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A Complete Guide About Shoulder Dystocia

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What is Shoulder Dystocia?

Shoulder Dystocia is a birth complication that happens during vaginal delivery. When this occurs, one or both of the baby’s shoulders get stuck inside the mother’s pelvis during labor. This causes a stall in the delivery process, which can be life threatening. In most cases, babies born with this complication are delivered safely. However, it can cause problems for both the baby and mother. 

Shoulder dystocia happens in 0.2 to 3 percent of pregnancies, and sadly, is unpredictable and unpreventable. When complications happen during labor, doctors turn to urgent cesarean delivery or surgery to avoid further issues. Although this may work in most cases, urgent cesarean delivery or surgery cannot correct this condition. 

Continue reading below for answers to all questions regarding this topic. 

Frequently Asked Questions:

What Does Shoulder Dystocia Look Like?

When Shoulder Dystocia occurs, the fetal head is delivered but the shoulders are not seen and are not being delivered with normal maneuvers. In other words, this delay in labor causes the baby to be trapped mid delivery. When this is happening, your midwife or provider tries to move your body and baby into better positions to continue natural delivery. 

The shoulder of the baby normally gets stuck behind the mothers pubic bone or sacrum. During this delay, the baby cannot breathe and the umbilical cord may be squeezed or wrapped around the baby’s neck. It is dire that everyone stays calm but acts quickly and efficiently to prevent further complications. The midwife will ask the mother to cease pushing so she can reposition her and the baby as needed.       

Why Does This Happen?

Shoulder Dystocia can occur during any vaginal birth, and without warning. Some of the most common causes for this are that the baby is too big, the baby is in the wrong position or the mother being in a restricting position. Oftentimes, your midwife or provider will change the mothers position to help free the shoulders from the pelvic area. 

It is nearly impossible to predict the risk factors of whether or not your baby will have this complication, but there are some things that can make it more likely. This includes:

  • Shoulder Dystocia occurred during previous pregnancies
  • Fetal Macrosomia (having a larger baby)
  • Having twins or multiple babies
  • Mother is overweight
  • Mother has diabetes
  • Labor induced 

Although these factors may increase the risk of a baby being born with Shoulder Dystocia, it is not clear why some pregnancies experience this complication while others do not. One statistic states that women with a history of having a delivery with Shoulder Dystocia are 10- 20 percent more likely to have a recurrence. 

What are the Complications?

Although most mothers and babies may not experience any further issues regarding this complication, it can bring about further issues. When delivering a baby with Shoulder Dystocia, a midwife or provider may have to break the baby’s collarbone to help with removal of the shoulders. This is a last resort, but may be necessary. This is only one risk that may come from this condition. 

Further risk for the baby may include:

  • Fractured collarbone (clavicle) or arm
  • Fetal brachial plexus injury
  • Lack of oxygen to the body
  • Brain injury due to lack of oxygen (this is rare)
  • Loss of baby (this is rare)

Further risk for the mother may include:

  • Maternal hemorrhage/ postpartum hemorrhage
  • Repairs for episiotomy or tearing during delivery 
  • Uterine rupture

Can You Prevent or Treat Shoulder Dystocia?

Like we touched on above, Shoulder Dystocia is extremely unpredictable and there is very little prevention. Being mindful of potential risk factors like diabetes and watching your weight during pregnancy are all things to help lower your chance of complications during labor. At Midwife360, we recommend our mothers to give birth lying on their side or on all fours to help natural movement of the delivery process. This will help prevent complications like Shoulder Dystocia. 

It is important to inform the expecting mother about the complications and risks of Shoulder Dystocia.  As well as reassure her that, as a midwife, we are trained thoroughly on how to deal with these complications in the safest and most efficient way for the safety of you and your unborn child.  

If You Have Further Questions

If you have any questions unanswered or need more information contact us at Midwife360. At Midwife360 we provide holistic gynecology and pregnancy services, including home and water birth to women throughout South Florida. Our mission and practice is designed to meet the individual needs of each woman and expecting family we care for. We believe women should be informed and educated about their healthcare options for routine care, family planning and birthing.

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Midwife360 Turns 7!

Insurance Midwife360 Updates

On April 1st, Midwife360 will be celebrating it’s 7th year of practice. As I sit here savoring my morning cup of herbal tea, enjoying the sunshine and beautiful weather only south Florida springtime can bring, I am remembering the early days – my big ‘why’, the successes and setbacks, the various people who helped (or hurt) along the way and the current state of affairs. 

MIDWIFE360 OVER THE YEARS

I started this practice to offer something different to the women and families of my community. After working in the hospital and OB office for 8 years, I know that many women, especially the millennials, want something different when it comes to the care of their gyn health and pregnancies. And I wanted something different and better for the babies. They don’t have a voice; I am their voice and I am shouting that babies want to come into this world gently, with love and respect.

“We” started out as “I” for years, along with various students that worked with me along the way. Most notably, I was able to help Rosalia Cannava become licensed after 3 long years of apprenticeship. Mandy Rojas (currently owner of Palm Beach Maternity Center) trained with me for a bit. And then in 2018 Lauren Danella, CNM moved to Florida to begin working with me. Last February Lauren left to work with Bliss Birth Center, but came back in November when we were getting so busy. Marlie Honorat started with us in September, and will continue having 2 office days a week. In addition, the people that have helped with keeping all of the details working smoothly have been essential to our success. These include Vanessa Scoz, Sandra Alandete, Kayleigh Taylor and Bruna Possobon. 

CHALLENGE IN BIRTH SERVICES

One of the consistently biggest challenges has been dealing with insurance companies. Like any business that sells services, the key to success is being able to charge appropriately for those services and to get paid for that work. Sometimes when I’m driving around and I see a landscaping truck or construction vehicles with the company logo or even the pool guy, I am envious that those people are providing services and getting paid. The healthcare industry is unique in the world of business in that most providers (if they work with insurance) do not do the work and then get paid. I am constantly shaking my head at the system that we have inherited from the last century. 

HOW INSURANCE WORKS WITH MIDWIFES

In case you didn’t know, here’s how it works. A provider has to go through a lengthy application process to become credentialed with an insurance company. They may have to wait 60-120 days to be approved. And one can be credentialed, but not invited into the network. If they are out of network, some folks with that insurance cannot see them and use their benefits or a request can be filed to have the services covered as if the provider were in network – this is called a GAP exception or single case agreement. This usually only works if the service is something no one else is providing – like home birth with a Certified Nurse Midwife (CNM). And this can be beneficial as the provider is allowed to balance bill the client for the difference between the contracted rate and the actual charges.

That’s another eye-opener. The provider’s charges are not what the insurance company pays. For instance, my charge for self pay full journey for pregnancy care with birth at home is $7000. This covers everything, no hidden fees. The rates that have been offered to me from insurance companies vary from $2300 – $3600 for what is called Global Maternity. AND the provider may not bill for the services until after the birth. So we provide 8-9 months of regular services, but cannot get paid until well after the main event and are lucky to receive half of our normal fees. In addition, some companies require us to apply for authorizations in order to qualify to be paid for certain services – services that are part and parcel of what we do, that they cover, and are part of our contract to be compensated. 

In addition to all of this, the system for filing claims is complicated, CPT (procedure) and ICD10 (diagnosis) codes must be accurate and present, and they only accept electronic claim filing through an electronic data clearinghouse. Therefore, a provider has to turn over a percentage of the already low amount of money they receive to a third party to file the claims and appeal any denials – which happen regularly. I’ve been told that insurance companies deny a percentage of all claims in the hopes that some of them won’t get appealed. It’s all part of the game. These are some of the headaches and drawbacks for the provider when playing the insurance game.

DOWNSIDE FOR PRIVATE INSURANCE PATIENTS

From the client’s point of view it’s just as bad. People get insurance thinking that they will be covered if they get sick or, I don’t know, have a baby. They are paying a monthly premium usually $300-500 per month and are always shocked at the sticker price when we do the breakdown of what their financial responsibility is even with insurance. If they have a deductible, they must pay up to the entire amount before the insurance will cover anything. In addition, if there is co-insurance then once the deductible is met, they will have to pay their percentage of what’s left according to the contracted rate. Then there are things not covered by insurance (birth tub rental, second licensed person at the birth, supplies, home visits) and this fee is added. They are typically paying us an average of $4000 in addition to their monthly premiums. 

Through the years this system has consistently been the limiting factor for Midwife360. I went through 7 different billing scenarios (including doing my own electronic filing for about 14 months until I couldn’t keep up with the appeals process) before settling on the current company that we use. Innovation Billing (thanks guys!) And they are great – really help me feel that they care about our success. However, all of this paper chasing has taken the joy out of the work. The constant need to keep up with figuring out who needs to have an authorization and following up on them. And the length of time that payment can take if there is a denial or any problems with the claim makes it impossible to know what the actual revenue is for any specific period of time. It’s a ‘keep churning out the work, fingers crossed and hope for the best’ situation. 

MIDWIFE360 IS A CONCIERGE PRACTICE

Another consideration – we are a concierge practice. We offer hour long prenatal visits with at least one home visit during the prenatal period. The client has prenatal care with the provider that will attend the birth. We come to the home for the active labor and birth and stay 2-4 hours after, providing immediate postpartum care to the mom and immediate newborn care to the baby. We come to the home twice in the first week of the baby’s life. We draw labs in the office. We can perform some simple ultrasound procedures. Clients who have had standard OB care in our community are familiar with the 5-10 min prenatal visits after waiting an hour in the waiting room, sometimes having to go to the lab for blood draws, getting a provider at the birth they’ve never met, and another stranger to care for the baby. And on top of all that, insurance companies are paying the OB providers more for that level of service than they pay us for the concierge level services we offer.

NO LONGER ACCEPTING INSURANCE

In light of all of the aforementioned issues, Midwife360 is going to discontinue working with insurance companies as of November 1, 2021. We will continue all of our current contracts through October 31, 2021.

We encourage prospective clients to come in for an hour long consultation. We charge $50 for the hour, and apply that to the fees once the client has decided to come in for care with us.

We will do our best to make our services affordable for everyone who decides that they want this level of care for one of the most important days of their lives! 

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Home Birth: Is it Possible to Have a Breech Birth at Home?

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What is a Breech Birth?

A breech birth is when the baby is in position to descend bottom first instead of head first.  Believe it or not, 3–5% of pregnant women at term (37–40 weeks pregnant) have a breech baby. Medical professionals will often consider this to be a high risk for natural birth however with proper monitoring and birth assistance there is no difference.

What Causes a Breech Birth?

The breech position is normal and throughout your pregnancy your baby will move around and change position (you may notice this during your ultrasound). However as the body prepares for birth your baby often moves into a head down position.

Baby’s Choice

In some cases, the body and baby make the choice not to turn into a cephalic (head down) presentation. Though it is rare, it can be completely normal and nothing to worry about with the assistance of a professionally trained midwife and doula. Your certified nurse midwife, Obstetrician-gynecologist (obgyn), or a maternal-fetal specialist will determine the causation ahead of labor to ensure there aren’t special measures that need to be taken.

Amniotic Fluid

The amniotic fluid in your uterus plays a role in your baby’s ability to move around.  Your baby may have too much or too little space to move around as a result of your uterus having too much or too little amniotic fluid.

Uterine Abnormalities

Another reason for breech birth is an abnormally with your uterus. Sometimes it’s a deformity in the shape. Other complications, such as fibroids in the uterus or placenta previa also can cause a breech birth. In cases like this, you and your medical team know months in advance to your labor preparation.   Which brings us to the next question…

Is it Possible to Have My Breech Birth at Home?

The answer is often, yes. It is possible to  birth a breeched baby naturally in any setting entirely depending on the reason your baby is breech. The reason and your risk level should be explored by your team of birth professionals before a decision is made.
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Photo Credits: First Light Doula Services
Mama would like to remain anonymous
Axel Alexander
7 lbs 6 oz, 19 1/2 inches
Born on Jan. 29th at 2:01am

Born at home during a planned breech birth.

“I couldn’t be more grateful for my wonderful birth team , they didn’t try to discourage me for one second when realizing at 37 weeks that my baby wouldn’t move from the breech position because there wasn’t much room. Although I tried everything he remained in the same spot. I was given the confidence with the experience and expertise from my wonderful Midwife and her amazing assistant midwife by cheering me on, while learning the proper hypnosis techniques I learned with my amazing doula My breech birth was simply 2 hours long, with beautiful meditation music in the background, essentials oils in the air, and relaxing ambiance in my husbands & my very own bedroom; it was intimate and beautiful.”
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8 Facts About the Placenta

The placenta is a vital organ that enables your baby to grow inside your womb. Within a few days of conception, this organ begins to grow. It takes over with the umbilical cord by the time your baby is 12 weeks old. This organ supplies antibodies, oxygen, and nutrients to your unborn child.

Here are eight interesting facts about the placenta.

1. Hormones
The placenta functions as a gland, secreting the HCG hormone that is responsible for the birthing process. It also produces estrogen and progesterone. All of these hormones are necessary in order for your baby to grow.
2. Immune System Support
This organ will transfer antibodies from the mother to the baby. It will provide around 3 to 6 months of immunity after the child is born.
3. Healing Fetal Cells
The placenta sends fetal cells to the mother in case of injury. These cells can also go to areas where there is diseased tissue in the mother, offering profound healing.
4. It Takes Two
This organ is created by both the dad and the mom. The cluster of cells formed when fertilization begins becomes the placenta and the baby. Both the sperm and the egg contribute to this process.
5. Disposable Placenta
The placenta is the only human organ that ejects itself when it is done. A new organ will be formed during each pregnancy and then is ejected when the pregnancy is over.
6. Edible
The placenta is edible. Many mothers eat this organ to help increase energy, boost milk supply, reduce postpartum bleeding, and balance hormone levels. This practice is done in many different cultures. The most common way to consume the placenta is through encapsulation. This is where the organ is cooked and dehydrated down and then put into capsules.
7. Spiritual Benefits
Many cultures believe that the placenta is sacred in pregnancy. In some cultures, it is known as an elder sibling or sacred twin. A Lotus birth will involve leaving the organ attached until the umbilical cord falls off naturally.
8. Cancer
The placenta will form in the body even if there is cancer present and will not be attacked by cancer. Researchers are trying to learn more about why this organ is not attacked by cancer. This may help in the future to protect against various cancers.

The placenta is truly a miracle organ helping your baby to grow and get adequate nutrition. The miracle of life would not happen without this amazing organ.

To learn more, reach out to us directly.
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Pieces of a Woman – Commentary by Fadwah Halaby

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On Friday this week, I had the privilege to watch this trending Netflix movie with Jen Kamel of VBACFacts and a few other birth workers. I enjoyed the movie as it invoked many emotions while watching this family unravel around the loss of their baby at a home birth. Pieces of a Woman.

I don’t typically pay attention to trending movies on Netflix, but my daughter – who is soon to graduate Medical School and enter her OB residency – alerted me to the movie with concern that it could harm my practice since it was a ‘home birth gone bad’.

At first I was worried as I thought the same thing, but after watching it, I don’t feel the same way. Yes, it depicts a scenario of a baby in trouble and ultimately dying that was born at home. It also is not very true to reality in regards to the amount of monitoring that we do at a home birth, so that part could be harmful as folks don’t know what we do and might assume that the amount of monitoring is just like the movie. But I also know that no amount of monitoring would have changed the outcome. And the outcome would have been the same if the baby had been born in the hospital. Bad outcomes happen in the hospital, but folks don’t typically say “if the parents hadn’t chosen to go to the hospital this never would have happened”. Yet they say that if there is a bad outcome at home without knowing the details of the case. The parents are blamed for their unconventional choice.

But this movie wasn’t a statement about home birth as unsafe. This movie was a poignant and powerful statement about the isolation and grief that parents suffer when faced with the loss of a baby. We watch the relationship between the couple completely break down as neither one is able to deal with their grief and it drives a wedge between them. We watch the mothers family grapple with their grief and their attempts to “do something” to obtain justice as some sort of compensation for their loss. We see relationships break down and we see relationships heal.

I recommend watching and hope that it highlights the need for more resources for postpartum people and families who are dealing with grief from birth trauma – which can happen even when there is no loss of life.

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5 Benefits of a Home Water Birth

Throughout your pregnancy, the one thing that lingers in your mind often is the time of giving birth. There are a variety of birth options available today. Depending on your overall health and preference, you can choose to give birth from home, and a highly recommended method is a water birth.

Did you know today, thousands of women worldwide are choosing home water births? To find out why, keep reading.

What exactly is a home water birth? It is merely a birth that happens at home and is attended by a qualified midwife or doctor. In this case, the baby is born in the water, usually a birth pool. You may choose to labor in the water and get out to deliver, or you could decide to deliver in the water. The concept behind a water birth is that it will be gentler for the baby since it has been in the amniotic sac for nine months.

Are you thinking of having a water birth? Or are you still unsure whether it’s worth it? Let’s dive into some of the benefits of home water births to help you make an informed decision.

Benefits of a home water birth

Water births are becoming more popular each day. Wondering why? According to the American College of Obstetricians and Gynecologists, water births comes with some incredible benefits, making them a worthwhile pursuit. These benefits include:

Increased relaxation

Most women choose water births because of the relaxation benefits the water gives. How so? The answer lies in the water temperature and motion that helps in relaxation throughout the labor. Contractions usually lose their rhythm if you are tense. Once you are in the warm water, you feel relieved and relaxed, making contractions less stressful and shorter.

Being fully immersed in water also lowers your blood pressure, giving you a more relaxed feeling. Water birth is also less stressful for your baby.

Pain relief

If you want natural birth pain relief, then water birth is your friend. Many women opt to deliver their baby in the water because they won’t need pain relief medication like an epidural. Being in the warm water makes it easier for you to manage your painful contractions.

A higher sense of privacy

A birthing pool and a dimmed room is privacy on another level. Who would not feel relaxed in such a situation? Compared to bright labor wards, the ambiance in your home is significantly more comforting. Your focus is solely on labor with this form of privacy. For some people, quietness is pivotal to keeping them calm.

Increased sense of control

The water’s buoyancy effect lessens your body weight, allowing you to move freely and switch angles until you find a comfortable position. In a nutshell, being in the water makes you safer, secure, and more comfortable.

Reduced chances of episiotomy

An episiotomy is a surgical cut performed to enlarge your vaginal opening while giving birth. To avoid tearing and stitches, water birth comes in handy. It makes the perineum to be more relaxed and elastic. As a result, it reduces the incidences of tearing and enlarging the vaginal opening.

Water births present a gentler welcome to the world for you and your baby. Delivering in a birth pool comes with tons of benefits that make it a worthwhile option to consider. Benefits range from reduced labor pain and increased relaxation, to the privilege of giving birth surrounded by your loved ones.

Contact us today for more information about home water births.

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Midwife360 Partners with Care Credit

Care Credit for Maternity Services Palm Beach

Introducing Care Credit at Midwife360!

Having a natural birth at home is becoming more and more appealing as the COVID numbers grow and healthy pregnant people begin to question the automatic choice to give birth in the hospital.

However, home birth is not always covered 100% by insurance (think deductible and co-insurance) and even with Medicaid, there are some out of pocket expenses that Medicaid does not cover. With Midwife360, the lowest out of pocket amount is currently $1200 and many folks with private insurance may have to pay around $5000 when the numbers are crunched for their particular benefit plan. Our self pay rate is $6700. While even that is a small price to pay for one of the most beautiful and memorable days of your life, not everyone has that kind of cash available or even that much credit.

Enter Care Credit. Care Credit is easy to apply for and most people are approved and the staff at Midwife360 will help. It allows for a 4th option (other than cash, debit, or traditional credit card) to pay for your care without breaking the bank. Depending on the program chosen, there is an option for 6 or 12 months credit with no interest, or a low interest 24 month credit card.

Midwife360 pays a small percentage and we get paid for our services while the client gets to pay over more time for no extra cost (when choosing the no interest option).

We are happy to be able to help our clients be able to pay for their care without causing undue financial stress. Contact us today to find out more!

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Natural Sacred ChildBirth

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Sacred Natural Childbirth

Natural childbirth for healthy, low-risk women is the only natural function of the human body that typically occurs in the hospital. “Why is that?”, you may ask. Because our culture has co-opted natural birth, babies, and women’s bodies for the benefit of capitalism – Big Pharma, Insurance companies, and Hospitals – the Trifecta of the medical-industrial complex. That is the only reasonable explanation as Women’s bodies have been successfully birthing live babies for literally millennia – else how would we be here? Birth has only been happening inside hospitals for about one hundred years and studies have shown that it’s safer to natural birth outside the hospital to avoid the unnecessary interventions that lead to worse outcomes. 1,2

Doctors are taught to fear birth

Medical schools have also contributed to the situation by instilling a climate of fear surrounding Birth mostly related to potential litigation. They believe that if the doctor is taught how to control birth, then they have control over being sued. In addition, natural birth is not taught to OBs because their focus is surgery. They are surgeons; the interventions they advocate frequently lead to surgery, and this is where they shine. Obstetricians are surgeons and if you are seeking the care of a surgeon, you are likely to have surgery. Very simple.

Birth cannot be controlled

Interventions in childbirth give the illusion of control over a natural bodily function that cannot be controlled. Women’s bodies will open and release the baby inside when the body and the baby are ready. This is normal, natural childbirth in a nutshell. Even the women doing the opening and releasing have no control over the process. The only control that is possible and productive is the act of surrender to this most basic bodily function. When a woman is able to fully surrender to every aspect – when and how – then when her body and the baby are ready, it will happen. The more surrendered a woman is to the process, the more efficient it is.

Thirty-eight percent cesareans in Palm Beach County

Our community (and there are many like ours) has not embraced this principle. It is very typical for women to be induced at 38 or 39 weeks of pregnancy for a myriad of reasons. We know that when labor is induced before the body and baby are ready, then things can go wrong. The body may not fully dilate no matter how much cervical ripening is chemically encouraged or how much Pitocin is given. Often the baby will not be able to tolerate the cocktail of chemicals involved between the induction drugs and the inevitable epidural. A woman may enter the hospital wanting a natural birth, but very few are able to tolerate the torture of hours of fasting, limited mobility and abnormally strong and consistent contractions, not to mention the flow of strangers into the room, the bright lights, uncomfortable bed, etc. An epidural is the only relief she can get in the hopes of maintaining her dream of vaginal birth. Palm Beach County has an average Cesarean rate of about 38%. That’s more than 1:3 women walking into the hospital expecting a vaginal birth and ending up having surgery to have their baby!This is NOT because Birth is dangerous. This is because our community has a culture of meddling with an otherwise normal, natural process. And that meddling leads to dangerous birth.

ACOG supports VBAC

The national organizations that oversee and regulate birth providers have reasonable recommendations regarding things such as vaginal birth after cesarean and breech birth. But the local OBs tend to disregard these reasonable and evidence-based recommendations. One example of how our local OB community rejects recommendations by ACOG (American College of Obstetricians and Gynecologists, the national organization for obstetricians and gynecologists), is with VBAC (Vaginal Birth After Cesarean) candidates. ACOG recommends that doctors offer vaginal birth to women who have had 1 or 2 previous cesareans. They also don’t recommend inducing labors for VBAC candidates. Yet many OBs in our community still recommend repeat surgery for these women or insist that they birth by 39 weeks. They routinely induce VBAC candidates at 39 or 40 weeks which can lead to the very complication that they fear – a ruptured uterus. Also, there is no solid evidence that a woman with more than 2 cesareans is not a good candidate for a VBAC, but there are very few OBs that are willing to “allow” these women to attempt a vaginal birth.

ACOG supports out of hospital birth

Another example of how our community defies the national recommendations is through a document is known as The Levels of Care document that was endorsed by both ACOG and SMFM (Society of Maternal and Fetal Medicine, the obstetric specialists). In this document, it is recommended that all healthy, low-risk women birth outside the hospital in Birth Centers. If the situation changes, the woman is transferred to a higher level of care – one where the ability to perform a cesarean or other interventions such as Pitocin or epidural is available. There are even higher levels of care such as Intensive Care where caring for someone who is on life support machines is available and not all community hospitals have this option for women during or after childbirth, so she would have to be transferred from the lower level hospital to a higher one. The idea is that we have lots of birth centers, less of the community hospitals and only one or two regional centers to care for the very complicated cases. However, our local OBs do not encourage their healthy, low-risk women to birth outside the hospital. Rather, they look for reasons to elevate a woman’s risk and encourage interventions such as unnecessary inductions.

Birth is sacred

Birth is a sacred event that happens to each of us only once as we enter the world. How it happens is important for the one being born and for the one giving birth. If we are going to see a world that is healed from all of the devastations of poverty, war, climate change, and abuse it has to start with how we care for those giving birth and being born. I have grown up in my Midwifery career hearing the saying that ‘Peace on Earth begins with Birth’. We have to honor the process and respect both mother and baby by not causing pain and trauma but rather supporting, facilitating, and protecting the process. This can happen more easily out of the hospital in a woman’s home or in a birth center. However, I have not given up hope that we can shift the culture of childbirth within the hospital by spreading information and demonstrating a better way. We do this by supporting natural childbirth centers and encouraging the growth in the number of birth centers in our community.

Support the ‘birth’ of Gentle Birth Centers

I’m happy to announce the addition of a new natural childbirth center in Wellington – opening soon. Gentle Birth Centers will be teaming up with Midwife360 to create an integrated practice of home, birth center, and hospital care for healthy, low-risk candidates. We plan to open this spring and are located within a mile of the nearest hospital. Let’s change birth together!

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What to Expect From a Home Birth

So you’ve decided to have your baby in the comfort of your own home. What should you expect? As a CNM who has provided home birth services for nearly 6 years, I am going to provide you with an overview of the general expectations that await you in this experience.

We visit your home 

Your provider will come to your home at least once during the prenatal period to assess home readiness for birth. We like to see that our clients have acquired all of the supplies that were recommended, including the kit of supplies that was provided by our practice. Some examples of supplies provided by the practice are sterile gauze, sterile gloves, a peri bottle, chux pads, a fish net (for pooper scooper if having water birth), a waterproof mattress cover, and potentially other items depending on the practice. The items that you are responsible for include a drinking water safe water hose, adapter for the faucet, receiving blankets for the baby and towels of various sizes, snacks for the laboring person and birth team, adult diapers or maxi pads, a waterproof covering for the floor and extra padding for under the pool. We like to see that the intended birth space is clean and clutter-free and in an intimate space where the birthing couple can get privacy if desired. It should be in close proximity to the bed and bathroom.

What happens when you go into labor? 

Once you have decided that you are in labor you will be in contact with your midwife and doula. We like our clients to set up a group text with their partner, doula, midwife and assistant so communication is transparent for all involved. This way the laboring couple are not asked the same questions by different people and everyone knows what’s going on. Typically the doula will arrive first, and if the laboring person desires a cervical check to see where things are at, the midwife or assistant will come to do a labor check. We will assess her contractions, her coping, when she last ate/drank/used the bathroom. We listen to fetal heart tones, take vitals and get an overall feel for what’s going on – including the emotional environment. 

Sometimes we have to reassure the partner more than the laboring person of the normalcy of the situation. If the cervical exam isn’t 4-6cm and the labor doesn’t seem to be progressing quickly, the midwife will leave and the doula may stay to help the couple perform some Spinning Babies circuits. Usually the doula will help to set up the tub when it’s time and let the couple know when it’s time to call the midwife back. At any point, if the couple wants the midwife to come, we will come and assess the situation.

Active Labor 

Once the laboring person is clearly in active labor, the midwife or assistant will stay and perform checks on the baby’s heartbeat and mother’s vitals on a schedule at least every half hour. We listen for a period of time through and after the contraction to get a feel for the response of the baby to the contractions. We are watching for anything outside of the normal range as well as for specific things like maternal bleeding, fever, or lack of coping. We have many tools we can employ – depending on the midwife and her range of experience. 

Our Toolbox 

We use herbs, homeopathic remedies, essential oils, posture changes, and of course, hydrotherapy. We make sure she stays well hydrated, well nourished, and well rested – these three elements are crucial to avoid exhaustion which is a laboring person’s enemy. Sometimes we use alcohol to aid relaxation and sleep if mom becomes exhausted and her labor is stalling out. Once she gets rest she is much more capable of continuing and usually the labor will pick up on its own. We have found that labor has its own waxing and waning rhythms much like each individual contraction and it works much better to flow with it rather than trying to force it to conform to some ideal pattern.

A note on hospital transferring 

If at any point along the way the laboring person changes her mind about being at home, for any reason, we will shift gears and transfer to the hospital setting. Of course we first assess if she is in transition as many people have doubts about their ability to birth in the crucial moments just before the baby makes his final descent. However, if we determine that she is no longer comfortable at home we will get her quickly into the car and to the hospital of her choice. We call ahead to give report and accompany her to the hospital.* Once there, we would stay until her care is fully transferred to her new care provider or until the baby comes if financial arrangements have been made.

Staying home 

Most people are happy to stay home as this has been something they have prepared for physically, emotionally, and spiritually, sometimes for years. Most also birth in the tub if they have rented one and are comfortable in it. 

Whether in the water or on land, baby comes out as slowly and gently as possible with lots of encouragement and coaching from the team. We have found that the slower the expulsion of the head and body, the less trauma to the mother’s vagina, labia, and perineum. Contrary to what we hear from our clients who transfer to us, we are well equipped to sew almost any tear that happens during birth. We carry Lidocaine for numbing and sutures for sewing.

“Self Starters” 

Most babies are what I like to refer to as ‘self starters’. They will spit or cough and utter a birth cry and then they are breathing. Most of them do not cry as their birth has been so gentle they have no reason to cry. We know when to employ helpful measures such as postural drainage, stimulation, rescue breaths, and suctioning and are fully equipped to perform a full on cardiac resuscitation on the newborn if necessary. 

I have seen 1 instance out of 250 home births, and 0 instances out of the over 1600 hospital births that I have assisted in my career of babies needing full on cardiac resuscitation. BIRTH IS A NORMAL, PHYSIOLOGIC FUNCTION OF A WOMAN’S BODY THAT RARELY NEEDS HELP FROM OTHERS. As long as the body is healthy with no underlying medical problems, giving birth outside the hospital is actually safer for the mom and the baby.

Post Birth Procedure 

We keep a close eye on both mom and baby right after birth, assessing vital signs and mom’s bleeding every 15 minutes or more often as needed. We carry 3 different drugs to treat hemorrhage, and one of them, methergine, we have both pill and injectable form. We will not hesitate to call 911 if there is any emergency event that requires hospital intervention. We stay for 3-4 hours after the baby is born, assessing vital signs and the baby’s transition. 

Once the placenta is birthed, we ensure that mom has eaten, showered and urinated. We perform an Eldon card so we know the baby’s blood type and can make recommendations for jaundice prevention or give Rhogam to the mom as needed for Rh negative moms. We make sure the baby is breastfeeding well and the parents are comfortable in their new roles. 

Postpartum Visits 

After the birth we make sure our clients know that they can call us for any problem with mom or baby and that we will be coming back to the house between 24-48 hours after the birth. At that visit, we perform the CCHD**, jaundice, and weight checks. We give the Vitamin K injection if the parents have chosen to have it. We would give the Rhogam shot if Mom is Rh negative and baby is Rh positive. We assess breastfeeding again and refer to the pediatrician if there are any concerns with the baby. We assess moms bleeding and comfort and any issues with depression. We return again to the home at 1 week postpartum to reassess all of the above concerns for the mother. And we will schedule the final postpartum visit at 5-6 weeks in the office to talk about family planning, pap smear schedule and any other concerns that arise.

This article gives an overview of what to expect when planning a home birth. Stay tuned for more educational articles from Midwife360!

*There have been a few instances where we have not accompanied a client to the hospital. These were rare and individual circumstances and not the normal scenarios.

** CCHD = Critical Congenital Cardiac Defect A screening test performed on the baby between 24-72 hours after birth to rule out any critical congenital heart defects.

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What to Expect from a Hospital Birth

What happens when you choose to have your baby in the hospital? The specific answers to this question depend on whether you are sent there for induction or are arriving in labor. It also depends on your planned mode of birth – vaginal or cesarean. We will talk about planned vaginal birth in this article. 

Know what you’re signing for

If you arrive at the hospital for a planned induction, you will be registered for your stay, then sent to the L&D unit to check in. If they have an available room for you, you will be admitted to that room, given a hospital gown to change into and asked to leave a urine specimen in a cup. A nurse will then come in and hand you a clipboard with a stack of papers to sign. Most of them are consent forms and she has likely perfected a quick synopsis of each form. You aren’t encouraged or discouraged from reading them thoroughly, and she will answer your questions. However, this part of the intake usually goes pretty quickly – if you get my drift. The forms include consent to treat for vaginal or cesarean birth, consent for blood products, consent for Vitamin K, eye ointment, (maybe Hepatitis B vaccine, circumcision for boys, and a new eye exam that includes dilating the baby’s eye and holding it open with a metal cup). Your provider is really the one who should be giving you the risks and benefits of each intervention that you are signing for, but in reality that almost never happens.

Triage and cervical checks

If you are in active labor, unless the baby is imminently coming, you will be processed through the labor triage room where you will be given a gown and asked to leave a urine sample and get hooked up to the monitors to determine your labor pattern. Then one of the nurses (or your provider if available) will do a cervical check to see if you are at least 4 – 6 cm. You will stay depending on your contraction pattern and your cervical dilation. If your contractions are not frequent enough or lasting long enough or too long, and your dilation isn’t at least 6, you may get an ultrasound and then (if everything is good on the ultrasound) sent home. This may happen several times before you are finally admitted in labor. It is not a bad idea to stay home as long as you feel safe before going to the hospital to avoid being sent home multiple times.

When you arrive in labor, whether breathing through your contractions or feeling like pushing, the above- mentioned forms still have to be signed once you are admitted – by you, the ‘patient’. If the baby is coming and you absolutely can’t sign, they will give them to you after.  You get the idea.

So what happens when you’re admitted? 

From here on out, whether induction or active labor, everything is basically the same. After the forms, they will come in with all of the IV equipment to start your IV and draw blood. Everyone gets an IV unless you make prior arrangements with your provider, and most providers prefer you to have the IV. You are also then hooked up to the monitor with a toco that documents the timing of your contractions and an US that displays the baby’s heartbeat. 

Things you need to know

Now you are basically tied down with 2 monitor wires and an IV line which makes it difficult to get out of the bed or even change positions. Unfortunately, this goes against one of the main aspects of efficient labor – that of free movement. Even L&D nurses are getting hip to Spinning Babies – a system of postures and movement that help the baby shift into the best relationship to the mother’s pelvis for a smooth birth.

You will likely have a cervical check once you’re all settled in, and you may or may not be asked for your permission. If you are not already 6 cm or do not achieve 6 cm within a couple of hours, the provider will likely want to start pitocin to speed things up. Again, you may or may not be asked permission for this. 

Induction process 

If you are there to be induced, sometimes they start with a cervical ripening agent. In south Florida, most providers use Cervidil which is a tampon-like insert that stays in the vagina for 12 hours. Some still use Cytotec which is ¼ of a pill that is less predictable than Cervidil and can cause strong contractions that come too frequently. It has been associated with fetal intolerance and uterine rupture. You have a right to decline this. Two hours after the Cervidil is finished and taken out, they will want to start the Pitocin and break your water bag.

Here comes the epidural

Once things get rolling, if you choose to get an epidural, the anesthesiologist or Registered Nurse anesthetist will come in to evaluate you, give you the risks and benefits of the procedure and forms to sign. If you are a good candidate for the procedure, they will ask everyone to leave the room, prep and drape you and place the epidural catheter. Afterwards, they lay you flat in the bed for about 20 minutes and then you will be able to sit up and turn side to side with help, but will no longer be allowed out of the bed.

It is not impossible to do some of the Spinning Babies postures while tied to the bed or with an epidural, but it is much harder and requires a dedicated doula or very motivated nurse to accomplish them.

Once you become fully dilated you may be asked to start pushing, even if you don’t feel ready. Alternatively, if your baby is high and you don’t have a strong urge to push (or have an epidural and can’t feel that urge) you may be allowed to ‘labor down’. This refers to the process of allowing the labor contractions to bring the baby’s head down through the birth canal so that the pushing phase can be much shorter. 

Let’s talk pushing + birth

Pushing in the hospital is typically more like an athletic event with everyone yelling at you to “PUUUUSH” and instructing you to hold your breath while you push for a count of 10. You will likely have your knees up in the air with someone helping you hold your legs back. There is a definite air of adrenaline inspired action and rush to get the baby out at this point. Once the head is born, you will be told to push again to effect birth of the body and the baby may or may not be placed on your belly. Typically the cord is cut shortly thereafter and then the baby is taken to the warmer to be stimulated and dried and “eyes and thighs” (eye ointment and Vitamin K shot) are done. The baby will then be swaddled in a receiving blanket and handed to you. Some L&Ds are supporting skin to skin with the parents and may not wrap the baby up before giving him back to you. 

That is a typical hospital labor and delivery scenario. There may be individual providers that do things slightly differently, but for the most part this is the way we do it in America.

Evidence Based Birth

In general, you are not asked permission for any of the procedures and interventions that are performed in the hospital. The general idea being that you have presented yourself there so you must be ok with whatever they feel is appropriate. The truth is that most of what is done in the hospital is NOT evidence based and you would significantly benefit from educating yourself on the different possible interventions (ask your provider what the typical birth scenario looks like to her). A web resource such as Evidence Based Birth is invaluable for expecting parents whether they’ve had a baby in the hospital or are expecting their first.

Interventions 

Another trend that I’ve witnessed is the trove of interventions that are performed on the newborn – especially if she is a premie. Our hospitals and hospital providers are making A LOT of money off the backs of our most precious and fragile resource – the next generation of human beings, who cannot speak for themselves. Please educate yourselves as parents and protect your little ones from these unnecessary interventions!

*As a nurse midwife who worked in the hospital Labor and Delivery units from 2005 – 2014, both as a Labor and Delivery nurse and as a CNM, I have had a substantial amount of experience seeing thousands of women and families come through to experience the birth of their babies. Since 2008, I have worked in my own home birth practice where we have periodic exposure to the hospital L&Ds with the clients that we transfer in for one reason or another. I have not seen many substantial changes happening for the process of hospital birth, other than perhaps a nod to the delayed cord clamping movement with a reluctant delay of a minute or two or milking of the cord in some cesareans (which is now thought to contribute to brain bleeds and not such a good idea). The only real change that has occurred has been the elimination of the regular newborn nursery, and this seems to have resulted in a greater number of babies being sent to the NICU – negating the potential positive outcome of having less babies experiencing separation from their parents.