skilled midwife, or at a Birth Center. Look into these options if you are low risk and seeking a natural birth. They are not so outside the box anymore. More and more women are seeking out these locations for their births because the return of a more a natural birth experience is becoming more and more mainstream. Many women are realizing that most hospitals treat birth as a medical event, a business, not a natural, normal process.
  • If you choose to use an OB as a provider, and there are many supportive, attentive, empathetic OB’s out there, find out how many other OB’s (and Certified Nurse Midwives who also may deliver there) are in the practice. It is not uncommon for a practice to have easily anywhere from 2 to 4 other providers, not counting CNM’s in the practice. So if you painstakingly do all your research and find YOUR PERFECT PROVIDER….please remember the chances of them being the actual person on call the day you go into labor are…well, you do the math. They rotate. So the chances are slim it will happen that way. So it’s best to wrap your head around that concept early on, and make sure all the providers are like-minded. Or find a smaller practice with a different doctor.
  • Education goes a long way. The more educated you are about pregnancy and birth, the more comfortable you will be when and if a deviation from your original plan happens. Take a childbirth class, a breastfeeding class, a newborn care class or all 3. Knowledge is power!
  • I can’t take the pain away…as a Doula I wish I could. But then I’d rob you of the experience of knowing you can and will do this. This experience will push you to the brink of your capabilities. It’s a rite of passage, no matter which way it happens. And the experience belongs to you. As a doula, I can be there by your side, helping you navigate the twists and turns, helping you stay as comfortable as possible, reminding you that you can do this, you’ve got what it takes to get through. Unwavering in my faith in you, and in the process.

You can do this….you will do this.

Remember you have so many choices along the way….

You can choose where to give birth.

You can choose to do it all natural.

You can choose a scheduled c-section.

You can choose an epidural.

You can choose to change your mind midway and go from all natural to an epidural.

You can choose to decline any or all medications for you or your baby.

You can choose not to consent to a procedure that is being recommended if you’ve carefully weighed the pros and cons and don’t believe it’s in your and your baby’s best interest.

But the beauty of this whole experience is you have a lot of power, and you have choices.

Don’t forget that!

 

 

 

A Page in Herstory

They gathered under a full moon. It was 3 a.m., but no one seemed to care. There was a buzz of nervous energy in the air. They all breathed a collective breath, ready to tackle the enormous task at hand, whatever it may bring. The 3 women traveled slowly, but with a purpose. Each would rely and lean upon the other at various times throughout this journey, starting now.
It is a journey that is always transformational, not just for the mother to be, but for all involved. To even be a witness to this event is to see the face of God in its many shapes and forms.
As they made their way to the next destination, which was far from the ideal location, but nevertheless would serve it’s purpose, the 3 women barely spoke. There was no need to. Each already understood what the other was feeling, saying without words.
When they arrived, ready to dig in to the task at hand, they were told there was no room for them. How ironic, they chuckled. No matter, we will find a way, they thought. We have since the beginning of time.
The tribe was separated for a brief time, and the earth tilted a little off its axis temporarily. But the women held strong to their vision, to the desired outcome, and overcame the obstacles that temporarily seemed to stop their progress together.   As soon as they were together again, the earth righted once again, and the magic returned. The dance began.
The lights were dim, the sounds were hushed, the people around them who became unknowing spectators to this great journey stared in awe and wonder at the power of the 3. The power ebbed and flowed, waxed and waned, transferred from one woman to the other, electrical and powerful and full of collective strength and wisdom. When one faltered, the others rose up to remind her “You are strong, you are powerful, you are loved, you are surrounded by everything you need “.
The one with child came in and out of her power. This was a most difficult journey for her in so many ways. This was not exactly the way she had hoped her daughter would enter this realm. She had hoped to be at home, surrounded by her familiar space, familiar sights, smells, sounds. This was far from that.

But in birth, as in death, one doesn’t always get to choose these details.
She rocks her hips back and forth, slowly in circles. This dance, which creates its own choreography, never has to be taught. It just is. It emanates from her inner Goddess wisdom. It is accompanied by sounds, low and deep. Resonating with Mother Earth herself, connecting her to her source. The transformation was happening, and it wasn’t easy. It would shake her to her core. It would drive her to the brink of madness and then return her back…But upon return, she was always greeted by her fellow sisters with a smile, a wipe of the brow, a reminder that this too shall pass and that the miracle of life was waiting to be born, struggling as hard as she was, waiting for her chance to come earthbound meet her tribe.
Time sped up, stood still, went backwards, and then stopped.
It was time.
The tribe slowly, wearily but steadfastly traveled the last leg of their journey. They arrived at their final destination and set themselves up for the final feat. They were ready, the time was here. They all took a collective deep breath. They connected to each other, to each one’s inner wisdom and collective strength, to the collective strength of the earth, of the cosmos, of all that is. And then the mother began the last part of the job of bringing forth the baby earth side.
It would not be easy.
It would not be painless.
But it would happen, as it always had.
And then suddenly, finally, the three women became four.
And the air was thick with the presence of a myriad of women…..the ones who had come before them…..those who had given birth or supported in the birth. Those who had raised children, those who had lost children, those who had loved children, who had taught children. They were all there, smiling, arms around each other, watching this newest miracle unfold in all its glory.
Watching the journey complete itself once again, as it always had, and as it always will.
womangoddessduringlabor