Q: What criteria determine eligibility for a homebirth?
A: Pregnancy of a single baby, that is head down before labor, is ideal. Twin pregnancy, for example may confer a greater risk to mom and babies and most often, the Midwife will choose a hospital setting for this triad. If a pregnant woman develops certain conditions of pregnancy, the consultation of a physician may become necessary. This may eventually lead to a decision to move the pregnancy and/or labor to a hospital. Some of these conditions are: Preterm labor (PTL), pre-eclampsia, pregnancy induced hypertension (PIH), gestational diabetes of pregnancy (GDM) that requires insulin administration, (a lot of 3 letter words). The individual Midwife will be the one that makes the decision as to whether or not she feels that this pregnancy is proceeding normally enough to continue care at home. This decision is made constantly over the course of the pregnancy as evidenced by screenings performed regularly at prenatal visits and during labor. That being said, most labor transfer rates from homebirth tend to be around 10%. The same cannot be said for the average transfer rates from most birthing centers, which usually range from 15-30%.
Cara Muhlhahn, CNM
Cara Muhlhahn Midwifery, New York
Q: How is the chance of giving birth via Cesarean Section affected by a choice to give birth at home?
A: The Cesarean rate for homebirths in the New York area is approximately 4-6 percent. And most of us know the numbers expressed in the national average, that has been climbing as of late (anywhere from 25-40%, depending on the hospital).It is important to add, of note, the other important statistic when trying to validate the exceedingly low C/S rate; that of the low perinatal morbidity and mortality rates as well (the other important statistic that speaks for the safety of practice). The reason for these impressively low rates is directly related to the wisdom of the management practices that Midwives can employ in the home setting. Rarely do we need to induce a woman’s labor, but if we do, our methods are quite low risk (administration of castor oil, preceded by a cervical sweep a few days before, for example). We use intermittent, instead of continuous fetal monitoring, to assess the baby’s well being in labor. Every respectable study has shown that this method is the best for preventing Cesareans, while ascertaining the baby’s response to labor. Midwives at home use simple labor augmentation techniques, like taking a long walk or lunging during contractions that help advance a slow moving labor. There are times when a laboring woman’s labor will stop. We interpret this as a need for her body and mind to rest not as a pathological development in labor progression. In the case of rupture of membranes, we do no vaginal exams, hence no infection, which translates into no need to precipitate labor and administer unnecessary antibiotics. These are just a few of the reasons why our Cesarean Section rate is one tenth to a fifth of the national average. And I am only one Midwife expounding on my techniques. There are of course many others.
Cara Muhlhahn, CNM
Cara Muhlhahn Midwifery, New York
Q: Why is there so much fear of homebirth in the United States?
A: First of all, life is precious. No one wants to play with that and homebirth is viewed as an option that doesn’t take the risks surrounding labor and delivery seriously. Nothing could be further from the truth. In fact, I believe that the promulgators of this information have colluded with a collective truth to expect that technology alone will deliver (pun intended) the perfection that we all are wishing for and working towards. The results of a recent study (2005) that evaluated outcomes of planned homebirths with CPM’s (Certified Professional Midwives), is helping to disprove this long held tenet and is now being used by the National Health Service in England to recommend and encourage homebirth as a safe option.
Safety is afforded by many factors that need to be present when a woman is giving birth and access to technology is only one of these. The main factor that has been completely pushed to the side by the lure of technology is another T word: Trust. If a woman can trust her body, her caregivers and the process of labor, without becoming controlled by fear, labor will usually progress much smoother and quicker and in turn effect safety of the outcome. There have been studies that demonstrate a relationship between the release of catecholamines (stress hormones) and meconium in the amniotic fluid ( sometimes noted and given weight in terms of evaluating fetal distress). And there are countless stories of women whose labor slows down as soon as they get to the hospital. Experiences such as this give verity to the power of the psyche as it relates to the physiology of childbirth. The ACNM’s (American College of Nurse Midwives) guidelines for the practice of homebirth recommend that a hospital who will accept transfers from homebirth should be located within a 30 minute drive.
Cara Muhlhahn, CNM
Cara Muhlhahn Midwifery, New York
Q: Why do you think women who are culturally conditioned to give birth in hospitals are now considering other options for childbearing including homebirth?
A: I believe that the institutionalization of childbirth has chipped away at the humanity that is required during one of the most important experiences in our lives and has replaced faith in our abilities as women to give birth, with a technological solution and even rescue from this indomitable physical and psychological experience.
Cara Muhlhahn, CNM
Cara Muhlhahn Midwifery, New York
Q: How Safe are VBAC’s? (Vaginal Birth After Cesarean)
A: The safety of VBACs is to me no where as controversial as the establishment would want women to believe. The data has been out there for some time that the risk of ruptured uterus in a woman with one, possibly two, previous low transverse c/sections is 0.5-1%. Not usually catastrophic and usually shows some early signs that a good practitioner can use to intervene. Often a change in the fetal heart pattern. Only rarely does a rupture occur that leads to fetal compromise. And in many cases when this happens even in hospitals the baby will be damaged before an emergency c/section can be performed. It is a shame that due to a guideline (not a standard of care edict) put forth by the American College of OB/Gyn (ACOG) where they changed one word, 'emergency help be "readily" to "immediately" available' that most hospital administrations upon advice from their risk management lawyers and upon fear from anesthesia departments have banned VBACs. When organizations that carry political and legal weight like ACOG put out "a guideline" it becomes a weapon for personal injury attorneys. I think they are just foolish if they believe their good intentions won't be used as fodder by trial lawyers. For more than 20 years, VBACs under safe criteria were recommended and standard of care. The decision should be made by the patient upon informed consent with her doctor. In most cases it is extremely safe and preferred over a repeat c/section. In Santa Barbara and Ventura counties in California ( my area ) there is not one hospital still allowing women this choice. They have to drive up to 70 miles to find a hospital willing to accommodate this option which essentially means we are back to once a c/section always a c/section. So unfair and unscientific. Even women who have had successful VBACs already are not being allowed this choice in subsequent pregnancies. Once the economics are against it you can pretty much say goodbye. Bottom line is that selected VBACs are very safe, just becoming unavailable.
Stuart J. Fischbein, MD FACOG
Co-Author, Fearless Pregnancy, Wisdom and Reassurance from a Doctor, a Midwife and a Mom
Q: I am an American living in a small village in France. The only option is hospital birth but the hospital requires IVs, epidurals, etc. My mother-in-law delivered six of her children at home unassisted with her husband and has offered to attend the birth of my baby at home. I don't like hospitals but am worried about something going wrong... I have been warned of hemmoraging etc. but I really want to be HOME! Any suggestions? The hospital is 20 minutess away.
A: Actually, I'll bet that you could find a homebirth Midwife in France and I would probably recommend that you do that as a compromise between unnecessary intervention in the hospital and complete lack of medical surveillance at home. Things could work out okay, but if they don't, I'm sure you will regret not having trained help available. Of course, if you can't find that option, another one might be to have a trained doula stay with you in early labor at home so that by the time you get to the hospital for delivery, you are already quite dilated. That scenario usually brings hospital intervention down. Good Luck!
Cara Muhlhahn, CNM
Cara Muhlhahn Midwifery, New York
Q: As a rape survivor that has gone through the healing process, I am still not comfortable with the idea of men being in the delivery room during my most volunerable state, is homebirthing a viable alternative to avoid that uncomfortable situation of having male doctors and staff present?
A: The psychological consequences of your unfortunate history may impact on your birth in many ways. Many women who are survivors need a bit of extra support in the pushing stage. They need as few vaginal exams as possible, and sometimes they may even be helped by an epidural. There is no way of knowing exactly how you will respond to labor. It is best to do some psychological work before labor with a competent professional. I would follow your intuition in terms of deciding who you feel safe with. That being said, I do know that if all is well in your pregnancy and you are a good candidate for a homebirth, you will be given the appropriate amount of time that you need to dilate and push a baby out in that setting. Giving birth is a physical as well as psychological process. There are also many very sensitive female providers, Midwives and Ob-gyns in hospitals that can enforce a policy of no vag exams and will try to enforce no men in the room, unless they don't have a choice. You may not be able to ensure this because there are alot of hospital employees and they can't all be female. I have had quite a few women who are survivors at home and if they start out, as it sounds like you are, having done some healing work, they will do much better, no matter where they are. So great good luck.
Cara Muhlhahn, CNM
Cara Muhlhahn Midwifery, New York
Q: I am currently reading the book Midwives, and I was wondering if you have read this book and what are your opinions on the book as a midwife.
A: I read the book and thought it was well-written if you like an exciting courtroom drama. I wouldn't recommend it to pregnant women, as they are already inundated with too many horrible birth stories. The story of the kitchen table cesarean was something that made a lot of midwives I know (and me, too) feel used even abused. We already have the job of resurrecting a profession that was beaten out of existence by the medical profession early in the 20th century. We've been swimming against the tide all the way, with organized medicine working against us and sometimes against those physicians who believe in us and think that women need midwives. Nothing like that kitchen table cesarean has ever happened in Vermont or anywhere else in this country. People need to know that.
Ina May Gaskin, MA, CPM
InaMay.com
Q: I am trying to get pregnant and it hasn't worked for me yet. Any advice?
A: It seems like we women spend the early part of our lives trying not to get pregnant and then when we want to, it doesn't happen as easily as we thought it would!
Before buying infertility kits, try these quick tips:
1. Pay attention to your mucus/discharge. It changes over the course of your cycle. When it is clear and stringy/elastic - you could place some between two fingers and it would stretch - that is a sign that you are around the time of ovulation. When it is thick and white, the timing is off.
2. Keep track of your periods. Mark on a calendar the day and length of each period. Your ovulation occurs 14 days before your period. Most women do not have a period that occurs every 28 days. It is more common to have a range, which can make knowing when you ovulate challenging. Charting your menstruation will give you a better idea. It will also give you a clear idea of when you have missed a period, or if you are having a "normal" period versus something called implantation bleeding. (Implantation bleeding occurs when the placenta attaches to the uterus and causes some bleeding that can be mistaken for a period. We initially determine your due date based on your period which can then be in error.)
3. Reduce your stress. Easier said than done. However, when women are tense and frustrated by not being able to get pregnant or other aspects in life, the body works against you. Take time to practice making a baby - pretend that for the next XX months, you are only "practicing" and enjoying each other. Also, take a look at what stresses you have in your life. Are they worth the negative energy that you give them?
4. Ovulation kits recommend taking your temperature before getting out of bed each morning. I see this as a tedious task that adds stress. Skip this for now.
5. When you are ovulating, have sex at most every other day. Otherwise, sperm count is greatly reduced.
6. If you are considering seeing a fertility specialist, the first thing that should be done is to have his sperm checked. Make sure your partner is aware of this.
7. Treat yourself like you are already pregnant. Take folic acid and prenatal vitamins. Cut down on bad habits (smoking, caffeine intake, etc) and eat well and exercise. Don't underestimate the importance of sleep.
Not knowing your age, your pregnancy history, your partner's "fathering" history, or how long you have been trying limits the advice I can give. Be kind to yourself. Have patience. Love your partner.
Good luck!
Hilary Prager, CNM, MPH
Women's Health Liaison and Public Relations Chair for NYC Chapter of ACNM
www.nycmidwives.org
Q: I live in Illinois and have always been interested in becoming a midwife. I am 35, I have 4 children, and I am just fascinated with birth. After having all my kids naturally I feel I have a lot to offer. Can you please give me some information on how to get this process started?
A: There are two pathways to become a licensed Midwife in the U.S. The more traditional route with licensure in all 50 states is through the American College of Nurse Midwves (ACNM).
The other route is through the Midwives Alliance of North America (MANA) with licensure in 22 states but growing.
The websites will give you info on midwives near you. Consult with local midwives about the state regulations regarding Midwifery in your state. There are distance learning programs, university based programs, the whole gamut.
Richard Jennings
Director of Midwifery
Bellevue Birth Center, New York
Q: I am planning to get pregnant in about a year. I want to have the most healthy body possible. What kind of multivitamin/supplements should I take now to prepare my body now for pregnancy?
A: There are different theories about the best diet, best supplements, best exercise routine - and plenty of self-help books to back each theory. The most important thing to do is to look at your lifestyle. Consider your eating, drinking, and exercise habits. Start living that healthy lifestyle now so that when you do become pregnant, it's not a shock. Of course, if you smoke, quitting should be your top priority. It's also important to reduce caffeine and alcohol intake.
Being in shape is important before becoming pregnant so that the pregnancy itself is easier on your body - less aches and pains, possibly, and so that you recover quicker. Choose what works best for you, be it pilates, yoga, sweating to the oldies..Calculate your BMI and be honest about a healthy body for you. Don't be unrealistic. Too thin is not healthy.
As for specific supplements, you'll get a different answer for every person you ask. I am of the belief that you should try to incorporate the nutrients you need into your food rather than a supplement. Studies show again and again that we do best when we eat a balanced, healthy diet and that taking supplements just isn't the same. Keep a food journal to determine whether you are receiving the needed nutrients and change your diet accordingly. If you still need help, go for the supplement.
As for what is required during pregnancy and so what you are looking for now, here is one site to peruse. Try to match the goals, without supplementation. Please read information from other sites as well, but be wary of the source of information.
Finally, a word on folic acid. The impact of folic acid in reducing the incidence of neural tube defects is seen within the first eight weeks of pregnancy. Many women do not know they are even pregnant before that window closes. It is recommended that a woman receives 400 micrograms a day. This can easily be achieved in diet. Start now.
It is wonderful that you are looking ahead like this. Try to reduce the amount of pesticides you ingest by washing your food well or buying organic when possible. Do not drive yourself crazy. Remember that fads come and go, what doctors recommend for one generation becomes exactly what you shouldn't do for the next. Be sensible and take all this - and any - advice with a grain of salt!
Take care,
Hilary Prager, CNM, MPH
Women's Health Liaison and Public Relations Chair for NYC Chapter of ACNM
www.nycmidwives.org
Q: Would having had a previous C- Section prevent a woman from having a home birth?
A: Many homebirth Midwives will do VBAC's at home. The medical establishment will most likely oppose this practice. The state that you live in may have something to do with the regulations, but I believe you should be able to find a homebirth Midwife who can provide what you are looking for. I know you could in New York.
Sincerely,
Cara Muhlhahn, CNM
Cara Muhlhahn Midwifery, New York
Q: My daugher is 39 and will be giving birth just short of her 40th birthday for the 1st time. She is strongly leaning toward midwifry at home. My conder is her age, her level of pain tolerance. She was sick as a dog 24 hrs a day for more than the first 3 months. Even now at 19 weeks she is still throwing up and exhausted. What wold be your recommendation and your advice to calm and reassure me?
A: I, myself, had my first (and only) son at 38 years old. If she is in good health, then pregnancy shouldn't put her at risk. The morning sickness is more just plain difficult for the mom, but is not related to a higher risk of problems with the birth. Sometimes pregnant women experience more nausea if they are carrying a girl, but, alas.... all of our theories are quite imperfect, so don't get too attached to my speculation.
Cara Muhlhahn, CNM
Cara Muhlhahn Midwifery, New York
Q: I have had two c-sections but really want a natural birth. Is there hope for me?
A: Of course there is hope for you. It will take commitment, research and to find a supportive and skilled practitioner. You will probably need to find out (if possible) from your medical records what kind of uterine incision you had. A classical incision ( vertical ) is not considered safe for a VBAC but 90% of incisions since the 70's have been transverse which poses much less risks for a rupture or separation.
During labor at the hospital you will probably be required to be monitored and induction or augmentation medications are not recommended. Hiring a doula and staying home until active labor is a safe solution.
As you interview practitioners, either doctors or midwives they will probably want to know the reason for the previous cesareans. I recommend you read Henci Goer's book, Obstetric Myths versus Research Realities before you start your interview process. She has an entire chapter on VBAC and there are wonderful data on VBAC with more than one cesarean.
On a personal note: I am the mother of 4 children. The first 2 born by cesarean followed by 2 beautiful and safe VBAC's. Searching into your options is already a huge step in taking charge of your birth. No matter what you decide, this process will be rewarding and empowering.
All the Best,
Ana Paula Markel, ICCE , CD (DONA), Certified Childbirth Educator, Certified Doula
APMarkel.com
Q: I have been diagnosed with a bicornuate uterus / possible didelphyc uterus. I am trying to conceive and have been told that I will need a c-section if I do become pregnant. I firmly believe in vaginal childbirth. Is there a possibility that I will be able to have a vaginal birth, even if my baby is breech? Will I be able to find a doctor that is willing to at least let me try before defaulting to a c-section?
A: The answer is first you must get to full term and the the delivery becomes the next issue. If the baby is head down a vaginal will be the method of choice. Breech is a more complcated question. If your baby is breech at 34 weeks I would start accupunture and speak to your midwife or doctor about version. If still breech most people would suggest a c-section.
Dr. Jacques Mortiz
St. Luke's-Roosevelt Hospital Center, New York
Q: I am a diabetic and I was wondering if you would recommend a homebirth or even a Midwife in a hospital?
A: It is not clear from your question what type of diabetes you have....is it gestational diabetes or did you have diabetes before becoming pregnant? Do you need insulin to treat your diabetes. There are CNMs who do births at home for women who have gestational diabetes if their blood sugars are well controlled and they do not require insulin. In my hospital based practice, I care for women with gestational diabetes; I comanage their care with my physician colleague and I am their provider at the time of their delivery if their blood sugars are well controlled. I think if you had diabetes prior to the pregnancy and require insulin your care would likely need to be in a CNM/physician collaboration. I encourage you to contact nurse-midwives in your area as they would be your best resource to find out what your local options are.
Deborah Frank, CNM
MidwivesWithWomen.com
Q: I am one of the many who experienced a c-section against my expressed wishes. I also had a midwife. I was told after 12 hours of labor (pit and epidural) that I had a narrow pelvis. How likely is it that this is true? I'm athletic, 5'7", over 160 pounds. My blood boils when I think of what was taken from me, presumably when it didn't have to be.
A: I think it is rarely one thing... e.g. a narrow pelvis....that is the only reason a woman might need a Cesarean. Whether a woman needs a Cesarean is determined by a variety of factors including the size of the baby, the shape of the mothers pelvis, the strength of the uterus and the health of her baby. In your situation it sounds as though you did not feel like a participant in the decision to have a Cesarean birth. I believe when women do not have a trusting relationship with their provider and do not feel like they feel they were a participant in the decision affecting them, they can feel very resentful. I would hope that if you have another baby, you will find a careprovider who can assist you to have a different experience.
Deborah Frank, CNM
MidwivesWithWomen.com
Q: I am a mother of a beautiful 7 month old girl. She born naturally, no thanks to the doctor who told me it was an emergency and I need an epidural. (He was kicked out by my hubby). We want to try for another when she turns one, but I cannot find any midwives in the Springfield, MO area.. What is the best way to search for them?
A: Unfortunately, Missouri is a prime example of what happens to midwifery in states where Certified Professional Midwives, who specialize in out-of-hospital birth, are illegal and where Certified Nurse Midwives, who practice primarily in hospitals, are bound by mandatory collaborative or supervisory contracts with physicians.
Because Missouri has such restrictive laws, CPMs do not practice openly or advertise their services, and few CNMs work under contracts that permit them to deliver babies at home and may be bound by other contractual restrictions that limit the care they can provide in the hospital as well. So women like yourself who are seeking midwifery care are left with few resources.
Your best bet is to start asking around. Doulas and childbirth educators in your area may know of local midwives providing home or hospital-based care. You can also join The Friends of Missouri Midwives at: www.friendsofmomidwives.org.
If you click on their About page, it will provide a link for you to join their yahoo list, which may also be a helpful resource. Their website also provides information about how to support legislative reform efforts to legalize CPMs, which will expand the available birth options for pregnant women in Missouri.
I hope this helps, and best of luck to you in your search.
Katie Prown, PhD, Campaign Manager
The Big Push for Midwives 2008
www.thebigpushformidwives.org
Q: When my son was born, I desired a natual delivery. I labored on my own at home for about 8 hrs, then went to the hospital where they put him on an internal fetal monitor and did not allow me to move around at all. His heart rate would drop during each contraction and it appeared to get worse over time. They finally decided to do a c-section and found that the cord was wrapped around his neck three times. He was fine though. It sounded like I could not have had him vaginally. What do you think based on the above infomration? I was would like to do an alternative VBAC with my 2nd child but I am little scared to put the baby at risk should something similar occur.
A: The first part of your question asks if it would have been possible to deliver vaginally. That is impossible for me to say without having been there. When the cord is wrapped around the baby's neck (called a "nuchal cord") we often see dips in the fetal heart rate. The important thing is that overall, we find the heart rate reassuring. This means that even though there may be some dips, the heart rate pattern still has other components that indicate the baby is doing well. In that case, yes, a vaginal delivery is possible. When those signs are not there, it is necessary to deliver surgically. This is a very real reason to do a cesarean section. "Fetal distress" as a reason for a cesarean delivery may be overused, but it is impossible for me to say if this was your case. However, good for you for laboring at home for so long! You should be very proud of yourself for each of those contractions you got through.
Absolutely consider having a VBAC. The success rates of having a vaginal birth depend on various things, one being the reason you had your first cesarean. In your case, it sounds like the reason was due to the baby and not your body. "Fetal distress" versus "arrest of dilitation" (stopped dilating). This bodes well for you in the future. The chances of having another problem with a nuchal cord should not weigh into your decision. It is healthier, under normal circumstances, for a woman to begin labor even if the end result is another cesarean. There are physiological processes that occur with labor that benefit both mom and baby.
Make sure that you have a copy of your surgical report. It is important for your next health care provider to see the type of incision that was made. You can have a trial of labor with a horizontal incision but not a vertical, or classical, one. The Classical incision is associated with a higher rate of uterine rupture. Chances are extremely high that you had a horizontal incision but it is helpful for the health care provider to know that.
Also, when it is time for baby #2, please ask your health care provider what his/her rates of VBAC are, as well as his/her philosophy. Look into the hospital rate as well. Do your research.
Having a cesarean birth can be disappointing if you wanted a natural birth. Although thankful for the health of your baby, you may be left with feelings of anger, frustration, doubt... It is helpful to talk through this as much as possible and to know that you are not alone. Look into your local La Leche League for a support group or search for an online group.
Take care,
Hilary Prager, CNM, MPH
Women's Health Liaison and Public Relations Chair for NYC Chapter of ACNM
www.nycmidwives.org
Q: My husband and I would like to start a family soon but I have asthma and heart palpitations and am worried this will make me high-risk. I would prefer to have a natural, at home birth with a midwife. Unfortunately we live in Nebraska where this is illegal and out of state birthing would be difficult for us to orchestrate. I am afraid a Cesarean Section will be forced on me (as it has been for nearly every woman I know) and was wondering what are some steps we can take to ensure that we have the birthing experience that we want?
A: Even though it seems that you are up against a lot, I think there is no reason why you could not try to put all the pieces in place to have a natural childbirth at home. First is your medical history. I have worked with many women with asthma and we have never had any problems with the labor. These women will consult with their primary doctor who deals with their respiratory issues and adjust their inhaler meds, if necessary, throughout the pregnancy. Some women actually breathe easier with pregnancy while others have a harder time. You should always have your inhaler available.
As for the heart palpitations, again, if you have a cardiologist that you are working with, I would consult with him/her regarding the risks of a natural birth. Seeing that pregnancy can sometimes cause this condition, I don't think it is a problem ultimately for the birth. Now, the politics in your area are another story. Homebirth itself is probably not illegal. Non-nurse midwives in Nebraska are not legally regulated but not prohibited either. Therefore, there may be midwives in your state that are practicing. There may also be some CNMs in NE that do homebirths. You can contact the Midwives Alliance of North America at membership@mana.org, tell them your state and they will forward you the names of midwives in your area.
If you have a healthy pregnancy, there is no reason why you can not have a normal, natural childbirth. A homebirth will help greatly because you will be with a midwife who believes in natural childbirth. But, ultimately, if you can't find a midwife in your area, be sure to bring a doula/advocate with you in the hospital. You CAN do it!!
Lots of luck with your birth,
Maria Iorillo, Licensed CPM
www.wisewomanchildbirth.com
Q: I am in my third trimester and my goal is to have a natural childbirth. During a recent conversation with my doctor she told me that she routinely adminsters Pitocin to help with the delivery of the afterbirth. Is this a common medical practice? Also, what are the benefits and risks of this procedures? Lastly, is it necessary?
A: Giving Pitocin before the placenta is born is an out-dated protocol that seems to be still alive in your area. Doctors used to routinely give pitocin "with the anterior shoulder" (meaning that a shot of pitocin was given as the baby's top shoulder was being born) in order to expedite the placental delivery and attempt to ensure minimal bleeding. In my area, which I believe is what is more common nowadays, doctors will give pitocin routinely after the placenta is born. Again this is to ensure minimal bleeding. In my homebirth practice, we only give pitocin postpartum when it is actually needed, and this is rare. Hospital routines are created to deal with large numbers of women to protect the one that would have a problem by treating them all. This is obviously not individualized care. Since you are in your third trimester, if you would rather not have the pitocin and trust your body, I would create a birth plan that states that you would prefer not to have pitocin after the baby is born, unless, of course, there is concern that you are having excess bleeding. Many women in my area having birth plans do exactly that. The time to negotiate and talk with your doctor is now that you are not in labor. Then, bring copies of the plan with you and remind them of your desires when you get to the hospital. A doula or advocate will help in this regard also. Good luck with your birth, trust your baby and your body!!
Sincerely,
Maria Iorillo, Licensed CPM
www.wisewomanchildbirth.com
Q: Is there a general Midwife opinion on Amniocentesis? I am 36 and just had a Nuchal Translucency test which came back stating that my baby's chances for Downs Syndrome or other chromosomal abnormalities are a slim 1 in 2000, but the doctors are still recommending I have the Amniocentesis. Is this needed in your opinion?
A: A Fetal Nuchal Translucency test performed between 11-14 weeks can be a helpful screening tool in assessing your baby’s risk of having Down Syndrome and some other chromosomal abnormalities as well as major congenital heart problems. The big question is what do you do with that information? The data is not clear as to whether a normal Nuchal Translucency decreases the likelihood of chromosomal abnormality in high-risk women. Thus, women are not being discouraged from invasive testing such as Amniocentesis because of a normal first-trimester ultrasound study.
An Amniocentesis is a medical procedure in which a small amount of amniotic fluid, which contains fetal tissue, is extracted from the amnion or amniotic sac surrounding a developing fetus, and the DNA is examined for genetic abnormalities for a more definitive diagnosis. The question still remains, what do you do with that information?
Although the Amniocentesis procedure is routine, possible complications include infection and failure of the puncture site to heal correctly. More serious complications can result in miscarriage. Previous studies as far back as the 1970’s reveal the chance of a miscarriage related to amniocentesis was generally thought to be 1 in 200. A recent study has indicated this may actually be lower, perhaps 1 in 1,600. The statistics appear to have improved tremendously. Unless, you are that one that encountered the miscarriage.
All prenatal testing can provide useful information. But, what do you do with the information? If you have decided that you are going to have your baby,no matter what the test reveal. You must decide if it’s worth taking the risk to know if there is a problem before the baby is born.
Many women agree to have the least invasive testing performed such as the fetal nuchal translucency and the multiple-marker serum screening (performed at 15-20 weeks) combined with genetic counseling to review the individual woman’s risk factors to determine the need for an Amniocentesis. Once again, it is the woman’s decision, given all the information to determine if an Amniocentesis is the right test for her.
Catherine K. Tanksley, CNM, MSN
Q: I am 36 and have slightly high blood pressure, is having a midwife an option for me?
A: Having slightly high blood pressure does not exclude you from having a midwife, necessarily. It depends on the type of midwifery service and how "slight" the elevation is, as well as other risk factors. Have you always had high blood pressure? Do you have other children? Was your pressure an issue in other pregnancies? (I am not focusing on your age because as a sole "risk factor" it should not interfere with midwifery care.)
I assumed you meant for a pregnancy, but just in case you were referring to regular gyn-care, you may absolutely use a midwife for all your gynecological services. In fact, it would be beneficial to find a midwife now, whether pregnant or not, to begin that relationship. If your risk factors do preclude you from continuing care with her/him at some point, she can help advise you where to go.
I am sure you already know ways to try to keep your blood pressure down, but you can visit sites such as the Center for Disease Control and Prevention for some helpful tips.
Good luck,
Hilary Prager, CNM, MPH
Women's Health Liaison and Public Relations Chair for NYC Chapter of ACNM
www.nycmidwives.org
Q: I am 30 weeks pregnant with my first child. I have been under the care of an OB/GYN since I got pregnant. I want to have a homebirth, but I don't have a midwife yet. Is too late to start looking for a midwife?
A: Even at 30 weeks, it's definitely not too late to switch providers and opt for a homebirth. Many women don't start to think about their birthing options until the third trimester, when childbirth classes are typically taken and the birth becomes more "real" in the minds of women. We midwives are quite accustomed to relatively late transfers. Please let me know if you need help in finding a midwife in your area.
Best Wishes,
Carolyn Havens Niemann, CNM, MSN
Princeton Midwifery Care
www.delvalobgyn.com
Q: I have had two c-sections but really want a natural birth. Is there hope for me?
A: Of course there is hope for you. It will take commitment, research and to find a supportive and skilled practitioner. You will probably need to find out (if possible) from your medical records what kind of uterine incision you had. A classical incision ( vertical ) is not considered safe for a VBAC but 90% of incisions since the 70's have been transverse which poses much less risks for a rupture or separation.
During labor at the hospital you will probably be required to be monitored and induction or augmentation medications are not recommended. Hiring a doula and staying home until active labor is a safe solution.
As you interview practitioners, either doctors or midwives they will probably want to know the reason for the previous cesareans. I recommend you read Henci Goer's book, Obstetric Myths versus Research Realities before you start your interview process. She has an entire chapter on VBAC and there are wonderful data on VBAC with more than one cesarean.
On a personal note: I am the mother of 4 children. The first 2 born by cesarean followed by 2 beautiful and safe VBAC's. Searching into your options is already a huge step in taking charge of your birth. No matter what you decide, this process will be rewarding and empowering.
All the Best,
Ana Paula Markel, ICCE , CD (DONA), Certified Childbirth Educator, Certified Doula
APMarkel.com
Q: I recently had an unmedicated birth at a birth center attended by certified nurse midwives. (My second child, and second ummedicated, natural birth.) My baby was born with a "nuchal hand." No one knew this was coming until the baby's head finally emerged with a little hand up against the side, but I had an unexpedtedly difficult and lengthy transition period (about two and a half hours). It was tough, but still a good birth, to my mind, and I am glad it happened without interventions, other than breaking my water at 9 centimeters to attempt to move the labor forward. I was wondering if a nuchal hand presents any special risks to the baby, and how the "stalled" transition period would most likely have been handled had I given birth in a hospital setting without midwives?
A: Congratulations on your birth. A nuchal hand is very, very common. I'd say by my guestimation that I see it in about one out of every five or six deliveries, so your baby was in good company! It presents no extra risks for the baby. As for a stalled transition, that would almost certainly have been treated with pitocin in a hospital. Doctors (and many midwives) are eager to get the proverbial show on the road, and rarely have the patience or good sense that your midwives did. It sounds as if you chose wisely in your caregivers. I hope all is going smoothly in the transition from one child to two.
Best Wishes,
Carolyn Havens Niemann, CNM, MSN
Princeton Midwifery Care
www.delvalobgyn.com
Q: I am 40 weeks pregnant and will be delivering in a birth center with a midwife. The past 9 months have been a life changing, educational journey for me and now I am extremely interested in birth activism. I would like to share my knowledge with women everywhere but I have noticed a great deal of women are defensive about these issues. Many women I talk with feel the need to defend their OBs. What is a good way to approach women about their choices surrounding birth without having them become defensive? Thanks!
A: You've certainly hit on something. When U.S. women learn they are pregnant, the vast majority call their OB/GYN for prenatal and birth care--it's a cultural reflex. For many women, this is the person who took care of their first pap smear, their first Pill prescription, their first yeast infection. There's a doctor-patient bond, made even stronger by the intimate nature of reproductive healthcare. So before activists and educators can even begin a conversation about birth options like midwifery care, they first need to recognize and respect this relationship.
At the same time however, pregnant women need to know--and childbirth educators and activists need to convey--that there are pressures and constraints on OBs and hospitals that often prevent them from providing optimal maternity care. For instance, most doctors I've talked to readily admit that continuous electronic fetal monitoring during labor is unnecessary and unhelpful, yet they have no choice but to require it of their patients for liability reasons. Optimal maternity care requires that a provider support the physiological birth process and intervene only when necessary. But if you are a typical maternity care patient, intervention will likely be routine rather than as-needed, and skilled labor support may not even factor in. I think one key to educating women is talking about the system as a whole, recognizing that there are forces stronger than any individual OB, no matter how progressive they are. Women can still maintain that doctor-patient relationship but may ultimately decide that they will get better labor support outside the traditional maternity care system. Choosing one doesn't require giving up the other.
Jennifer Block
Author, Pushed: The Painful Truth About Childbirth and Modern Maternity Care
www.pushedbirth.com
Q: I am currently pregnant with our fifth child, the others, ages 5 and under. I had the first naturally in the hospital, and the next 2 were born at home. The third started out at home, but the baby flipped from head down during labor (not engaged) to a footling breech. My midwife was nervous as his bottom wasn't applied, so off to the hospital I went! The team knocked me out and because he was so stuck from being so far out, they had to do an upside down T-cut. I know I am now stuck with cesareans, but is there somethings that I can do to make even my c-section as natural as possible?
A: I'm guessing that the transfer to the hospital after your attempted home birth and the fact that you were knocked out for the cesarean made for an especially stressful birth of your fourth. Most women feel nauseous after a general anesthesia, so that plus the post- surgery pain aren't very much fun.
A planned cesarean doesn't usually require a general anesthesia. Have you discussed what kind of anesthesia your doctor will want to use? Probably, it would be either a spinal or an epidural, and these kinds don't cause nausea in most women. For most women I've been with who've had c-sections, the thing that matters most to them is that they get to have the baby with them right away, once the baby is breathing well. Relating with your baby as much as possible helps promotes the optimal hormone levels in both you and the baby.
You'll need plenty of help at home with your young family, either from a trusted family member (or members) or a postpartum doula. Good wishes for the best birth possible!
Ina May Gaskin, MA, CPM
InaMay.com
Q: My husband and I are trying to get pregnant. I have a history of disc problems in my back (2 surgeries) and have some paralysis in one leg as a result. Is home birth an option for me?
A: I would need to know more information about your specific history and severity of the problems and paralysis, but the situation you describe would not necessarily risk you out of a home birth. Your pregnancy and labor itself could be perfectly healthy and be completely appropriate for a home birth, but the issue at hand will more likely be the amount of physical stress on your back and how you deal with it.
The weight gained in pregnancy and physical stress of labor may exacerbate some symptoms, and the hard part is that you won't know or be able to predict to what degree until it happens. This would be something for you and your midwife to work with during pregnancy, possibly using other resources such as physical therapy, chiropractic, acupuncture, or concurrent care with the care providers you have used for your back problems. Although I have never had a client with the issue you describe, I have attended births for women with a variety of back issues, including scoliosis and other structural abnormalities, and I would offer you the option of home birth. I encourage you to seek out and interview midwives in your community to explore your options.
Best wishes!
Amy Willen, CNM, MSN
www.awomansplacechicago.com
Q: I'm wondering how I can find information on my doctor's c-section rate. I'm not due until 4/5, but today she indicated that I'm measuring large (39cm) and wanted to discuss a c-section after confirming the baby's weight with an ultra-sound. This seems so unnecessary to me and now I do not trust my doctor at all to do what is in our best interest. Any advice would be appreciated.
A: Measuring 39cm at 38+ weeks gestation is within the normal range. Sonograms for estimated fetal weight are notoriously inaccurate at full term. ACOG (American College of Obstetricians and Gynecologists) guidelines recommend elective c-section ONLY for diabetic women or women with an estimated fetal weight over 5000g (4500g for diabetic women). Also, ACOG does not recommend primary elective c-sections. Based on the information you gave, there appears to be no reason for an elective c-section. Discuss your concerns with your doctor and if you are not satisfied with the answers you receive, do not hesitate to look elsewhere. You have to consent to a c-section, which means you have the right NOT to consent, as long as you and the baby are healthy.
As far as discovering your doctor's c-section rate, the statistics may be difficult to obtain. First, try discussing this with your doctor. You can also try to call the hospital Patient Representative or the director of the ob/gyn department.
Good luck,
Hilary Prager, CNM, MPH
Women's Health Liaison and Public Relations Chair for NYC Chapter of ACNM
www.nycmidwives.org
Q: I was diagnosed with Placenta Previa mid-way through my pregnancy. I will have a follow-up ultrasound to determine if it has grown out of the way at 32 weeks. My questions is, first, is there anything other than time to help this process along? And second, how far out of the way does the placenta have to be to be a candidate for a vaginal birth?
A: No, there is nothing other than time that can take care of a placenta previa -- and even that isn't always enough. There is a difference, however, between a low-lying placenta and a complete previa. A complete previa blocks the cervical os, which must dilate for the baby to come through the cervix. Obviously this presents a problem, as the baby cannot pass through the placenta safely on the way out. The only solution for a complete previa is a cesarean delivery, and it is a very justified indication for surgery. Fortunately a complete previa is rare, however.
Far more common is a low-lying placenta. This condition often rights itself as the lower uterine segment develops in late pregnancy. When this part of the uterus grows, the placenta appears to migrate up the wall of the uterus. Though it has not actually shifted, the location of the placenta relative to the cervix has changed, and often enough to alleviate worry about any complications. Imagine if you draw a spot near the valve of a balloon. As you blow up the balloon, the spot appears to move away from the valve. This is very similar to the placenta relative to the cervix.
A sonogram late in pregnancy will likely be able to identify how much, if any, of the placenta is encroaching on the cervix. If it is the entire placenta, a cesarean delivery will be necessary. If the placenta has moved away completely, there should be no additional risks. And if the edge of the placenta is near the edge of the cervix, you and your provider will have to discuss the risks and benefits of both vaginal and cesarean delivery. Remember, too, that the later in pregnancy a sonogram is performed, the more the lower uterine segment will have developed and the better chances the condition will have resolved.
Good luck!
Carolyn Havens Niemann, CNM, MSN
Princeton Midwifery Care
www.delvalobgyn.com
Q: I am 38 weeks pregnant and scheduled to deliver in a hospital with an OB/GYN. I just watched this film and now understand my complete frustration with the entire process up to this point with my doctor. I was made to believe I had something to fear about my baby being breach at 19 weeks. She did flip and has been head down for the past 6 weeks that I know of. I was also told I have 2 uterine fibroids (small, 5cm) and he brings this up at every single appointment, like it makes me high risk. I am also afflicted with genital herpes and have been taking Valtrex since 36 weeks to decrease the risk of shedding in order to have a vaginal birth. So far, my pregnancy has progressed completely normally, but I fear my doctor is going to try and push me into a cesarean for any one of the various reasons listed above. Do you have any suggestions for me during the delivery to try and avoid as much medical intervention as possible? Also, if I have future children, do you think that using a midwife would be possible for me given all of these circumstances?
A: Thank you for reaching out after seeing the film and questioning the medical interventions that you see looming over your upcoming birth. I wish you had a relationship with an obstetrician who was able to focus on the positive and health supporting ways that you could approach these potential pregnancy risks and how he as your obstetrician could help support you in reducing the impact of those risks and achieving a vaginal delivery rather than instilling fear and making it feel like these issues have turned your pregnancy into a disaster waiting to happen. Unfortunately, a common, cynical perspective in modern obstetrical care is that the risks of nature are ticking away like time bombs within us. The false hope of obstetrical intervention alleviating those risks and achieving better outcomes is in fact only a partial remedy which has its own risks. I am the obstetrician who was interviewed in the Business of Being Born paraphrasing a doctor who trained me during my residency: "They can never fault you for doing a cesarean. When in doubt, just section 'em." So no wonder you are already feeling the threat of a cesarean looming ahead. One quarter to one third of all babies are now being born by cesarean section in the USA. It does not have to be this way!
Perspectives on your "risky" issues:
1. Your baby is no longer breech, so it sounds like this is no longer an issue. Most babies are not head down at 19 weeks, and most babies turn head down by 34 weeks, and those who don't can be encouraged with breech tilt exercises, moxabustion by an acupuncturist, Webster chiropractic technique, and external cephalic version. Also, breech birth has an approximately 1 in 8 chance of a problem (i.e. morbidity and mortality arising), but modern obstetrics still dictates cesarean for the 7 out of 8 women who would have no problems (per UCSF Dept. of OB/GYN conferences).
2. Uterine fibroids' impact on pregnancy depends on size and location. Unless the fibroids are in the lower uterus or other location where they could either get in the way of the baby's passage, or where they could get in the way of the cervix dilating, they should not cause an issue other than perhaps discomfort locally (or getting in the way of doing a cesarean section depending on location).
3. Regarding genital herpes, there is about a 17% risk of transferring an active herpes infection to the baby with vaginal delivery without treatment, which is why treatment and cesarean section if active lesions are present is recommended. I know of several birth stories in which herpes lesions were covered and vaginal delivery of a healthy baby did occur, but there is still a risk and I doubt it would be worth it. However, if there is NO active herpes lesion and you have negative herpes culture near the time your baby is born, I see no reason you could not proceed with vaginal delivery. Information is interesting, but your obstetrician's perspective is still an issue. A knowledgeable and supportive doula is my first thought, someone who is truly experienced and willing to be your advocate during your labor and can help you communicate with your obstetrician. At 38 weeks, your time is limited as labor may come anytime. You may also create a birth plan, you can find sample birth plans and ideas online and in books. A written birth plan spells out in advance what your orientation, preferences, and goals are for your birth and can help you communicate with your obstetrician and maintain your intentions when you are busy being in labor and can serve as a guide to help your doula and other support people support you best. Discuss what is going on with your partner, support people, people who have seen the film and know what you are thinking. Getting all the support you can now will help regardless of how the future unfolds. The book by Henci Goer, A Thinking Woman's Guide to a Better Birth gives information and statistics about various birth interventions and can help you in making decisions and communicating with your obstetrician, and Ina May's Guide to Childbirth by beloved midwife Ina May Gaskin is a wonderful book that tells you what your body is truly capable of, completely supported by statistics and science.
And lastly, LOVE: approach whatever arises from a place of love, not fear, even if others are expressing fear and doubt. Love will give you more clarity, as fear may be likely cause confusion and reactive responses. Have faith in your body, your baby, and your true intentions. Staying home with your support team and doula until you are in hard labor is a possible option to discuss with your OB as well, since at home you will have the freedom to move and eat and be in your comfort for as long as possible. Personally, as an obstetrician, I would choose home birth for myself and I encourage my patients to consider it. There is nothing about your circumstances that sounds like it would prevent you from being cared for by a midwife with a future birth, and even this birth if the herpes goes away in time. I send you my best wishes and hope that my words have provided you with insight, support, and information to help you have an optimal and safe birth experience and a healthy baby.
Peace & well being,
Eden G. Fromberg, DO, FACOOG, DABHM
SoHo Obstetrics and Gynecology
www.dredenfromberg.com
Q: I'm already being seen by a high-risk OB. I have a history of miscarraiges, pre-eclempsia and PIH, I'm a Type II diabetic and have a cerclage. The more I read about homebirth and natural childbirth, the angrier I am at how my delivieries have gone. Is midwifery care an option for me? I really would like to have an unmedicated, non-pitocin childbirth as this is my last, and I want to not be constricted to a bed during labor, choosing to labor at home as long as possible.
A: I would agree that because of your Type II Diabetes and history of miscarriages, that you should be considered higher risk. The preeclampsia and PIH may be problematic in this pregnancy too, but that you will just have to wait and see. Some women have pre-eclampsia and blood pressure issues every time, while others have more normal vitals in subsequent pregnancies. You could look into seeing an acupuncturist to help with your blood pressure as well as working on a stellar diet. The diet will be so important for your diabetes history as well. I think you could find a midwife who could help you with all of these issues. Many times, OBs do not have the time to really work with women in a more holistic way. A local midwife can help you and will know the resources in your area.
However, even though you should have a hospital birth, this certainly does not mean that you can’t have a natural childbirth. If you do not develop pre-eclampsia and can keep your blood sugars under control, I think you have a strong argument for going into labor spontaneously and not being induced. Then, it’s up to you to do the work of having a natural childbirth. As long as you do not have an epidural, you should be able to walk around and get into whatever positions feel the best at the time. Always, an experienced doula will go a long way to helping you have an empowering birth experience. I would also make sure that your care providers at the hospital are supportive of your choices. Don’t be afraid to switch practitioners until you find one that will really support the birth that you are trying to achieve. I think it will take a lot of work on your part, but hopefully your body will cooperate and you will have a healthy pregnancy that can lead to a completely natural childbirth. Good luck!!
Sincerely,
Maria Iorillo, Licensed CPM
www.wisewomanchildbirth.com
Q: Does having a positive GBS (Group Beta Strep) rule out having a homebirth? If so, is there anything one can do to change that positive to a negative?
A: GBS can be treated at home, in the same way that it is treated in the hospital, which is by giving antibiotics intravenously according to protocols dictated by the Center for Disease Control. However as most of my moms would rather avoid an I.V. if possible, I have developed a protocol to be used at home that I think is superior to the methods used in hospital and allows for adequate treatment without an I.V. I have used this protocol now for 12 years without fail. I screen all of my patients at 35-37 weeks as recommended by the CDC. I screen differently than most practitioners who just identify if GBS is present. I have the lab do a culture and sensitivity, which means that if GBS is present, all of the antibiotics that can treat it will be listed. If this isn't done, you can't be sure that the gold standard antibiotic, penicillin, will even treat it. After that I determine a relevant treatment, as derived from the list. One of the antibiotics that usually works is available in a vaginal cream which can eliminate the need for an I.V. After we do the treatment, we conduct a test of cure to make sure that we did in fact eliminate the GBS. It is important to make sure that the GBS does not return.A reculture is done to make sure that the GBS does not return. There are many other methods that some midwives are comfortable with. Some of them involve vaginal and perineal washes with hibiclens, or vaginal suppositories with tea tree oil. I choose not to comment on these methods, as I have found a method that I feel offers minimal intervention with maximum safety. There are also some simple things you can do that could make your body over time, less likely to have GBS in the future.
Cara Muhlhahn, CNM
Cara Muhlhahn Midwifery, New York
Q: I just had my first baby 7 months ago. Prior to the labor, I spoke with my Dr. and mentioned that I wanted to deliver my placenta, not have her pull it out. She kind of laughed it off and said, "Of course we won't do anything we are not supposed to do." After the birth, as I was waiting to deliver the placenta, she masaged my stomach 3 times and when I looked away, she pulled it out without saying a thing. About 30 minutes later, I hemmoraged and almost bled to death. I am not the only person I know that this has happened to. Are there studies that show the effects of pulling out a placenta with no medical necessity? How common is it for this to happen?
A: I am sorry to hear that your wishes were not respected in something so seemingly simple as the natural delivery of your baby's placenta. In most cases, the placenta will let it be known when it is ready to come out: there may be a gush of blood, the umbilical cord may lengthen out of the vagina, and the uterus may rise up in the belly. There may even be a milder urge to push if the birth is unmedicated. As with childbirth, it is easier to deliver your placenta while in a squatting position. The force of gravity is in your favor, the diameter of the pelvis is wider, and the expulsive forces of pushing are more effective in the squatting position. From your inquiry, it sounds like you were on your back since the doctor pressing on your belly would be more difficult in an upright position with your back unsupported. When the doctor pulled out your placenta without saying a thing, it could have been an opportunity for you to say something and request an explanation, although by then I realize it was already too late and you should not have been put in that position. It is hard to say whether early removal of the placenta was the cause of your hemorrhage, since hemorrhage is a potential risk with any birth for various reasons, however it is certainly possible that it was related. Keep in mind that in the supine position, it is more likely for the placenta to detach but not come out on its own soon after, and blood and clots may form behind it and that in situations like this it can actually be therapeutic to help the placenta come out and massaging the uterus or even manual removal of retained clots may be necessary. I cannot emphasize enough the benefits of a squatting position. Since most American obstetricians continue to conduct deliveries in the dorsal lithotomy position, it is not surprising that they also massage the belly and pull on the cord as a matter of routine in the delivery of the placenta. If the umbilical cord breaks, they then remove the placenta manually and give antibiotics to prevent infection, another example of iatrogenic effects - medical treatment causing further problems. Your doctor's choice to pull your placenta out was in the context of a wider orientation towards childbirth. This illuminates how important it is for pregnant women seeking to avoid unnecessary interventions to seek out doctors and midwives who will truly respect their wishes and who have the insight and orientation to work with the natural birth process as it unfolds, reserving interventions for situations of true necessity. If such providers are unavailable in any geographic area, then the current system is not truly serving patients and providing the spectrum of options that women deserve.
Eden G. Fromberg, DO, FACOOG, DABHM
SoHo Obstetrics and Gynecology
www.dredenfromberg.com