Categories
Birth

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.

Categories
Birth

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.

Categories
Birth

Top Ways to Prepare for a Positive Birth Experience

The top ways to prepare for a positive labor and birth experience begin long before the actual labor starts. At Midwife360, we talk about our “Recipe for Success” when we are discussing a client’s birth plans. 

The core of our recommendations include self-education through reading books and online resources (see the reading and web organization list at the end of this article) and commitment to a healthy lifestyle through clean eating and regular exercise. We strongly advise eliminating processed foods, dairy, and inorganic foods. Through clean eating and regular exercise, it is likely that there will be an absence of disease processes such as diabetes and high blood pressure which can make a pregnancy cross the line into a truly high-risk status. If the pregnancy can be maintained in the low-risk status range, then recommendations such as induction of labor are more easily declined. 

Our “Recipe for Success”

Our “Recipe for Success” also includes hiring a doula and taking a deep meditation for labor course such as Blissborn or Hypnobabies. Many times the doula will be the one who teaches these courses. Doulas are invaluable as educational resources and typically have a wealth of information regarding comfort measures and labor preparation activities. They will meet with the client usually two times prenatally and will be the first to show up at the labor. They help with labor support if things are not progressing, and will let you know when to call the midwife or leave for the hospital. Meditation or hypnosis is a tool that can be used to cope with the surges of labor. It helps to keep the mind occupied with positive thoughts to allow the body to perform the work of releasing the baby unimpeded.

Positioning of the Baby 

The most common reason that labor doesn’t progress is the positioning of the baby. We recommend becoming familiar with an online resource called “Spinning Babies” that teaches postures that can be used prenatally to help ensure proper positioning of the baby in relation to the mother’s bony pelvis. This will ease the baby’s passage and create a more efficient labor process. Your doula will most likely be familiar with this resource and have the ability to guide you through the postures as well as know when to employ them in labor.

Using a Birth Tub 

The final recommendation in our “Recipe for Success” is to use a birth tub for labor and birth. The benefits of hydrotherapy have been recognized by midwives and laboring women for years. Some people call it a ‘liquid epidural’ as the sense of relief is so great when entering a warm tub of water in active labor. Sitting on a yoga ball or stool in the shower can have some of the same sense of relief, but immersion in water is better and helps lift the belly to remove the heaviness caused by gravity. Also, releasing the baby into the water helps with vaginal and perineal stretching and reduces tearing.

Visiting a Chiropractor and Acupuncturist 

In addition to the “Recipe”, we strongly recommend developing relationships with a chiropractor and acupuncturist who are skilled in caring for pregnant people. Get regular massages and take yoga classes or do yoga at home. All of these adjunctive therapies contribute to a body that is well adjusted and free from muscular and energetic blockages that can inhibit the passage of the baby when it’s time for birth. 

Preparing for a positive labor and birth experience ideally starts before pregnancy. However, with a determined mindset and a willingness to do the work, preparation for a positive experience can easily be accomplished in the 40 weeks of pregnancy. Decide where you want to give birth and hire a care provider that you trust. Check out the resources listed below and prepare to have an amazing, informed, respectful labor and birth experience!

Categories
Birth Pregnancy

Natural Birth After C-Section

Can I have a vaginal birth if I already had a c section?

The short answer is, “YES! YOU CAN!” While the long answer requires a conversation about various risks – risks of a VBAC, or vaginal birth after cesarean, AND risks of repeat surgery. Unfortunately, it is the second set of risks that are routinely left out of the conversation when you speak with a hospital provider (OB or CNM) about it. And, also, unfortunately, these same providers often offer the VBAC and then find a reason at the end of the pregnancy that either induction of labor is ‘necessary’ (not the best plan for a successful VBAC) or a repeat surgery if the pregnancy goes beyond 39 or 40 weeks. 

Where can I have a successful VBAC?

This drives many women to seek an out-of-hospital birth provider for their planned VBAC, even though everyone agrees that the hospital is the best place due to the easy and quick access to emergency services. Since VBAC is prohibited in Birth Centers, this leaves home birth as the only option. And home birth is not for everyone. It is certainly not the best idea for someone whose main reason for choosing it is to avoid the hospital. It is always better to run towards something rather than running away from something. In other words, the choice to have a home birth should be driven by the desire to have your baby in the comfort and safety of your home, not by the fear of the hospital.

Successful home birth requires dedication and preparation

We have seen a situation like this where the client chose to have her baby with us because of her fear of having another c section and her inability to find a hospital provider who would support her decision to birth vaginally. She did not have a doula or take a birth preparation class. (These are 2 of Midwife360’s 3 keys to successful, efficient birthing. The 3rd is using the birth tub.) Consequently, she was unprepared and unsure when her labor did start, and did not request the midwife presence in a timely manner. She birthed on the toilet and her baby actually went into the toilet! They had the midwife on the phone throughout the process and she was able to guide them verbally (the part about the toilet came out later!) and everything turned out well. 

This is an example of how normal the process is for most people – even those who have had previous c sections – and for most babies. Babies are resilient and born to survive and know how to start breathing with little to no help in most cases.

Most predictions by OB providers are wrong

“Your baby is breech, and even if it turns, your pelvis is too small to push. There’s an 80% chance you’ll have to have a c section if you try, and then it would be an emergency surgery, which is more dangerous. So let’s just schedule the c section as this will be safer.”

I’ve heard this same speech from many clients over the years. This particular client told us this story of her first birth – the baby turned out to be 5#5oz. When she got pregnant the second time, they said she would have to have another surgery – it would be safer, they said. “But my mom had a c section and then pushed my brother out right after – he was over 10# – can’t I at least try?” “No”, they said, “it’s not safe”. There was no discussion of the risks of surgery, all focus is on the risks of trying a vaginal birth.

You can do it!

When this woman got pregnant a third time, she knew that she could birth her baby vaginally. She drove an hour away from her home to find a provider that believed in her and would support her. And although she did not take advantage of the 3 keys to success, (she used the birth tub only), she was so determined and dedicated that she was able to adequately prepare herself mentally for the big day. She was able to birth an 8#3oz baby vaginally in the birth tub with her sisters, husband, mother-in-law, and daughters all present and cheering her on! She pushed for over 2 hours, but barely tore and the baby came out quickly with no problems.

Our bodies and our babies are made for birth

When will OB doctors and other birth providers stop telling women what their bodies cannot do? Women are created with the social imperative to create life and deliver it to the outside world. Among many other things, we are very well designed birthing machines! If you didn’t know this already, then you do now!

Be empowered, be informed, stand up for yourself and your baby!