Category Archives: evidence based

Exploring Your Options Series – Part 5

Deciding on a place of birth is simple for most women. Most women choose to give birth in a hospital. Women generally feel safe in a hospital. Are there any other safe options? Is it safe to give birth out of the hospital? YES! Studies show that out of hospital options, such as a birth center or at home, are safe for low risk women.

I would encourage you to consider and research the different options and their safety before coming to a conclusion about where to have your baby. The location of your birth will determine what other options are available to you. Some links to help with your research Science and Sensibility “Is Home Birth Reasonable Option?”Science and Sensibility “Birth Outcomes by Birth Location”Science and Sensibility “Flaws In Recent Home Birth Research”, Science and Sensibility – “Obstetricians Claim Homebirth is Unsafe…Again. Where’s The Evidence?”

Part of the decision making process should include weighing the pros and cons of each birth place. Previous decisions (ie: deciding on a care provider) will also have an influence on where you give birth. If you want a physician to attend your birth, having a home birth may not be an option. Not many physicians attend home births, but there are some. I am not sure there are any in Utah, though.

Below are some pros and cons I came up with. Because everyone is different and there is no one right answer for anyone, these things may not apply to your situation. Feel free to make your own pros and cons list to figure out what is the best option for you. Where you feel the most comfortable and safest will be the best place for you to give birth.

Most women in this area plan to have a hospital birth and never consider a birth center or home birth. I would encourage you to consider and research the different options and their safety before coming to a conclusion about where to have your baby. The location of your birth will determine what other options are available to you.

  • Hospital
    • Pros –
      • Specialized care for high-risk pregnancies and births.
      • Pain medication readily available
      • A nurse to take care of you and baby, meals brought to you
    • Cons –
      • Birth is seen as a medical crisis.
      • Mother and baby are often separated
      • Difficulties are often resolved with medications and high-tech procedures
      • Standardized care rather than individualized.
      • Often noisy, lack of privacy, strangers (the nurses are likely people you will not have met prior to your birth. Your particular doctor or midwife may not be the one to attend the birth)
      • Institutional feel.
      • Understaffed.
      • Higher risk of infection.
      • Have to pack and travel to birth place
  • Birth Center
    • Pros –
      • Less infection risk than hospital.
      • Midwifery Care Model
      • More home like than hospital
      • Most problems that arise can be dealt with on location.
      • Baby is never separated from the mother
      • Continuous support
    • Cons –
      • Have to pack and travel to birth place
      • Higher transfer rate than home birth.
      • Fewer pain medication options available
  • Home
    • Pros –
      • Your own space/Familiarity
      • Midwifery Care Model
      • Low-risk treatments used to resolve issues that may arise.
      • One-on-one care with your chosen birth attendant (although this isn’t always the case now. There are some homebirth midwives in the area that have a “practice” much like doctors)
      • Individualized care.
      • Continuous support
    • Cons –
      • Arrange for someone to take care of mom’s needs, the home, and other children.
      • No pain medications available
      • May need to transfer if difficulties arise.

Part 1 | Part 2 | Part 3 | Part 4

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Exploring Your Options Series – Part 4

questions to ask a potential care provider

After you’ve setup interviews with doctors and/or midwives, you’re going to need some questions to ask them. For this post I want to talk about how to conduct an interview.

Hence Goer, author of Thinking Woman’s Guide to a Better Birthsuggest asking questions in a way that does not give away your opinion. If they know what your opinion is, they may tailor their response to your opinion instead of what their actual answer is. It is important to ask open-ended questions. Begin a question with “When do you usually recommend….?” Using the vision of your birth experience as a guide, ask questions about key elements of your birth vision. If you want to push in different positions than the traditional-hospital-position of laying on your back with legs in stirrups, ask your potential care provider about this. You could ask “What is your opinion of pushing in upright positions?” or “What is your approach to the pushing stage of labor?”

When the care provider answers the question vaguely, such as “I only do that when it is necessary”, follow up with more questions. If the answer they give is “I only do that when it is necessary”, ask “In what situation would it be necessary?” or “How often do you find it necessary?” If it is important to you not to have an episiotomy (when the care provider cuts your perineum), and the care provider says they find it necessary in every first time mom and about 80% of the rest of moms, then this is probably not the best care provider for the birth experience you want.

Is the care provider answering with feelings instead of facts? These types of answers can be very misleading. At first it seems like they care about your experience, when really they are trying to appeal to your emotion rather than using evidence based practices. If they answer with a feeling based answer, follow up with questions to get them to state specifics. In the situation of episiotomies, would you rather hear “Would you rather have a clean cut than a jagged tear?” or “I do them very rarely. It’s been about 3 years since the last time I did one. They are routinely done as part of a forceps delivery”.

Does the potential care provider seem comfortable with you asking them questions? If they seems irritated or impatient with your questions, they may not be the best care provider for you. If they are not comfortable with your interview questions, how would they react if you had a “dumb” question to ask. Think to yourself, “would I feel comfortable asking them a ‘dumb’ question?” There are times during pregnancy or birth that something doesn’t feel right or you unsure about what is going on with your body and you should feel comfortable talking to your care provider about these things without feeling stupid about it.

Here are specific questions to ask a potential care provider:

  • Are you board certified (physicians only)?
  •  Under what circumstances would you transfer my care to an obstetrician (midwives and family physicians only)?
  • Do the midwives attend births? (if you are interviewing at a practice that has both midwives and OBs)
  • What is the likelihood that you will attend my birth?
  • What are your dietary recommendations? How much weight should I gain?
  • What is your policy on ultrasounds?
  • Under what circumstances do you recommend inducing labor?
  • How do you handle slowly progressing labors?
  • What are your policies regarding monitoring the baby’s heart rate in labor, IVs, drinking or eating in labor, breaking the bag of waters (amniotomy), epidurals, episiotomies?
  • What are your reasons to do a cesarean? How often do you find it necessary? How do you try to avoid the need for cesarean?

The Thinking Woman’s Guide to a Better Birth, Henci Goer, p. 195-196

 

Henci Goers book has a lot of information about evidence based practices and I would recommend getting your hands on a copy. It may help you define your birth vision. In the particular section referenced about she also has “Red Flag Responses”. Great read!

Here are some links to help with questions to ask a potential care provider: http://www.askdrsears.com/topics/pregnancy-childbirth/first-month/interviewing-midwife 
http://pregnancy.about.com/od/prenatalcare/a/10q4doc.htm 
http://www.ahaparenting.com/ages-stages/pregnancy/Choosing-doctor-or-midwife

Read the previous posts in this series here: PART 1 | PART 2 | PART 3 | Part 5

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Delayed Cord Clamping

Delayed Cord ClamingA common routine practice within hospitals is to immediately clamp and cut the umbilical cord following the birth of the baby. Although care providers (doctors and midwives) give many excuses for this practice there is no evidence to support it. In fact, there is much evidence to support delaying clamping of the cord.

Below is some of the evidence I’ve collected that shows the benefits of delayed cord clamping. As you read through and view this information you can learn about the benefits for yourself and make the best choice for you and your baby.

Science and Sensibility, a blog by Lamaze International, has gathered a plethora of information on delayed cord clamping. Here is a post in which they refute, with evidence, some of the common objections care providers use in regards to delayed cord clamping.

“In some cases this continued practice is due to a misunderstanding of placental physiology in the first few minutes after birth. In others, human nature plays a role: We are often reluctant to change the way we were taught to do things, even in the face of clear evidence that contradicts that teaching.”

Click HERE to read the full article.

To view all the articles they have on the subject of delayed cord clamping, click HERE. They have a really informative video series about delayed cord clamping given by Dr. Nicholas Fogelson, MD A.P. Department Obstetrics and Gynecology USC School of Medicine. To watch this series click HERE.

Dr. Judith Mercer, PhD, CNM, FACNM, a member of the faculty at the University Rhode Island, is the Principal Investigator on a randomized controlled trial at Women & Infants Hospital examining the effects of delayed cord clamping on outcomes of preterm, very low birth weight babies. She was interviewed over at Science and Sensibility blog. She relates an amazing experience she had at a homebirth in 1979 that helped to influence her decision to research delayed cord clamping.

“I had an epiphany at a home birth in 1979. An infant was born very rapidly with the cord 2 and 1/2 times around his neck. He was as pale as the white sheet his mother had on her bed and limp and breathless. I was very afraid that I would not be able to resuscitate him.  I placed him on the bed and immediately unwrapped the cord from around his neck and dried and stimulated him with no response. His heart rate was well over 100 and the cord was pulsating vigorously.  I noticed that his color was changing from the pale white to pink as his body gained the blood back into it. His heart rate was always over 100. In about 1 and 1/2 minutes, he flexed his extremities, opened his eyes and took a gentle breath.  He looked at us like “What is the fuss?” and never cried.  I tried as hard as I could to get him to cry as I believed at that time that he should do but I could not get him to.  He nursed very well and was a normal child at one year of age when I last saw him.

I knew that I had seen a miracle and one that I would never have seen in the hospital.  In the hospital, we would have cut the cord and taken the infant to a warmer to resuscitate him. In doing so, we would have denied him exactly what he needed – the opportunity for the blood squeezed out of him in the birth process due to the tight cord around his neck to flow back into his body.  This event marked the beginning of my research career.  I vowed that at some point in my life I would research what I had seen but did not fully understand.”

To read the rest of her interview, click HERE.

Below is a video where Penny Simkin talks about the amount of blood lost when we practice immediate cord clamping. She talks about the benefits of delayed cord clamping in a visual way that really helped me understand the way it works. Watch the video, it’s a really great way to spend 5 minutes and you’ll walk away with some beneficial information on this important birth option.

Along with all of the clinical benefits and researched evidence noted in the above links, a benefit that I have seen is the way delayed cord clamping slows down the birthing process. Sometimes in the hospital there is so much routine that is practiced by the doctor/midwife and nurses everything happens so quickly. I believe it is important to slow this process down. When the birth of a baby is slowed down the mother and her partner have the chance to savor the moment and the experience is etched into their memory. Slowing down the birth process is one way to improve and protect the memory of the birth.

As you consider your birth options and preferences, I hope you will research the information available on delayed cord clamping to make the best choice for you, your baby and your situation.

The midwives that I know of who attend home births regularly practice delayed cord clamping. It is important to talk to your care provider to find out their regular practices.

Picture above take by OpieFoto. Taken at the home birth of my 3rd child.

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