CHAPTER 1 Approaching Birth with Confidence Congratulations! As a pregnant woman planning to bring a new life into this world, you are embarking on an amazing journey. Pregnancy and birth are as ordinary and extraordinary as breathing, thinking, or loving. Whether you are pregnant for the first time or are already a mother, pregnancy will call on your creativity, flexibility, endurance, and humor. You will face many choices that will affect your pregnancy, birth experience, and life as a new mother. As you consider your options, you'll want to learn as much as you can about your developing pregnancy and various childbirth practices and think about the experiences you hope to have. What kind of care do you want to receive during pregnancy? Where do you wish to give birth? Who would you like to be with you when you are in labor? Most pregnant women are bombarded with advice from well-meaning friends, relatives, and even strangers. Everyone seems to have an opinion on what you should or shouldn't do, and it's easy to feel overwhelmed by their conflicting recommendations. This book will help you sort fact from fiction. By drawing on the most accurate research, the personal experiences of many individual women, and the advice of midwives, physicians, and other health care providers, it will give you the information you need to make wise decisions and approach birth with confidence. CLIMATE OF CONFIDENCE, CLIMATE OF DOUBT Pregnancy and birth are normal, healthy processes for most women, the vast majority of whom have healthy pregnancies and babies. But when was the last time you saw a newspaper article titled "3.5 Million American Women Had Normal Labors and Healthy Babies This Year" or a TV episode that showed a healthy woman giving birth to a healthy newborn, without a sense of emergency or a heroic rescue? The media's preference for portraying emergency situations, and doctors saving babies, sends the message that birth is fraught with danger. Other factors, including the way doctors are trained, financial incentives in the health care system, and a rushed, risk-averse society, also contribute to the popular perception that childbirth is an unbearably painful, risky process to be "managed" in a hospital with the use of many tests, drugs, and procedures. In such an environment, the high-tech medical care that is essential for a small proportion of women and babies has become the norm for almost everyone. Some advocates for childbearing women describe this as a "climate of doubt" that increases women's anxiety and fear. In contrast, a climate of confidence focuses on our bodies' capacity to give birth. Such a climate reinforces women's strengths and abilities and minimizes fear. Some of the factors that nourish a climate of confidence include high-quality prenatal care; healthy food and time to rest and exercise; a safe work and home environment; childbearing leave; clear, accurate information about pregnancy and birth; encouragement, love, and support from those close to you; and skilled and compassionate health care providers. As your pregnancy develops, do what you can to seek out such resources. When I found out I was pregnant, my blood pressure was a little on the high side. But I had a great doctor who helped me take care of myself and my baby. She knew all the details of my personal problems -- being unmarried, and with a partner who had an addiction problem -- and she treated me with nothing but respect. I think it made all the difference in having a healthy baby. In spite of my difficult circumstances and the stress, I actually had a very good pregnancy and had a lot of love and support. My husband loved my pregnancy. He'd want to play jazz to my belly and sing to my belly. He'd rub cream on the stretch marks and tell the baby the play-by-play of the baseball game. He and our cat both seemed more protective of me and I felt very loved by my little family of two. QUESTIONING HIGH-TECH BIRTH The path to motherhood involves navigating through a health care system that can be complex and sometimes intimidating. While some aspects of maternity care are shaped by economic, social, and political forces that are beyond our individual control, there are things you can do to increase your chances of having a healthy and satisfying pregnancy, birth, and early postpartum period. The following chapters provide advice, support, and resources to guide you as you learn about your pregnancy, seek prenatal care, and face decisions about the kind of birth you want. As you make these decisions, it's important to understand that some elements of the care most women receive during pregnancy and childbirth are not based on the most reliable research on what is safe and effective. Some high-tech procedures are overused in the United States, while other practices that have been shown to improve birth outcomes are not offered widely. Being aware of this can help you access the best care for your situation. When used appropriately, maternity care interventions such as artificial inductions of labor (use of drugs or techniques to try to start labor), episiotomies (cutting to enlarge the vaginal opening), epidurals (a kind of anesthesia), and cesarean sections (surgical deliveries) can improve health outcomes and even save lives. Yet far too often, these interventions are used routinely on healthy women who are at low risk for medical complications, despite clear scientific evidence that they are unnecessary, ineffective, and/or can cause harm. The widespread routine use of medical interventions during labor and birth has failed to improve the safety of childbirth for low-risk women. In addition, these interventions can disrupt the natural rhythms of labor, undermine women's confidence in our capacity to give birth, and decrease our satisfaction with our birth experiences. At the same time that such procedures are overused, practices that have been shown to improve birth outcomes -- as well as increase women's satisfaction with the experience of giving birth -- are widely underused. These practices include receiving continuous one-on-one support from a skilled, experienced caregiver during labor; being able to change positions, get out of bed, and walk during labor; and using comfort measures such as massage, warm baths, and birthing balls. (For more information on how and why U.S. health systems are not always providing the best care possible and about efforts to change this, see Chapter 17, "Advocating for Better Maternity Care.") As much as possible, surround yourself with the kinds of supportive practices that have been proven effective but are sometimes underused, and avoid unnecessary medical interventions. Choosing a health care provider and birth setting that make judicious, conservative use of interventions, learning about the advantages and disadvantages of different medical procedures and treatments that are offered to you, and declining those procedures and treatments that you do not need can help you have a safer, more satisfying birth experience. My tips for pregnant women? Exercise. Eat healthy but splurge once in a while. Enjoy all of the attention. Wear comfortable shoes. Sleep every chance you get for as long as you can. Read and educate yourself about all of your choices regarding childbirth so you can feel in control and not like it is something that is happening to you. In addition, have an open mind [in case] things don't go how you planned. It really helps to have someone there (if in a hospital) who can act as an advocate for the mother, like a doula [trained birth companion], mother, or good friend....You also have to make very clear what you want, because hospitals have certain routines and procedures that they are used to, and unless you tell them otherwise, they will go ahead with their routines (examples: putting drops in the baby's eyes right away and giving the shot of vitamin K, giving the baby a bath). I would say to keep an open mind, learn what your options are, [and try] to be an active participant in the whole process. PLANNING A BETTER BIRTH If you are healthy and have no medical complications that call for a "high-risk" approach to your care during labor and birth, you can increase your chances of having a safe and satisfying vaginal birth by trying the following strategies: Find a doctor or midwife with low rates of intervention. Some caregivers have much lower rates of intervention than others. While rates of intervention will vary depending on the population served (for example, women carrying multiple babies and women with high blood pressure are more likely to need interventions), they also vary by the type of provider and the practice style. Although there are many exceptions, family physicians tend to have lower rates of intervention than obstetricians, and midwives generally have the lowest rates of all. These differences are partly due to varying degrees of risk among the women who choose an obstetrician, family physician, or midwife (for example, a woman with pregnancy complications will likely choose an obstetrician), and partly due to the differences in practice styles between types of providers. (For more information, see Chapter 2, "Choosing Your Health Care Provider and Birth Setting," particularly the section "Models of Maternity Care," page 15.) Choose a birth setting with low overall rates of intervention. Some birth settings have far lower rates of intervention than others. Use of interventions is much lower in out-of-hospital birth centers and home births, compared with hospitals. However, the rates of intervention among different hospitals can also vary widely, depending on the practices and policies of the hospital as well as the health problems of the women it serves. (For more information, see "Birth Settings," page 22.) Create your own birth plan and discuss it with your caregivers. Writing down your values, preferences, and priorities can help you clarify your own thinking and feelings. Moreover, this type of birth plan helps prepare you to discuss these issues with your partner and your caregivers. Find out if your caregivers will work with you to meet your goals and preferences. If their response does not satisfy you and you have other options, seek a better match. (For more information, see "Birth Plans," page 37, and "Some Questions to Ask Midwives and Physicians," page 21.) Arrange for continuous labor support from someone with experience. Arrange for someone in addition to your partner to be with you throughout your labor and birth. You can work with a doula (a trained labor support companion) or ask a friend or family member who is experienced with birth and with whom you are comfortable. Women who receive continuous, one-on-one support have fewer complications, better health outcomes, and greater satisfaction with their birth experiences. (For more information, see "Your Birth Team," page 32.) Explore your options for pain relief. There are a wide range of medications and nondrug approaches to managing pain in childbirth. Learn about the advantages and disadvantages of all the options. (For more information, see "Planning for Pain Management," page 38, and Chapter 11, "Coping with Pain.") Avoid continuous electronic fetal monitoring when possible. Continuous electronic fetal monitoring (EFM) increases the likelihood of both cesarean sections and operative vaginal births (births in which forceps or a device known as a vacuum extractor are used to help pull the baby out of the birth canal). Continuous EFM does not offer clear benefit for babies when compared to monitoring the fetal heart rate intermittently during labor. Talk with your caregiver and check hospital policies to find out whether they are willing to check your baby's heart rhythm with a handheld device or occasional use of EFM instead of continuous EFM. With some types of intervention that involve increased risk (for example, epidurals for pain control), you will be required to use continuous EFM. (For more information, see "Fetal Monitoring," page 174.) Avoid routine use of other medical interventions when possible. Using medical interventions when there is no clear medical need offers no benefit to mothers while increasing the likelihood of harm. For example, labor augmentation (use of drugs to increase the speed and strength of your contractions) can increase the discomfort of contractions and lead to fetal heart patterns that cause concern. Some research links labor induction (use of drugs or techniques to try to start labor) with increased likelihood of cesarean section, especially in first-time mothers, or before full term, or when the cervix is not soft and ready to open. Avoid having a provider break your bag of waters (artificial rupture of membranes) before labor starts or in early labor, unless there is a clear medical reason to do so; early breaking of the bag of waters may increase the likelihood of a cesarean. It is also good to avoid arbitrary time limits for your labor. There is no need to turn to a cesarean if you and your baby are doing well. Talk with your caregivers about these practices and how to avoid them. (For more information about induction, see page 146. For information on rupture of membranes, see page 180.) Being informed can help you negotiate the choices you face during pregnancy and childbirth. While you won't be able to control everything that happens in the months to come, you can clarify what is important to you. Excellent support can also help, so surround yourself with caregivers and others who understand your priorities and will advocate for you. At first I was really scared of labor. I knew I wanted a birth as free of interventions as possible, but I thought this meant I had to be some kind of Amazon who squatted in the field, grunted out her baby, then stood up to pick the crops. Or else a superfit marathon runner who had endless endurance and tolerance for pain. But the more I learned, the more I talked to other women, and the more support I got from my midwife, the more confident I felt. I took great comfort in the fact that women have been giving birth forever -- every one of us had a mother who managed to birth us! QUESTIONS TO GUIDE YOU IN MAKING INFORMED CHOICES Whether the question is "Do I want to have an amniocentesis?" or "Do I need an epidural?" the following set of seven questions can help you gather the information you need to make a decision that is right for you. You may want to bring the questions with you on your health care visits. 1. What is the problem I am trying to prevent or to fix? 2. What are the benefits of the proposed test, treatment, or procedure? 3. How is the procedure done? 4. What are the chances it will work? If it doesn't, what next? 5. What are the possible risks and adverse effects (complications and "side effects")? 6. What are the possible alternatives? (Repeat questions 2-5 for each alternative.) 7. Does it need to be done now, or is it possible to wait awhile? Copyright (c) 2008 by The Boston Womens Health Book Collective Excerpted from Our Bodies, Ourselves: Pregnancy and Birth All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
