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So you’re planning a natural birth, and you’re starting to realize that heading to your chosen birth place, iPod loaded with relaxation tracks in one hand and a stack of copies of your well-researched birth plan complete with bullet points and stock photos of beach scenes, might not get you the warm reception you were hoping for. Should you scrap the idea of a birth plan to avoid ruffling feathers, or should you stand with your hands on your hips and declare that you have rights?
Probably neither. It’s a tricky spot to be in – realizing that you do have the right to make choices about your labor and your child’s birth – and treatment thereafter – all the while recognizing that doctors and midwives and nurses are people too, trying to do their jobs, and knowing that a stressful, high-conflict environment is not conducive to relaxation nor to a healthy, positive labor and birth experience. (Not to mention that if you can stand there with your hands on your hips like that, you probably left for the hospital too soon – but that’s another post for another time!) The fine art of positive communication with your birth team means you’ll need to balance assertiveness with tact and kindness, and explain your wishes with a willingness to hear the other person’s reasoning.
Before we even start in on ways to do that, I’d like to throw in a little side-note public service announcement: Positive communication will only get you so far. Starting with a care provider whom you trust and who is generally on the same page as you regarding the type of birth you desire must come first. Sometimes your attempt at positive communication while sharing your birth wishes will reveal that your doctor or midwife is, in fact, on a completely different page from you, and possibly not even in the same book. This situation probably cannot be fully corrected with positive communication, so be glad you found out ahead of time and take it as an opportunity to explore your options and find out what other care providers in your area might be a better fit for you. Don’t be afraid to make that jump to the care provider that’s a good fit. Who is going to carry what happens the day of your child’s birth for the rest of their lives? (Hint: It’s not the doctor.) That’s right, you and your baby. It’s one of many “deliveries” to the care provider, but it’s the only time you’ll give birth to this baby, and it’s the only time this child will be born.
OK, back to the subject at hand: positive communication. For a lot of couples, the first time this really starts to be important is when they start talking about their ideal birth scenario with their doctor, a conversation often initiated when they show up with a birth plan at a third-trimester prenatal appointment. If you’re at that point in your pregnancy now, that’s a fine time to start. But if you haven’t gotten to the point where you’re working on that yet, discussing questions and concerns with your doctor at your next few visits is an even better way to begin practicing that fine art of balance I mentioned earlier. The following guidelines will serve you well at prenatal visits, while deciding how to phrase your birth plan, and of course when communicating with your care provider, nurses, and other staff during your stay at the hospital. It’s important for you and your partner to use the guidelines, since during labor you may not be able to speak for yourself at times.
The first principle to keep in mind is to remember that you’re dealing with a person who has feelings. Think about being at your place of work and having someone approach you with a question about why you do things a certain way. Depending on the tone, the wording, and the body language of the asker, you might feel happy to answer and explain, or you might immediately begin to feel defensive. Yes, you are dealing with a professional, so he or she should maintain professionalism (and if they don’t that’s on them), but wouldn’t you rather have that professional look forward to conversations with you rather than internally bristle when they enter your room? Starting and ending the conversation with a sincere compliment or other positive statement (sometimes called a “compliment sandwich”) is a great way to start. You can thank the doctor for being thorough, or be appreciative that they take the time to answer questions – anything relevant, but be sincere.
My next suggestion is to be straightforward. Explain exactly what your question, concern, or request is, without wishy-washy language or apologies. Phrases such as “I’d like to know…” or “It’s important to us that…” communicate your desires clearly without abrasiveness. Words like, “Our birth hopes…” or “…if that’s ok with you – I don’t want to be a bother” may communicate to the listener that the things you are discussing aren’t too important to you, and that you probably won’t put up much of a fuss if they don’t happen.
Next, listen to their side. Really listen; don’t just watch their mouth move while you formulate your next argument. (Maybe you would never do this, but I know myself…) There may be reasons you are not aware of for your care provider’s advice, or more recent research than you had access to. Perhaps he or she can provide you with some literature or references you can look up on your own. And it could be that you hear what your care provider has to say and don’t find therein any reason to change your mind. But if you want to be listened to, then you need to listen too.
Another thing to remember is to avoid making demands or being bossy. This goes along well with my first point but I think it requires its own paragraph, and this is where that balancing act comes into play. It is possible to be assertive and straightforward without being demanding. For example, when it comes to writing a birth plan, think about the difference between, “I have prepared for a natural birth; please do not offer pain medication. I know what is available to me,” and “DO NOT offer pain medication.”
My fifth suggestion is to ask for help. At prenatal visits, that could take the form of asking for more information or literature on a topic you are having difficulty coming to an agreement on. When writing your birth plan, it could include prefacing the sentence about pain medication in the previous paragraph with, “Please help me use natural methods such as the tub or birth ball to cope with labor.” During labor it could be as simple as asking the nurse for help filling the tub or how to use the controls on the bed. Your nurse is there to help and most nurses sincerely want to help. If you let her know what kind of help you need, she can be an invaluable part of your birth team. During labor it could also take the form of, “Please help us understand,” if a detour from your birth plan is being suggested.
Sixth is to remember names, especially in labor. Your doctor may not be the one on call, and you most likely have never met the nurse before. Jot down names upon arrival and at shift changes. At many hospitals, staff will do this for you on a whiteboard in your room, but if they don’t, have your partner or doula write it in a notebook or on the whiteboard, and then remember to use those names. It makes for a warmer, more personal feel and shows your consideration for the feelings of your birth team – you made the effort to remember their names.
Finally, remember to be polite. “Please” and “Thank you” are the magic words, so use them!
Following these seven points should go a long way toward a positive relationship between you and your birth partner and those who will be caring for you during pregnancy and birth. In addition to this just plain being nicer for you and for them, it will facilitate better and more thorough communication, contribute to a peaceful labor environment, and make it more likely that your desires will be honored*.
So in summary,
- Remember that you’re dealing with a person
- Be straightforward
- Listen to their side
- Avoid making demands
- Ask for help
- Remember names
- Be polite!
*Unfortunately, once in a while a situation can arise where even if you’re sweetness itself, your legitimate concerns and wishes aren’t being respected. Choosing a care provider wisely as discussed early on in this lengthy post makes this an even more remote possibility. If this happens though, please don’t take this post to mean that I think you shouldn’t at that point put your hands on your hips and demand your rights. Do what ya gotta do! And then say, “Thank you!” – because, you know, keeping it positive and all. And there is just some satisfaction in that, isn’t there?
By 40 weeks of pregnancy I’ll have to admit that I, like many women, was curious about my cervix. Was it doing anything in there? I hadn’t had any signs of cervical change (mucous, “bloody show”), but maybe it was a little dilated. Maybe it was starting to efface. Hopefully it was at least soft!
Most women cared for by obstetricians in the U.S. have got some kind of an idea about the answer to those questions by the time they are “at term”, because vaginal exams in late pregnancy are extremely common. Most women accept them as a matter of course. Their doctors do them routinely, so they must be beneficial, right? They certainly couldn’t be harmful, anyway. And who doesn’t want to know whether they’ll be going into labor soon?
If only it were that simple.
To make an educated decision about any intervention, it’s important to understand what the procedure, drug, test, etc. involves as well as its inherent benefits and risks. Let’s start with a description of what a vaginal exam involves. During pregnancy, these are examinations of the cervix, often performed weekly from 36 weeks of pregnancy up to the time of birth. During an examination, the care provider, with a sterile glove on his/her hand, places the index and middle finger into the vagina and assesses the situation. He/she will be feeling for cervical ripeness or softness, effacement (the “thinning” of the cervix), and dilation (how far open the cervix is). The position of the cervix – posterior (toward mother’s back) or anterior (toward mother’s front), station of descent – how far down into the pelvis the baby has come, and presentation – head-down or breech and which way baby is facing, may also be noted.
That seems like a lot of information! Good things to know, right? Well, what are the benefits of learning all of these things about your cervix? Does it tell you how soon labor is likely to begin? No. A mother with “nothing going on” can go into labor within a day or two, and a mother who is effaced and dilated a few centimeters can walk around that way for weeks. Does it tell you how long labor is likely to last? Not really. So why are these exams performed? What benefit do they confer in exchange for their inherent indignity and discomfort?
With the exception of the presentation of the baby, which, if it turns out to be something other than head-down, will likely affect your choices surrounding the birth and which, by the way, can usually be ascertained by external palpation of the uterus*, the information gained in a pre-labor vaginal exam isn’t particularly beneficial to you, the mother. It satisfies curiosity, sure, and it lets the care provider know a couple of things – whether your cervix is favorable for induction (I will be posting in the future about the bishop’s score and what that has to do with all of this), and, when you present in labor, whether your cervix has changed since your last exam. The second part is a little helpful but certainly not necessary, and as for the first part, well, the usefulness of that information depends on whether you are planning to consent to an induction.
OK, so there is a little bit of information to be gained from a vaginal exam. Its value is questionable, especially when the exams are done as a routine procedure rather than for a particular indication, but it’s a pretty minor, low-tech procedure, right? Yes, it’s low-tech, but it’s not without risk. First of all is the psychological effect of the exam. It’s painful (moreso than exams you received when not pregnant), which is in and of itself a consideration. Also, finding out that you are three centimeters dilated can seem pretty exciting. You’re going into labor any moment, right? Not necessarily. Or, you find out that your cervix is high, closed, posterior, and thick. Bummer! It’s going to be a while, right? Maybe not. Remember, the findings of the exam don’t have great predictive value as to when you are going to go into labor, but it’s hard not to read into the information and thus add to the emotional roller coaster of the last weeks of labor. In addition to being No Fun, this can lead to discouragement, stress (remember that stress hormones fight your labor hormones) and a higher likelihood of consenting to procedures, such as induction, that you may not have really wanted. Many women find it better to peacefully wait it out without exams, knowing that labor will start when it’s right for the baby.
How about physical risk? Yes, there are real physical risks to vaginal exams. Although the care provider dons a sterile glove, they are not inserting it into a sterile place. We all have normal “vaginal flora” in the lower part of the vagina, which, during a vaginal exam, is pushed onto the cervix. The result? A higher risk of infection of the membranes of the amniotic sac, which is a serious complication. Studies confirm a link between vaginal exams, infection, and premature rupture of membranes**.
It’s up to you to weigh the benefits and risks of any intervention proposed during your pregnancy and birth (and really for all of your life and your child’s life for the first 18 years). When it comes to vaginal exams during pregnancy and other procedures, remember the “BRAIN” acronym: What are the Benefits, what are the Risks, what Alternatives do I have, what does my Intuition tell me, and what happens if we just do Nothing and let nature take its course?
So then, what’s the deal with vaginal exams during pregnancy? The nutshell version is that they sometimes can provide some useful information, but if there is no indication and the exam is simply being performed as a routine procedure, it may be that the benefits do not outweigh the very real risks in your individual case. If the exam is being proposed due to a particular indication, you still (and always) want to ask the BRAIN questions in order to make an informed decision.
*If external palpation leads the care provider to suspect that your baby is not head down, he or she will likely want to confirm the baby’s position via a vaginal exam or ultrasound.
Thank you, Penny Simkin!
Babies Want to be Born…
This idea has been rattling around in my mind a lot lately, and I thought my first “real” blog post was a great place to let it out.
It seems like an odd thing to say, doesn’t it – “Babies want to be born.” Do fetuses have wants? Doesn’t it call to mind the sweet female relatives saying, “Oh that baby is so cozy in there he doesn’t want to come out?” Doesn’t a lot of our verbiage around a woman’s due date revolve around the idea that baby’s going to have to leave his snug warm abode and that mama’s going to ‘kick him out?” Of course it’s always said in jest and with the most well-meaning sentiments. But doesn’t it kind of reflect the way we often look at the baby’s journey – as one forced upon him and against his wishes?
I have a feeling that it’s not quite like that.
One thing I try to instill in mothers and in couples in my childbirth classes is that mothers and babies (and fathers too!) are a team when it comes to birth. That baby is working to be born just as mother is working to give birth – and father to support and protect his family. Maybe it’s obvious to you and to others, but for me, it was the sprout of an idea that has been forming as I talk to students about this topic… Babies want to be born.
We know that instinctively, babies use the stepping reflex to push off as mother’s fundus pushes down, piston-like, during the second stage of labor. We know that unhindered by narcotic medications, a healthy, alert fetus will perform a series of “cardinal motions,” rotating his head and shoulders, extending his neck, to be born. These are normal responses to the actions of the mother’s body during labor. Babies work hard to be born as mother is working to give birth.
But what about before labor begins? Is labor “kicking baby out” of his cozy environs? Well, it’s theorized that structures in the hypothalamus of the fetus monitor his maturation and help trigger labor when the time is right. So presumably, the fetus is at least subconsciously partially responsible for the onset of labor.
Another thing that got me thinking recently was a video I watched, produced to increase awareness about late preterm birth. A mother in the video talked about the end of pregnancy – how even though women know that labor is not going to be a cakewalk, they look forward to it – they long for it to begin. She said that the end of pregnancy seems to be designed to make women want it to end.
I think it may be the same way for the baby. Cramped and getting cramped-er in the snug warm womb, even though labor must be a difficult journey for the baby, the baby instinctually knows that it’s time to be born. Time to make his entrance into the world of humanity, time to meet the mother face-to-face that he has known always. I am not talking about a cognitive, conscious awareness of this, but of an innate, instinctual urge.
So how can this idea, this concept of babies wanting to be born be translated into something real and meaningful? I think that remembering this can help us to remember to respect the baby. Respect that the baby wants to be born. Let him choose when the time is right. Don’t rob the baby of his ability to be an active participant in his birth by needlessly cutting him out of his mother’s body or by interfering with his labor – by starting it artificially, speeding it up artificially, inhibiting his ability to work with the labor by drugging him (via mother’s medications) or inhibiting his mother’s ability to move and work with the labor and facilitate his movements. Let him find his way – don’t twist and turn a baby’s head who was doing the job very well on his own, thank you very much. And of course, reward baby’s hard work by greeting him with love, sensitivity, respect, consciousness, and by immediately allowing him to go right to the place he was working so hard to get to – his mother’s arms, between her breasts.
I know there are times when intervention is warranted, but really, as Christiane Northrup states in Giving Birth by Suzanne Arms, ‘When birth is done on an eight-hour workshift, we miss the magic. And I think we do more harm than we know.’