A healthy dose of birth fear is fine and normal; it motivates us to put in place what we need to birth. Paralysing, debilitating fear on the other hand is counter productive and it’s those fears that need to be explored safely.⠀

It’s no wonder so many of us carry fear around birth – often from our earliest exposure to it we learn that it’s dangerous, painful and undignified. This basic belief is reinforced over and over again by TV and movies, other women’s traumatic birth stories, the media and a multitude of other influences. There’s very little good stuff going around to balance out the scales, and this is only made worse by the fact that often our very first experience of real birth doesn’t occur until we finally get behind the Secret Walls of the Labour Ward ourselves.⠀

Fear is a funny beast. Where it exists, it will have its way, whether you choose to acknowledge its existence or not. It has a way of sneaking up on you and biting you when you least expect it. Unspoken fear can bleed into every aspect of your birth experience. It can influence your decision making in ways that you’re not even aware of until you start picking those decisions apart after the fact. Whatever it is that frightens you, use the precious time you have in pregnancy to find a way to work through it. Shameless plug – doulas are wonderful at this! A large part of prenatal work with a doula involves identifying and exploring your fears in a safe space, and developing strategies to help you work through them before labour.

Check out an absolutely amazing series of posts over at My Natural Baby Birth with some practical advice on starting this work yourself.  And take a look at my Feel the Fear board over on Pinterest for some inspiration as well!

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Informed Consent - knowing what you don't know | Toowoomba doula

One of the scariest things about pregnancy the first time around for me (and even the second time!) was owning my choices.

“Informed consent” is bandied around the birth world like a mantra. But what does that really MEAN when you find yourself unexpectedly pregnant with your first baby, fairly in the dark about the fact that you even have choices, and not confident that you know enough to make those choices responsibly?”

For a lot of us, it means that we leave the decision making to other people by default. It means we decide to “go with the flow”.  It means we give away our power…not because we don’t want it – but because we don’t how to keep it, yet.

Going with the flow leaves us open to good things happening, but all too often in birth it leaves us vulnerable to having an experience that doesn’t respect our babies, or who we are as women. One of the hardest things to get your head around about giving birth in our maternity system for the first time is this:

 

If you don’t make a birth plan or understand that you have choices, your care providers DO have a birth plan for you, and your choices will be made for you.

 

You might be just fine with that. But what if you’re not?

Your birth plan might not ever make it out of your bag, and that’s fine.  Just the process of researching it, of starting to understand where you have choices and what the possible outcomes are – means you go into your birth more prepared than most. For too many of us, it takes dealing with the aftermath of a birth that was nothing like we imagined, to make us realise that the power and the choice always should (and always does) lie with us.

 

 

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So you know you need to write a birth plan, right?  If you’re birthing in hospital (or even if you aren’t) writing a birth plan is an important part of birth preparation, and there aren’t many scenarios I can think of where it’s wise to skip it.  Even so, I know that many of you find this process incredibly overwhelming and time consuming.  Years of guiding clients through this part of their preparation has taught me one thing – we usually fall into one of two camps when it comes to birth plans.  The first camp will spend weeks creating a document that’s the love child of a birth manifesto and a medical journal.  The second camp starts off okay – understanding quite correctly that no one can control every aspect of their birth – but then take this to the extreme.  They become overwhelmed by choice and throw up their hands, declaring they’ll just “go with the flow on the day”.  Neither approach is ideal.  But if you recognise yourself in there, I have some good news for you!  (as well as an awesome free tool to show you how to write a simple birth plan…read on!)

 

 

Most of us don’t need to spend days doing a crash course in midwifery through the University of Google to write a good birth plan.

There are five key areas that really need to be thought about for a hospital birth plan.  These “The Big Five” are most likely to have the biggest impact on your birth- so if the goal is to keep the process simple, they’re a good place to start.

Fetal Heart Monitoring

The Decision:  Doppler vs Continuous Monitoring (CTG) 

If your pregnancy is low risk and remains so throughout labour, you have a choice about how your baby’s wellbeing is monitored during labour.  There are specific risks and benefits associated with the two main methods available – hand held doppler and CTG (the elastic bands with the discs and cords on them).   More than any other issue, women seem to know the least about monitoring options even though this one decision arguably has the most potential to change the course of their birth.  As with any proposed intervention, you’re free to decline monitoring all together – though you might experience resistance to this.

Starting Point Resources:  Evidence Based Fetal Monitoring

 

Pain Relief Options

The Decision: Comfort Measures vs Pharmacological Options (gas, opiates, and epidural)

Planning to birth without drugs?  Signing up for the full enchilada immediately on admission to the labour ward?  Keeping an open mind until the big day?  No matter what your plans, it’s important to understand the risks, benefits and potential knock-on effects of the multitude of options available for managing labour pain.  I can’t promise you anything about how your birth will be for you, but I can absolutely guarantee you that by the time you opt for an epidural in labour, you won’t be even slightly interested in listening to the anaesthetists long disclaimer before he/she gives it to you.  On the opposite side of the coin it’s kind of annoying to realise an hour into your planned hypnobirth that you actually really, really hate that hypnobirthing CD, and will probably stab your ear with a pencil if you have to listen to that woman’s voice One.  More.  Time.  Except you can’t form the words to tell someone.   It’s always better to prepare for these things from an informed place before labour, rather than a panicked one during it.

Starting Point Resources: Childbirth Connection – Options: Labour Pain

 

Induction and Augmentation of Labour

The Decision:  Artificial Rupture of Membranes (Breaking Waters) + Synthetic Oxytocin (syntocinon/pitocin) or not – and under what circumstances.

I know, I know.  This isn’t going to happen to you…right?  Hopefully it won’t, but the reality is that according to Queensland Health, about 40% (no, that is not a typo) of labouring women are being given syntocinon (a synthetic form of oxytocin) to either start labour or at some point during.  For a good proportion of these women, labour will be induced because their pregnancy has lasted beyond their due date.   If you’re birthing in hospital, it’s a good idea to get your head around why so many women are being induced, how inductions are managed, and the risks and benefits of this process.  Also, find out when your hospital or caregiver would put induction on the table – you’d be surprised at just how much this can vary depending on where you’re having your baby.  This puts you in the best position to make the right decision for you and your baby, should that time come.  There’s nothing worse than being pitted against the clock and having to get your head around a huge topic like induction, when you should be just enjoying the last days with your baby in your belly.

Starting Point Resources:  In Defence of the Amniotic Sac, Induction of Labour – Childbirth Connection, Induction – A Step by Step Guide

 

Umbilical Cord and Placenta

The Decision:  Physiological vs Managed Third Stage, Immediate vs Delayed Clamping and Cutting.

When I first began attending births eight years ago, getting delayed cord clamping required negotiation akin to something that might go on at the United Nations.  Fortunately, this is now getting easier to obtain for those women who want it – particularly if a supportive birth place and caregiver is chosen.  There’s growing evidence that leaving the umbilical cord unclamped and uncut for a period after the birth has health benefits for both mum and baby.  Connected to this issue is the option of private cord blood banking.  If this is something you’re considering, do your research on the likelihood of baby needing the blood later against the risks and benefits of him receiving his full quota of cord blood at birth.

Starting Point Resources:  Common Objections to Delayed Cord Clamping – What is the evidence?

The First Hour After Birth

The Decision:  Extended Skin-to-Skin vs Hospital Routines

The first hour after birth is often called the Golden Hour, for good reason.  While it seems the action is all over, for both baby and mother there are some very complex physiological processes going on that get breastfeeding started, facilitate bonding and slow your postpartum bleeding.  Unfortunately for many of us, this first hour will be spent being poked and prodded while bleeding is checked, stitching is done, observations are taken of you and baby, baby is weighed, measured and given shots, and often forced to breastfeed before he/she is ready.
While there are certainly good reasons for some of these things, the execution of them can be lacking in busy birth units.  Time pressures sometimes mean that baby will be strongly encouraged or even forced on to the breast rather than being allowed to self attach, and that critical skin to skin is interrupted for reasons that can be more to do with getting through a to-do list than immediate medical need.  Protect this critical time with your baby by understanding normal hospital procedures in the first hour after birth, knowing what needs to be done right away and what can wait, and listing your preferences for how this is to be handled on your birth plan.

Starting Point Resources:  Evidence for the Vitamin K Shot in Newborns – Evidence Based Birth, A Timeline of A Baby’s First Hour

What Next?

Want to write a simple birth plan, but not sure where to start?  Let me help you! I’ve created The Simple BirthPlan Checklist just for you!  This easy, free tool will take you through your options for each of the five areas described above, giving you a quick outline for your birth plan.  You don’t even need to print this baby off – just tick off your preferences and any extras you need to remember, right on the PDF.  Grab it – it’s absolutely free!

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We’ve all seen it – that movie with the pregnant woman minding her own beeswax, perhaps sorting through apples in the fruit aisle, when….plop! She looks at her feet in shock as a mad frenzy ensues to get her to the hospital, because she might just have her baby on the floor of the supermarket, ANY MINUTE.

One of the most common questions I’m asked as women reach the end of their pregnancies is about waters breaking – or in technical terms, spontaneous rupture of membranes.

Did my water just break? How would I know? And most importantly – how can I make sure this doesn’t happen to me in the middle of Woolworths?!

 

It might surprise you to learn that the vast majority of labours don’t begin with waters breaking – in fact, only about one in ten spontaneous labours will start this way. For the other 9 in 10, waters will remain intact until they rupture on their own well into labour, or until consent to rupture them artificially is given. Something else I’ve noticed in my years as a doula, and that many midwives will also atest to, is that waters often break or begin to leak late at night. So even if your labour does begin this way, it’s fairly likely that you’ll be in the privacy of your home rather than the fruit aisle. Phew.

Before I go further, a caveat – if your pregnancy hasn’t yet reached term, is high risk, or you don’t know if your baby is head down in your pelvis, there are special factors to consider and you should contact your caregiver as soon as you can.

How Will I Know If My Water Breaks?

  • For most women, the dramatic gush of Hollywood labours doesn’t happen. Usually, waters breaking before contractions begin is experienced as a trickle of fluid, rather than a flood.
  • Contractions might not begin right away – so don’t assume your water didn’t break just because you aren’t having any yet.
  • If you’re soaking a pad every five minutes, it’s a pretty safe bet that this is not a test run.
  • A trickle or small amounts of fluid can occasionally be confused with urine leaking, or lots of watery vaginal discharge. A good way to check if it’s urine is to clench and try to stop the flow, just as you’d do on the toilet mid-stream. If you can’t stop it, it may be amniotic fluid.

What Should I Do?

    • Pop a pad on, grab your phone and lie down for about 30 minutes. Amniotic fluid pools in the vagina when you’re lying down – so if your waters have broken, when you get up again you’ll probably feel it coming out onto the pad right away. If it was just urine or discharge, you won’t notice anything much when you stand up.
    • Call your careprovider or hospital – some will want to see you, others will ask you a few questions and be happy to watch and wait. You’ll most likely be asked about:
Colour

Is the fluid clear? Is it tinged (pink, yellow or even green/brown)? Clear or light pinkish is normal, other observations need to be discussed with your careprovider.

Smell

Amniotic fluid smells vaguely like semen, or bleach.  There shouldn’t be any sort of nasty smell to it.

Amount

Was it a big gush, or a trickle?

Time

When did you first notice it? Are you still noticing it now?

There are a number of medical tests that can be used to determine whether or not your water has broken. Depending on the policy of your care provider or hospital, these may be offered to you. If you do choose to go into hospital, remember to ask questions to help you decide your best course from there. Some starting points could be:

      • What are my options while I wait for labour?
      • If I remain in hospital, how long before you would recommend further action to begin labour?
      • If I go home, is there anything I should be looking out for?
      • If labour doesn’t begin in the next 12-24 hours, what would you be suggesting we do?
      • What are the risks to my baby and me at this point? What can we do to manage those risks?

In the meantime, no sexy-time for you – if your water has broken, sex increases the risk of an infection. But you SHOULD get cuddly with hubby, and get those oxytocin receptors firing. Remember to rest and stay well hydrated – you have a big task ahead!

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With many hospitals and private obstetricians requiring you to book pretty much as soon as a pregnancy is confirmed, the temptation is strong to just get into whoever you can and be grateful you got in to anyone at all. After all, caregivers are all pretty much the same, aren’t they?

Well actually, no.

There are some key differences between midwifery and obstetric models of care. Just as no two accountants or lawyers practice in the same way, maternity care givers are also a diverse bunch. Amongst other things the way they care for women in pregnancy and labour is influenced by their training, their own previous experiences, and their hard wired beliefs around birth. This means it’s generally a good idea to talk with a few in early pregnancy, and make an effort to find a care provider whose approach aligns with yours.

This list is focused on specific, key questions that will help you identify a care giver who is genuinely supportive of natural birth but it’s by no means comprehensive! If you’re looking for this type of care, it’s helpful to understand what a potential care provider views as a hands off situation, and when they believe intervention might be needed. These questions should give you a feel for where your midwife or obstetrician stands, and can be a jumping off point for exploring your own feelings about intervention in your birth as well.

1. What’s your approach to post dates pregnancies? At what point would the care giver recommend you consider induction or other intervention to start labour? In Queensland, 24% of women will be induced, and a further 19% will have their labour augmented (ie. be given an intravenous drug during labour to regulate or strengthen contractions). Most commonly, inductions are scheduled when a pregnancy lasts beyond the estimated due date. Caregivers will vary as to how far is too far for them, anything from a couple of days, to a few weeks. If you’d like to avoid induction where possible, finding a care giver with a more relaxed approach can mean you and your baby navigate the final days of your pregnancy without pressure.

2. What’s your caesarean rate for normal, uncomplicated pregnancies? If a prospective care provider is evasive or vague on this question it may be a red flag. Our caesarean rate in Australia averages around 30%. While private hospitals don’t have to publish their data on an individual level, as a group they consistently report rates above this. Asking about the rate for uncomplicated pregnancies removes any confusion that may be caused by the inclusion of high risk pregnancies (these would usually be attended by obstetricians).

3. What’s your approach to the management of gestational diabetes? Gestational diabetes is being diagnosed more frequently in women with no prior risk factors, and in recent years the cut off point for diagnosis has been dropping. Around 8% of pregnant women will be diagnosed with gestational diabetes, most around the 28th week of pregnancy. If you’re one of them, the way your care provider routinely manages a GD diagnosis can have major implications for your pregnancy and labour.

4. Under what circumstances, if any, would you be likely to perform an episiotomy? Fortunately episiotomy rates are declining, but they’re still unacceptably high, especially among first time mothers. A care provider with a high episiotomy rate may be one who is quick to intervene generally. If this is your first baby, you could ask how many first time mothers in their hospital or practice receive an episiotomy to get a clearer picture.

5. What will happen if my baby is breech at term? This is a loaded question and the answer will tell you quite a bit! It’s highly unlikely that your baby will be breech at term, but asking your care provider what they’d usually do in this situation can be enlightening. Obstetricians and midwives who don’t view breech position alone as an automatic indication for caesarean are very likely to be a low intervention, hands off care provider for a woman with a head down baby.

6. When would you recommend routine continuous monitoring of my baby in labour? Continuous monitoring during spontaneous, normal labour in low risk women has been shown to increase the likelihood of caesarean without improving outcomes for babies. If your pregnancy has been normal and you labour spontaneously and unmedicated, intermittent listening with a doppler has been shown to be as safe, and won’t increase your risk of surgery. Nonetheless, some care providers insist on continuous monitoring for all women, regardless of their risk status. If you want to use the shower for pain relief and be able to move around to manage pain, this might be something to ask about.

Depending on your priorities for your own birth, this list barely scratches the surface of what you might need to ask a potential care provider. Can you think of anything else it would be important to know? Share with us below!

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