1. What is your induction rate/what percentage of your patients begin labor spontaneously?
Ordinarily I would induce labor for medical indications such as high blood pressure disorders, preeclampsia, and severe diabetes that is not well controlled. Ideally in a normal pregnancy we allow people to go into labor spontaneously; however, after 42 weeks gestation the risks of uteroplacental insufficiency start to rise. Approximately 10% to 15% patients beyond 42 weeks will have evidence of placental insufficiency.
Therefore if a patient goes beyond 42 weeks I would recommend an induction of labor. I cannot give you an exact percentage of the rate of induction.
2. Under what circumstances would you recommend an induction? What are the benefits and risks of an induced labor/delivery?
The benefits of an induction are to get the baby out if the intrauterine environment is not favorable. The risk of an induction is that the baby may not be fully mature or the cervix is not inducible. This could lead to cesarean section.
3. How far will you let me gestate before inducing? What if I do not want induction?
In a normal pregnancy with no problems I would not recommend an induction before 42 weeks. At 42 weeks I would recommend an induction. We cannot force anyone to do anything they do not want to do. We can only give recommendations.
4. What is your c-section rate? Under what conditions would you recommend a c-section? What are the benefits and risks of a cesarean birth?
The C-section rate for first time C-sections is 11%. Taking all patients which would include first time cesarean section as well as repeat cesarean section, the rate is approximately 22%. The most common reason for a cesarean section for the first time is failure to progress in labor. If a woman has adequate labor and does not show satisfactory progress over a period of several hours then cesarean section is considered. The benefits of a cesarean section are again to remove the baby from an environment that may be hostile. There is no particular benefit to the mother. The risk of the cesarean birth includes the risks of all major surgery, namely, blood loss, infection, anesthetic complications, and potential injury to adjacent organs such as the bowel and bladder.
5. How do you regard written birth plans and how closely do you follow them?
Birth plans are welcome. Most of the time the things that are listed on the birth planare things that we already do routinely. If there is some unusual request then we need to at least talk about it ahead of time. The vast majority of people request things that we do anyway.
6. Who do you allow present in the delivery room (vaginal or c-section)? Who do you not allow?
Normally in the delivery room there is myself, a circulating nurse and an assistant. There is also a nurse for the baby. In a vaginal delivery there can be as many people as you desire as long as there is enough room for us to do our work. If children are going to be present in a vaginal delivery there needs to be a responsible adult for them. The number of people that are in the delivery room for a normal delivery is really dictated on your wishes. For a C-section ordinarily the husband is allowed in. Occasionally, a
second person is allowed if it is okay with anesthesia.
7. Who would be your replacement if you were to have other women in labor at the same time or couldn't be there for my care for some reason?
If I was unable to be there for your delivery because I was tied up with other obligations there are 10 other partners that are available if needed.
8. When and how often will I see you before, during, and after birth once I am in labor? How often you would see me during the labor would depend on several factors?
The time that you are admitted to the hospital, the duration of labor, the presence or absence of any problems all determine the frequency of visits.
9. Will I be allowed to walk around or eat? Can I labor in different positions? Do they have birthing tubs, squat bars, birthing stools, or any other labor aids that I can utilize?
You certainly can walk around and eat when you are in labor. You can be in any position that you want to and in fact normally changing positions is encouraged. We do have a whirlpool tub and squatting bars and a giant ball that can be used in labor.
10. How long, and under what circumstances will you let me labor for before interventions are offered? If my labor stops, how long will you wait before you try to augment it?
There is no set time during your labor as to when interventions would be made. It determines what kind of problem is present. For example if there is evidence of fetal distress intervention is going be sooner compared to the labor that is not progressing very fast. If your labor stops usually we would give it at least a couple of hours before trying to stimulate labor. Part of that decision is dependent on how long the membranes have been ruptured.
11. Will I have an IV inserted upon check in or at any point in my labor? For what reason(s) would I need an IV?
An IV is not routinely placed during labor. However, if you require intravenous pain medication or an epidural an IV is necessary.
12. How often will cervical checks be performed during labor? What are the benefits and risks of cervical examinations?
The number of cervical checks is again variable depending on your progress. Ordinarily there is going to be at least one when you are admitted and at least another one to determine if you are completely dilated. Between those 2 times there could be anywhere from no additional checks to multiple checks. The benefits of cervical examination are to determine if you are making progress; the downside is it can be uncomfortable at times. In addition, multiple cervical examinations can raise the risk of infection if the membranes are ruptured.
13. What is your standard for using Pitocin? How often and why do you use it? What are the benefits and risks of labor augmentation using Pitocin?
Pitocin is used for augmentation of labor and also for induction of labor. The risk of augmenting labor is that the uterus may become overstimulated and contract too frequentiy. For this reason, the dose of Pitocin is carefully controlled by a pump and
labor is monitored.
14. What is your policy on rupturing/stripping membranes? For what reason would you want to perform AROM (artificial rupture of membranes)? What are the benefits and risks of AROM?
I do not routinely strip the membranes. Some people have requested this and I will do it if they desire. As to rupturing the membranes if you are in active labor and the membranes are still intact normally I would rupture the membranes since this seems to enhance labor. However, if you do not want this performed that is fine with me. If labor has stopped and the membranes are still intact rupture of the membranes frequently will return labor to norntal. The benefit of rupturing the membranes is to enhance labor and also determine if there is any meconium in the amniotic fluid. The risk of ruptured
membranes is a risk of infection if the membranes remain ruptured for a prolonged period of time, that is greater than 24 hours. There is also a risk of the umbilical cord coming down in front of the baby's head.
15. What happens if my water breaks and there is meconium present? During labor? After birth?
Meconium is a common occrurence in the amniotic fluid. If it is very thick meconium there is a risk of causing inflammation of the baby's lungs. If it is thin this risk is minimal. If there is very thick meconium the intensive care nursery staff is present to suction out the baby and clear the airway after birth. Beyond this nothing different is done.
16. Will I be able to get an epidural at any point in my labor? How will it affect my labor? What are the benefits and risks of epidural anesthesia?
Getting an epidural is at your discretion. We will not give you any medicationwithout your desire or consent. In my experience an epidural really does not have any effect on labor. The benefits of epidural anesthesia are pain relief that can last throughout the duration of labor. The risk of an epidural anesthetic is one of a spinal headache and possible drop in your blood pressure.
17. What other kinds of pain management do you offer? What are the benefits and risks of each?
The other pain management would be the use of IV analgesics. The benefit is more rapid onset of pain relief. The medication can cross over to the baby's bloodstream and if the baby were born shortly after the injection of the medication the baby may be
somewhat sleepy. The IV medication needs to be repeated, which can be both an advantage or a disadvantage.
18. Do you perform episiotomies? When and why? What are the benefits and risks of episiotomies?
Episiotomies are a judgment call. As the head distends the opening of the vagina you get a sense of whether or not there will be any tearing or not. If it appears that the tear will occur normally I would place local anesthetic in the perineum and make an
episiotomy. However, if people desire that the perineum tear rather than making an episiotomy that is fine with me. A tear will heal as well as an episiotomy; the only difference will be the episiotomy is a straight incision whereas a tear could be somewhat
irregular and jagged. The benefit of an episiotomy is to make a delivery possible and give more room if the baby is large. The risk of an episiotomy is that it could extend into the rectum.
19. What is your rate of forceps/vacuum extraction of the baby? Under what circumstances would these procedures be necessary? What are the benefits and risks of manual extraction of the baby?
I cannot tell you the rate of vacuum or forceps I use. I use primarily forceps rather than vacuum. The most common circumstance for the use of forceps is somebody that is pushing who runs out of energy and cannot make any progress. Ordinarily it is difficult to effectively push more than 1 to 2 hours. A second use of forceps would be if the baby does not tolerate the pushing phase of labor and it appears that it will be a long time before the mother will be able to deliver the baby normally. The benefit of forceps
delivery is to expedite delivery. The risk of forceps delivery is there's a potential harm to the infant because of incorrect placement of the forceps.
20. What sort of fetal monitoring (if any) is offered while I am in labor, and under what circumstances? How accurate/effective is each type of monitoring?
Normally we would monitor your labor along with fetal heart rate if you are lying in bed. We would use continuous external monitoring. If you want to get up and out of bed and walk around this is not a problem. Monitoring is accurate when it is normal. When it is abnormal it does not automatically mean that the baby is having problems, but it is not always easy to determine if the baby is truly having distress or whether the baby may be perfectly healthy. That is the limitation of monitoring.
21. What do you think causes fetal distress? Main cause?
The most common cause of fetal distress is uteroplacental insufficiency, meaning there is not an adequate blood flow from the placenta to the baby.
22. What are your recommendations for avoiding interventions and medications? What is your definition of natural birth?
I would recommend that a person be in good physical condition, attend prepared childbirth classes and practice the techniques of prepared childbirlh. If they want to avoid interventions also practicing healthy habits during pregnancy including healthy eating
and avoiding medications will lessen the chances of needing interventions or medications during labor. To me a natural birth would be a spontaneous delivery of the infant without the use of forceps, vacuum, or cesarean section.
23. How do you handle shoulder dystocia?
Shoulder dystocia necessitates trying to disengage the upper shoulder from the pubic bone and create enough room in the pelvis to deliver the baby. There is no one way to handle dystocia. Many times several maneuvers need to be done in order to effect delivery.
24. Are you comfortable with assisting vaginal breech births? What are your procedures for handling breech pregnancies?
We do do vaginal breech births. If a baby is breech position at term certain criteria should be met in order to minimize the risks. These include the baby being in a frank breech presentation, there being adequate room in the pelvis, the baby being in either a
chin tucked down position and the estimated fetal weight being less than 8 pounds. If a person has a breech presentation at term one option is to consider trying to turn the baby before labor. A second alternative would be considering the vaginal delivery if the above mentioned criteria is satisfied and the third alternative would be a cesarean section.
25. Are you comfortable with different pushing positions (i.e. squatting)?
I have no problems with people pushing in different positions and in fact this can be effective. However, when it comes to the actual delivery squatting poses some dangers to the infant since we cannot get adequate access to the infant.
26. Will you allow me or my husband to catch the baby if that is what we wish? If one of us is unable to catch the baby for any reason, will you let me birth the baby onto the bed?
Because of liability issues and the hospital policy, you or your husband cannot actually deliver the baby. You can certainly keep your hands on the baby while the baby is delivered but the physician in charge is the one that actually does the delivery. Ordinarily we would not want you to deliver onto the bed in an uncontrolled fashion.
27. How do you feel about delayed cord clamping/cutting? (Until the placenta has been delivered?)
I have no problems wlth delayed cord clamping and cutting as long as the baby is healthy. If the baby is not vigorous then it may need to be attended to and this would necessitate clamping the cord. I would not recommend waiting until the placenta actually
delivered before clamping the cord since there can be bleeding from the baby through the placenta at that point. However, when the cord stops pulsating it is reasonable to clamp the cord at that point.
28. What do you think of vernix rubbed in rather than washed/wiped off of baby?
There is no problem with rubbing in the vernix rather than washing off the baby.
29. What if I refuse to have the baby taken away from me after birth? How do you feel about doing any necessary newborn procedures while the baby is in my arms (or the father's arms)? Will any newborn procedures be done without first getting mine or the father's consent?
Ordinarily the baby can be with you as much as you desire after birth. They can do all the procedures required by law in your room. Those procedures that are required by law would be explained to you ahead of that time; other procedures may not be required, but may be advised. It would be up to you whether or not you wanted to have these done.
30. How long will you wait before forceful removal of the placenta? What methods do you use, and why?
There is no set time to wait until removal of the placenta. However, if 20 minutes have elapsed and there is no sign of placental separation then we do start thinking of at what point we would need to do a manual removal. This would be determined on the
amount of bleeding that is present and how the mother is actually doing. The methods to remove the placenta could be using my gloved hand to physically remove the placenta or sometimes removing it in the operative room with a D&C.
31. What are your methods for handling postpartum hemorrhage?
Postpartum hemorrhages are handled by manually rubbing the uterus. This stimulation of the uterus frequently will cause the uterus to contract down and slow any bleeding. Sometimes medications are given both as a shot or through the IV. Ultimately,
if none of these methods work there may need to be surgical procedures to handle the bleeding.
32. If my baby has a problem after birth, will you allow either me or the father of the baby to accompany him/her at all times?
If the baby has any problems after birth and has to be transferred to the neonatalintensive care unit either you or your husband certainly can accompany the baby.
33. If I decide that I do not want anybody including nurses, doctors, friends, and family in my birthing room at any time during labor, birth, or post partum, will my wishes be respected?
According to your question if you did not want anybody including nurses, doctors, friends, or family in the birthing room at any time during labor your wishes could not be respected. Then you would need to be at home. The purpose of the hospital is to provide care and in order to do that a nurse and doctor need to attend to you. However, if there are certain personality conflicts between the hospital personnel and yourself these can be substituted for other people and also the number of attendants can be minimized.
34. If I decide I do not want to be touched or bothered in any way, will my wishes be respected?
Taking your question literally it would not make sense in the hospital because there are certain procedures that need to be done in order to accomplish the goals of a safe delivery. These procedures can be minimized but cannot be totally eliminated if you are going to deliver in the hospital.
35. Under what circumstances would you perform a procedure or intervention in my labor or birth without first getting the consent of me or the father of the baby? Or do you always ask for consent before doing anything? (Interventions/procedures include, but are not limited to, cervical checks, administering anything into my IV, episiotomies, manually "helping" the birth in any way, c-sections, etc.)
The only circumstances in which a procedure or intervention would be performed while you are in labor is if this was extremely emergent to save your life or the baby's life. That is highly unusual and even under most emergency circumstances there is time
to discuss the procedure and its benefits and risks. So for the vast majority of the time consent is obtained before doing anything and that includes cervical checks, starting IVs, administering any medications.
36. Will I be allowed to leave the hospital at any time if I am not satisfied with the care I am receiving?
You can leave the hospital at any time if you are not satisfied with the care that you are receiving. Nobody can force you to stay in the hospital. However, when it comes to the infant this is not as certain. If in the judgment of health care providers that removing
the baby from the hospital would be a threat to its life hospital personnel have the authority to keep the baby in the hospital. This is extremely rare.
I appreciated that my OB was honest with me and answered all of my questions, but I felt that he left a lot of things out and danced around a few things. After reading these responses, I don't think I could have a baby in a hospital and feel totally safe and in control.
How do you think your OB or care provider would answer these questions? Would these answers make you want to birth at this hospital and/or with this care provider?
You can chose to do or not do this soon after it is born (within a week), within a few months after it is born, or only when necessary. However, it may be necessary for a birth certificate so check with your registry to cover your bases.
If CPS becomes an issue, often they just want the baby to see a pediatrician to ensure it is receiving "proper medical care." So it might be a good idea to get a newborn checkup just to have that under your belt.
Do this only if you feel it is necessary but listen to your body. You may be subjected to a number of procedures you may not want, and they may take your baby from you and admit him or her to the NICU.
This largely depends on the hospital, the staff, and perhaps if you were to have a tiny baby or not. Child Protective Services may or may not become involved if you refuse any treatment they want to do to your baby as this has occurred in other unassisted birth instances. Remember your rights.
At this point, you can also call your midwife to come check in on things.
If for some reason you need to cut the cord before it stops pulsating, you will want to tie off (many different things can be used, two common ones are shoelaces and dental ribbon) or clamp the cord in two places and cut between them. Otherwise you may choose to only clamp on baby's end, or not at all. Make sure you use a sharp, sterilized scissors to cut.
Some moms opt for a lotus birth where the placenta and cord remain intact until it is naturally removed from the baby.
You may choose to birth your placenta into a bathtub, bowl, or on a chux pad. It may come out 5 minutes or 5 hours after birth. Some women have even gone days before they delivered their placenta. As long as mother appears healthy and is not concerned, there is no need to worry. If you feel you need to help the placenta out, there are herbs you can take, uterine massage, and it is a good idea to nurse the baby as much as possible as this helps the placenta decend.
Do not pull on the cord or try to remove the placenta forcefully, as this will most likely cause you to hemorrhage. Once it is out, inspect it to ensure it is whole, and that there are no pieces missing. Even if it appears you may have some retained placenta, as long as you are not bleeding too much, this is no cause for concern, as the pieces will most likely come out on their own over the course of several days.
Seek medical help if you feel it is necessary. If you want to encapsulate or otherwise consume your placenta, either take care of it immediately or put it in the fridge to keep it fresh. You may also choose to freeze it and perhaps bury it later.
Ensure that baby is breathing (it might be a good idea to use APGAR scoring, it is up to you) and mother isn't losing too much blood.
After giving birth, you may find that you have torn. Take appropriate measures to resolve any problems properly, even if it means a trip to the hospital. Also keep in mind that every mother is different. One woman can lose a lot of blood and be fine, and another may lose less but need help. (Generally, if you have lost more than 2 cups of blood, this is cause for concern.) This is why it is important to take good care of yourself during pregnancy. Hemorrhage is definitely a concern for those women that are anemic (have low iron levels). It might be a good idea to get your hemoglobin checked during pregnancy. Normal range is 11-14. Tears can be glued together with liquid bandage or super glue, or you can choose to do nothing and hold your legs together in bed after the birth. It depends on the woman, and the tear.
Also, it is not necessary to wash the vernix off of the baby. Vernix is beneficial. It protects the skin and will soak in within a few hours after birth.
Remember that everything may not go as "planned," so be open to the possibility of anything happening, and listen to your body's (and your baby's) cues. One advantage to having a natural, unhindered birth is that it is much easier to go deep inside yourself, and you can feel everything that is going on.
You don't have anyone telling you what to do or scaring you, and you accept and realize that you are the expert on your body and your birth. Do whatever feels right to you. Eat, drink, moan, change positions, jog around the house if you feel like it. Push when you feel the urge to push. Here are a few natural birthing positions
You may opt for perineal support or massage. You can do this yourself or have someone else do it before the birth with olive oil (massage), and use hot wash cloths to loosen the tissues before and during birth. that may help you.
Generally women opt for no support during the birth, and if you are in a squatting position (so the baby's head is not pressing as hard against your perineum as it is in a supine position) and don't push too fast, you are unlikely to tear, even with a large baby.
As for catching the baby, this is up to the mother. Some want to do it themselves, some want (or need) their partners to do it. Otherwise, the baby does not need to be caught at all and can be born on whatever surface the mother chooses to birth on.
Birth kit supplies may be purchased from a variety of sites (some may be cheaper on certain sites than they are on others, and supplies vary, so look around), but a popular site to purchase from is this one: http://inhishands.com/shop/Birth-Supplies.
I personally recommend doing a search for a particular item you want one at a time, unless you plan to order many different things. (A lot of things can be found at a local department store or laying around your house.) You may also decide that you want monitoring (the baby's heart rate, your blood pressure, cervical checks, etc.), in which case you can use supplies that you have used for your UP (or purchase them via the www.unhinderedliving.com, or wherever you feel comfortable getting them from).
You might even decide that a birth kit is unnecessary. Alternatively, it might be a good idea to pack a hospital bag, in the unlikely event you need to transfer.
Visualize your birth and decide what you need. If you think you might run into (or fear) a certain complication, you may want to especially prepare for that one, even just for peace of mind. Most women find that they don't need hardly anything that they put in their birth kit but it is better to be prepared than need it and not have it on hand.
This is important as it documents what your wishes are, ensures your birthing attendess know what you want and is important in the event you need to transfer to the hospital.
In your birthing/back up plan:
It is helpful to have your birthing plan and medical documents all together prior to giving birth.
Include any prenatal care documentation
Outline your birthing desires so all people involved in your birth have a reference.
Determine ahead of time what warrants a trip to the hospital, and make sure your birth attendant(s) know what to look for. For instance, if you are turning white and passing out, you could be losing a lot of blood (internally or externally) and need immediate medical attention.
Also, it is a good idea to include all of your medical information with your birth plan should you need to be transfered to the hospital as this expodites the process.
It is a good idea to read about and learn how to handle complications (variations of normal) at home and possibly print out the "variations of normal" sheets (from the Unhindered Living website or from wherever you chose) to have with you when you are in labor and giving birth. Hope for the best and plan for the worst.
Be ready for any possibilities, so that you don't find yourself panicking when your baby begins to emerge in a breech position or his shoulders get stuck, or if the cord is wrapped around the neck (which is common). Most "complications" do not require medical assistance, especially for the possibility that you might feel you need to transfer to the hospital.
This will help you to tolerate your labor better, and you won't have to try and think of what feels good or helps you cope when you are in a lot of pain. You will already know a lot of positions to try, and you will soon figure out which ones feel best to you. Here are few suggestions of positions.
What helps you relax? Massage, music, deep breathing? You may find that labor is suddenly very intense and that you need to relax to relieve pain or use breathing techniques. It helps to know what best relaxes you. And remember that pain in labor is your body signaling you to do something: move, eat, change positions, rid yourself of fear or emotional upset, relax, etc. It can also signal that something is wrong.