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Interviewing Obstetricians

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Life circumstances and changes in our choices can lead us to seek out a new obstetrician. The provider you used for your gynecological or fertility care may not be who you feel comfortable with for your obstetrical care. You may want a different experience if you are no longer a first time mom and longed for something different during your birth. Your insurance may have changed and no longer covers your original ob/gyn and hospital as in network. Maybe your friends or mommy group are raving about a different practice in town and you want to investigate. Whatever your reasons, feel open to the idea of interviewing a different provider.

This post is focusing on in hospital providers because the majority of women do give birth in hospitals and there are many articles and posts about interviewing home birth providers. It is also titled Interviewing Obstetricians because our country has a majority of obstetricians providing prenatal care. In hospital providers are typically obstetricians or certified nurse midwives but may include family practitioners in some areas.

You will begin by calling the office of the practice or provider you want to interview and asking for a pregnancy consultation or a “meet and greet”. This appointment will give you a chance to meet the provider and ask questions — it is not an exam. Having a list can help you focus and maximize the time afforded to you.

The list below is a starting point of questions you may want to ask and is by no means all inclusive to every scenario or your individual circumstances.

  • Is your practice suited to my wishes and desires for birth? (I want to go natural, I want an epidural upon request, is delayed cord clamping or immediate skin to skin encouraged and available?)
  • What sorts of prenatal tests do you offer or require?
  • What tools are available to help me achieve the birth I desire? (birth balls, peanut balls, squat bars, showers, tubs, wireless monitoring or intermittent monitoring, heating pads or a community microwave for hot packs, iv narcotics, nitrous oxide, anesthesiologists available all hours, etc.)
  • What are hospital policies regarding freedom of movement, nurse ratio to patient, triage, acceptance of doulas, photography rules, eating and drinking, and how would those change if medicine was used or not used?
  • Will I be staying in the same room I birth in or moving to a postpartum floor? (both scenarios have pros and cons).
  • What is your on call schedule like? Will I have a chance during my pregnancy to meet anyone who may be delivering my baby or can I request a specific provider to catch my baby?
  • Are there time limits on my labor or pushing if mom and baby are doing okay? What is your epidural/cesarean/natural rate (keep in mind that numbers may only reflect they are a higher risk practice or hospital, but this can lead to more questions about their philosophy.
  • How do you feel about up to date evidence based recommendations made by ACOG (American Congress of Obstetricians and Gynecologists)? Should an issue arise that requires a decision will we make time to discuss risks/benefits and discuss alternatives (barring an outright emergency).
  • What level NICU is available on site or would there be a transfer of baby if there was a serious problem?

Again, this list is not exhaustive and you may want to tweak or add more questions but it will hopefully get your thinking cap on so you can make the most of your interview. You may want to ask more details about postpartum policies or cesarean policies if those are important to you and depending on how much time you have with the provider. Whatever your list of questions becomes, listen carefully to the answers and then pay attention to what your intuition tells you as you process the visit.

Kimberly Sebeck, CLD, CCCE, HCHD  Knoxville Doula 2016

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Important information for every woman, whether you have given birth by cesarean or vaginally, whether you have had no children of many. Hysterectomy is the most common non-obstetrical procedure for women in our country. Approximately 600,000 are performed each year in the U.S. 1 in 9 women will have one. It’s time for us to focus on our pelvic floor health.

August ICAN of Knoxville Meeting — Pelvic Floor Health

Please join us to hear our guest speaker, Autumn Synowiez, OT, speak to us about our pelvic floor health. Whether you are planning to get pregnant, are pregnant, or have birthed your babies in the past — we can all benefit from good pelvic floor health. Those with diastasis recti, perineal repairs, and cesareans will especially benefit from this information.

Meetings are FREE, however we gratefully accept donations for our local 501c Non Profit Chapter. (suggested donation $1-$3)

Partners and children are welcome for most of our meetings. We respectfully ask that if your child is needing a quiet moment that you step out if needed.

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What Would You Tell Ina May to Include in a Book?

I stumbled across a fabulous podcast with Ina May. The interviewer did not have a natural birth and felt as if there was missing information in Ina May’s books — at first I thought this was going to be simply a critical viewpoint of Ina May.. but it’s not.

If you have ever struggled with disappointment or a feeling of failure because you didn’t have the candle lit, in a birth pool, 100% intervention free birth — please listen to this.

At the end you are given options of how to let Ina May know what you would like included in her current or forthcoming books.

 

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Cesarean Rates – With a Grain of Salt

Note: This post is not about your medically necessary cesarean, or even one you chose. The author of this post respects all births and philosophies.

As more education and advocacy spreads about high rates of cesareans many natural birth advocates will encourage women to ask for their doctor and/or hospitals cesarean rates. Sometimes it is hard or impossible to find these rates as they are not always maintained by each physician, hospital, or even in public records. It is usually easier to find your state or region’s cesarean rates.

What is a woman to do when she searches and cannot find anything but internet reviews and anecdotal accounts?  What if she asks her obstetrician and they say they do not know what their cesarean rate is? What happens when a woman finds out that the hospital she has chosen to birth at or the obstetrician she is using has a 30%, a 60%, a 25% rate of cesareans? What does it all mean?

Information is always useful. But consider a few things.  If your state or regions cesarean rate is 30% but a certain hospital has a cesarean rate twice that — it could give you pause. Or you may consider if they only accept high risk women and are staffed by all or mostly high risk women’s specialists. Perhaps your provider is a large supporter of women who are attempting VBAC (vaginal birth after cesarean) and this skews their overall cesarean rate because there is always the chance a previous cesarean will result in another cesarean for the same woman. Large hospitals may not have accumulated statistics any more recent than a few years ago or even longer.

A rate will not guarantee you will have the information about choosing a hospital or provider.

Some suggestions for finding out deeper information are to ask these questions:

  • Ask your ob/gyn if they can provide a recent cesarean experience concerning their philosophy on birth. Was it due to a time limit? Was baby or mother not faring well?
  • If the birth facility itself has a seemingly high cesarean rate ask if this is due to specialists, high risk situations, hospital policies, or something else?
  • Has the doctor or facility implemented any measures since the most recent statistics that could help lower the chance of an unnecessary cesarean? Such as welcoming doulas, adhering to ACOG recommendations about reducing non medical inductions and considering active labor as beginning at 6 cm instead of the outdated 4 cm, utilizing midwifery care, and updating the tools provided to laboring women?
  • Does your hospital or doctor keep current on certain methods that can reduce unnecessary surgery by providing peanut balls for women with epidurals, having wireless monitoring for mobility, water labor options, etc.?
  • Does your hospital or doctor support VBAC?
  • Does your provider speak with compassion and understanding when you ask these questions or are they defensive or minimizing your concerns?

I hope some of these questions have helped to show that a rate is not always just a rate. Again, information is useful. It is a good starting point to ask more questions to make sure your provider or place of birth is in line with what you want for your birth options. Ultimately labor and birth is an unknown and you can only do the best with the information you have at the time.

Happy birthing!

All Rights Reserved, Knoxville Doula, Kimberly Sebeck 2016

 

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A Home Birth Transfer Story

We hear a lot about birth plans. What happens when a planned home birth doesn’t go the way it was planned? Please enjoy this birth story shared by my friend, Sarah Haselton, a fellow doula and midwifery student about her home birth transfer.

You’ve heard it said the best laid plans of mice and men go awry. While I wouldn’t say Samuel’s birth went awry, it certainly didn’t go as I had envisioned it to be. You see, in my mind I had this beautiful home birth vision with my baby slipping gently from my body into the water and being laid upon my chest. I had dreams of birthing my placenta, baby still attached, photos of the glorious moment, and in my mind it was mandatory that I birth without medication. I had this huge expectation in my mind since my first son’s birth went so beautifully that my second home birth would be no different. Boy was I wrong in just about every aspect. The only thing that DID go as I had planned it was that I birthed my baby through my vagina and not a cesarean cut.
I had been anxiously and excitedly awaiting the moments of birth for months. I knew Samuel’s birth would be beautiful and I knew exactly what I wanted. When I found myself pregnant again I carefully considered who our midwife would be, taking into account that we would be using insurance that often doesn’t pay for a home birth and rarely pays for a birth center birth. There simply was no question, Kim was to be our midwife and I knew I could count on her and trust her advice after having worked with her before and she was the assistant on Nathaniel’s birth. It just made sense for us to employ her again.
A few days before things began, I spent several hours preparing our bedroom for what would be our birth space. I was anxious about giving birth in my living space, but what little anxiety I had disappeared once I thought about my goals for our birth. Looking back, this should have been my first clue that things may not go as I had hoped. My instincts were trying to tell me something but I wrote it off as pre-birth jitters. I just knew Sammy was coming in that bedroom space I had so lovingly prepared. The thought of birthing in the hospital was always immediately written off as my anxiety disorder playing tricks on me, and I wasn’t about to let that bring me down.
Two nights after I prepared our room, doing a test run with the birthing tub, I started to have contractions. They were mild, erratic and didn’t quite feel like labor to me but I knew from my training as a doula and my previous experience that this could happen, so I waited for things to change and napped or went back to bed. I didn’t feel the need to call anyone in at this time. I was coping well and actually enjoying the sensations, knowing that labor could pick up at any moment. I had so desperately hoped that our son would make his way earth side the following weekend anyhow, so I just patiently (okay not so patiently!) waited for my labor to kick in, fully convinced that the full moon would call him out next week anyhow. I wanted to share a birthday with him, but he had other plans.
The following Tuesday, the one after the super moon, my sensations became strong enough and close enough together that I decided I needed to call in my doula and friend to help my husband and to help with our older children. (It should be noted at this time that THIS also played a huge factor in my labor story!) My friend/doula, who ultimately stayed with me the most throughout this month long ordeal, brought along her camera, some essential oils and her awesome take out ordering skills to the party. She fed me, making sure I was staying well hydrated and was quick to fetch either myself or my husband anything. She was our fairy godmother of the birthing world. She sat quietly and timed my contractions, being sure to only speak to me when I was not in the middle of a contraction. When she finally remarked about how close together the contractions were (after doing some acupressure points and my intensity level almost immediately picking up!) I looked at her and gave the signal to call our midwife. I kept thinking to myself, this is happening! We are really having this baby tonight.
I asked the girls (we had two helpers, one for photos/support and the other to help with support for all around) to start getting together the hose and items to fill the tub, all the while knowing in the back of my mind that I probably wasn’t as dilated as I had hoped. I remember Amanda saying to me, are you sure you don’t want me to fill up the tub? I insisted that I wanted to wait to be checked but that I felt like it could be soon. Yet another clue in my story that I should have been listening to my intuition! I knew, yet I didn’t know! Kim arrived and checked me, only to announce that I was 25% effaced and dilated to a 2. I was so disappointed that almost immediately my contractions vanished. It just wasn’t time yet.
“Okay” I thought to myself “you’re still a little more than a week out from your due date and Nano (what we call our middle child) was almost two weeks past his due date, you still have time. Relax!” I was so tired of being pregnant that I just built up my expectations that Sammy would come early. My birthday, September 25, came and went without a baby. I was disappointed, a little annoyed and a little sad but I still was in good spirits about being pregnant. Then the super moon weekend came and went, the weekend I was SURE our babe would be arriving on. Another week rolled around though and I was less than thrilled. I still was having contractions this whole time, with a few small bloody shows, but nothing major was happening. I was beyond annoyed now. My frustration was starting to build and this played a huge role in how much I started to doubt myself, yet my friend Amanda kept on encouraging me and a few other trusted doula friends were offering me advice and encouragement along the way as well.
My due date of October 2 came and went with no baby. At this point my brain started to flip a switch. My own self-doubts began to creep in and a remark that my husband made MONTHS prior to this kept replaying in my head. (I will get to that in a bit, it is quite relevant to my story.) I spoke with my midwife about my husband’s concerns, his (seemingly) unsupportive attitude and my own frustrations. I also started to play scenarios over and over in my own head about what would happen if baby did not make it out by 42 weeks. Again, this should have been another flag not to be ignored by myself, yet I was overly cocky about my previous birth experience and did not want to admit that a transfer could happen to me. Screw what I knew to be true (that every birth was different!) I was not about to let that get in my way. (Can you tell I can be radically stubborn?!)
Another week passed and fear began to set in. My midwife agreed that if by 42 weeks I did not have the baby, she would send me for a biophysical profile. I was overly familiar with these ultrasounds, as I had them frequently with my oldest child and I never doubted that I would pass with flying colors. My baby was active, I was doing well with keeping myself hydrated and for the most part eating a sound diet. I was also staying active, so I felt I was doing everything in my power to stay as healthy as I could. I probably could have done a bit better, especially in the end, but I have a lot of struggles with keeping a healthy view of food and some days I just didn’t care enough to fight myself and take better care of my body.
The Wednesday prior to turning 42 weeks my midwife saw us for a regular office visit. By this point we were nearly a month in with the stop start contractions and I was getting frustrated. She checked me for progress and I was getting closer to active labor, but still not enough progress to be there yet. By this point my own mother was asking me when we would be breaking my water, thinking that would be the magic solution to speeding along my process. She was worried about my well-being but also frustratingly persistent concerning my plan. I am a planner too when it comes to the big events, so I understand. I always want to know what the plan is but I am also okay with flying by the seat of my pants. My midwife knew this about me and could read me well enough to know when I needed to have a plan and when it was okay to just let things happen.
We talked to great lengths about what my plans were and what her recommendations were with proceeding forward. The big thing she kept saying was that we did have a small time crunch, but a lot can happen in a week. Give it time and relax. She knew something was bothering me but I had not voiced it to her. (Remember that comment I mentioned earlier?) She suggested I watch something funny, have an emotional release and to do some fear releases. She knew I struggled with anxiety and could sense that was playing a big role in what was going on with my labor. Maybe because I “know too much” and maybe because I get inside of my own head too much, but I needed to let some things go before I could birth my baby. I was holding him in, so we marched our not so happy little butts home and did just that.
Hypnobabies became a sometimes multiple times a day routine and I was thankful for it. Upon getting home I decided that I would finally address my thoughts with my husband. I cried a lot during this conversation but I shared with him how scared I was of another cesarean birth. I did not want to have my baby cut out of me, especially since I knew I could birth vaginally, but that I feared this was where my birth was headed. I shared with him about a remark he made when he had newly found out I was pregnant about having a feeling this birth would end up in a C-section. I shared, very tearfully, that he could not make remarks to me like this because I was in a sensitive place and these remarks wreaked havoc on my already frayed mental state. He felt awful and from that point on, unless he had major concerns that were needing validated, he kept his thoughts quiet.
This helped some and my contractions did in fact pick up again, but still no luck. My biophysical profile came and went. As I had suspected all was well and healthy. There were no concerns about baby or myself, so we were cleared to continue on a little longer. Sunday I was at the end of my rope and I met with the midwife again for a check. Some changes were being made again, but nothing major. She offered me some homeopathies to help move labor along and we agreed that we would meet Wednesday afternoon if labor did not kick in by that point to further discuss my options. I was determined that come hell or high water I was having this baby vaginally and by this point I didn’t give a rat’s ass where that occurred. I sure as hell wasn’t going to let any doctor boss me around though and I set forth to making a new plan should I land in the hospital. (Remember those little warning flags?! Here was yet another one!)
I barreled into Monday morning with a renewed sense of purpose. I was going to get this baby to come out, or at least some kind of meaningful labor to happen before Wednesday. My contractions picked up as soon as I started in with pumping and the cohoshes. My friend Amanda was given a heads up about our plan (this woman is seriously a saint!) and my husband made arrangements with work to be with me as much as humanly possible. We determined he would not take off work until things got going for real, but he would be there when I needed him. By Monday evening I was having contractions closer together and certainly more intense. Amanda came and I was ready to get this party started but when bed time rolled around things tapered off. I texted Kim and we chatted a little bit and determined we would throw castor oil into the mix as discussed at my last visit. Amanda camped on my couch, phone at the ready to call our midwife and our extra helper when the time came. The kids went to stay with my husband’s parents for the night and arrangements had been made for them to be picked up the next day by my mother, who had taken time off of work to help out with our little ones.
Tuesday in the wee hours of the morning my labor picked up again. I was awoken by strong contractions and I was elated! This was what I had been waiting for, yet something felt off. Since the kids were gone we were in communication with our families about what was happening. We assured them that this time was not a drill and we were for real having this baby. I was so excited I could hardly contain myself. I knew I had a lot of work ahead of me, but I was one determined woman. I had my husband call off work, since I knew we would be needing him around, especially once I started the castor oil as I had been instructed to continue on with. That stuff is NASTY! I mean it! Unless you are down to desperate measures, try to avoid it! The side effects, while desirable, are less than enjoyable. I found myself vomiting along with taking multiple trips to the bathroom.
My contractions continued all day long and that afternoon they became close enough together that we decided to call in the extra helper. While she wasn’t entirely needed, I felt like an extra set of hands would be helpful since Amanda had been with us for nearly 24 hours and could probably use a small break. She arrived and lent a hand getting things together. I had a few household chores that needed attending to and the girls were able to get them done for me so that I could focus on the task at hand.
My contractions kept on coming and showed no signs of stopping. I kept on with the routine of pumping, taking the cohoshes, walking and doing general self-care. Any time I would break from the methods listed above my contractions continued. After a while I was overwhelmed by everyone around and suggested I take some time to just be alone with my husband so I could refocus. I would call everyone back when the time was right or when I needed them again. A few hours later things got intense again, so I called back our photographer. I needed her doula support and she made the phone call to our midwife a bit later.
Once again the midwife came, but I wasn’t making any progress. I knew it was because I had too many people around earlier and she agreed that keeping it small seemed like a good idea. I didn’t need the added stress of trying to stay present when what I needed to be focusing on was getting my body to open and allow myself to birth. Prior to the midwife coming, I had Amanda fill the tub for me and once the midwife checked me, so agreed it was okay for me to labor in the pool for a little while, even though we all knew my contractions would slow down some once I hit the water. Slow they did, but the water felt amazing and I was able to relax and even hold a conversation with everyone for more than a few minutes. I needed that time, if for nothing else then to boost my moral and keep me present for the work ahead.
Kim stayed for a while and suggested I try and get some rest. She would stay for a little while but would let me sleep for as long as I wanted. At some point she headed home but she left assurance that she would be in contact with me first thing in the morning, unless I needed her before then. The next morning I was to do another round of castor oil and continue with all of the pumping and herbs. At this point I had made peace with the idea of transferring to the hospital, but wanted to give myself the rest of the night and the majority of the day Wednesday to gain some more progress. I knew, without saying it, that come evening we would be headed to the hospital. The tone of our labor shifted at this point from sheer determination to acceptance and preparation.
Amanda stuck around, sleeping in one of our children’s rooms while I rested, but was close at hand should I have needed her. I awoke Wednesday bright and early, showered, ate some eggs, started pumping, took a dose of castor oil and set about the day. Kim contacted me around 8am to check in. She stated she would be by sometime that afternoon but to please call her if she was needed. She would check in around lunch time and she assured me I was in her thoughts and would be close by if I needed her. Amanda forced me to walk stairs, feed me and I was encouraged to walk the block, taking special care to hike up the hill next to our house as much as possible. At one point in early afternoon, after a particularly rough time I started to exhibit classic transition symptoms. I was laughing and crying all in one sentence. I even said I just knew I couldn’t do this. My husband, bless him, knew what he was seeing and suggested a phone call be made to Kim to get her opinion. I have no idea what was said during that time, but I knew I was quite out of it. I was even getting sick. I had been having lots of bloody show that day, so we all knew my cervix was making changes in the right direction, and from what I could tell it was happening in spurts.
I proceeded to hang out in the bathroom for a while. Sitting on the toilet felt good, but as soon as I had that one meltdown, things went back to the pattern they had been in for two days by this point. If I had to use one word to describe it, erratic is probably my best choice. While sitting on the toilet I had one particularly difficult contraction where I felt like my water had broken. It was such a little amount though, I remarked to David and Amanda that it couldn’t have possibly been my water because it felt like urine. Both of them agreed it was probably just that because I wasn’t leaking anything, and we wrote it off.
Around 4 in the afternoon Kim called and said she was on her way over. We would talk about our plan for the evening and our options. I knew what this meant but I felt an amazing sense of peace wash over me. I knew I was heading to the hospital, but I wanted to talk through everything with Kim first. When she arrived she checked me. I was between 7-8 cm, what I had been the previous night, but I was now 90-95% effaced. Great news since I had only been at 50% the previous night! We talked over our options and breaking my water was discussed, however we both agreed that would be a poor choice since I was group b strep positive and did not want to risk infection. At this point the only other option was for us to wait a little longer or head to the hospital. With absolute mental clarity I agreed that transferring was the best option given my labor history with my son and the fact that I was a VBAC.
Bags were packed, the pool was drained and preparations were made to transfer. It was low stress, easy and a good choice I felt. There was no emergency or sense of urgency for me or baby, we just knew we needed to be there to have him. We loaded my car, headed over and I was checked in. I spoke with the nurses, where they got my personal and medical history and I met the doctor. I was quite firm with him that I wanted to VBAC and that I did not want antibiotics for baby or myself. (Maybe a little too firm, but my point was made and we came to agree to disagree.)
Once I was moved to a regular room the doctor personally checked me, where he declared that my water seemed to already be ruptured, because of this he strongly urged the antibiotics. It was then that we remembered the sensation I felt earlier in the day, but still he urged us. I asked for a minute to discuss it with my husband and he agreed to give us a few minutes. David, Kim, Amanda and myself all very briefly discussed it and everyone was in agreement that antibiotics, given my GBS status, would not be a bad choice. I consented and they were administered.
Dr. Selman was somewhat reluctant at first to offer Pitocin, since my contractions were so spread out and mild, but I pressed the issue and continued to ask for them. I knew what my body needed was just a little extra help to nudge it into active labor. Once the Pitocin hit my blood stream, the contractions became extremely intense. It should be noted that the doctor inserted a scalp electrode to ensure that my waters were in fact ruptured. We saw clear fluid and it was determined for certain now that my waters were broken. Since my waters were in fact ruptured the intensity was somewhat more challenging to deal with, but I continued to press on. I labored at this point with my whole body. I was also given the option to try out a new device that would eliminate the belts around my belly and give me some more mobility that the previous fetal heart monitors did not allow for. Since I originally wanted to move about, I jumped at the opportunity. It was torture to lay on my side for the ten minutes, but I’m glad I did it!!
Once I was able to get back up I labored on the bed, leaning over the back. I also labored beside the bed and even attempted the birth ball for a while. That said, I was exhausted and after five hours of enduring some of the most intense labor I have ever experienced I begged for the epidural. I will spare you the details of that experience, but suffice it to say I cried a lot during the insertion but profusely thanked the doctor once it was inserted.
It was agreed upon by my midwife and friend that they would head home for the time being. Amanda had been with us almost consecutively for three days by this point and needed to get back to her family. Kim wanted to nurse her son and get a little bit of sleep while I too rested. I was to call as soon as I started feeling the pressure most women experience with an epidural. I kid you not it was not fifteen minutes after they walked out the door that I started to feel that pressure! I remarked to my husband that I knew pushing was getting close but it wasn’t quite time yet. He should rest and I would wake him when it was time.
Roughly 10 to 15 minutes after that I felt the urge to push. I called my nurse in and told her what I was feeling. She agreed to check me, but I was only between an 8 or 9 and that I still had a little ways to go. I thought to myself, but I KNOW what I am feeling. Maybe if I get a bed pan and sit on it and have a stool I may feel better. As soon as I said that she sat me on only to think twice and check me again because I was uncontrollably pushing. She immediately calmly stated “Sarah, don’t push. The baby is right there.” I practiced what I had been taught as a doula to do and blew candles, but it really didn’t help. In my mind it was rather comical because the doctor was rushing in while gowning up and throwing on gloves. My epidural was turned off, but I still felt quite a lot. Our midwife was going to miss it, but David was able to call her and tell her briefly what was happening. We all had a good laugh about it later, because she even thought it would be longer before Sammy arrived!
Moments later I was given the go ahead to push. Almost immediately I felt the ring of fire. My baby was coming!! I felt a surge of determination and two beautiful pushes later I reached my arms up to grab my precious baby. He let out a lusty cry and immediately relief and pride washed over me. I cried as I looked at his perfect face and my husband kept telling me “good job Sarah! I’m so proud of you!! You did it!” I of course did all of the things a new mom does in the moments after birth. I checked to be sure he was still a boy. The nurses swooped in to wipe him off, but I was able to ask them to please leave him be. I did not want him bathed, he cord was still pulsing and he seemed like he was perfectly content parked on my chest. After a moment was had with our new baby, I looked up from my new son to apologize to the doctor for being so demanding and to thank him for being so patient with me. I told him he was fantastic and that I was glad he was the doctor on call when I came in. He knowingly nodded.
I had to have a few stitches to repair a small tear but otherwise everything looked good. I was sat up, nursed my baby, but then I started to feel hungry and extremely tired. Something didn’t quite feel right, but I figured I had been in labor for three days by this point, I was probably exhausted! Something deep down kept telling me that it wasn’t quite right, and it was confirmed moments later by my nurse who announced “I’m a bit concerned with your bleeding. I am going to run the Pitocin wide open if you are okay with that.” I consented knowing I had already nursed and if that didn’t slow my bleeding, a little medication was probably needed. I messaged my uterus and the nurse came back in to check on me about 2 minutes later. Still she wasn’t happy with how much blood I was losing and remarked my uterus felt “boggy.” Having attended quite a few births, but never having encountered that term before I knew it couldn’t be good. She said she needed to consult with the doctor. My husband looked at the other nurse in the room with a bit of concern in his eyes, yet he wasn’t saying much. I knew something was up. It was THEN that I realized why I had transferred to the hospital. I was bleeding more than I needed to, but I wasn’t in dangerous territory yet.
The nurse walked back into the room and looked at me very seriously. She was such a calm presence but I sensed the urgency in her voice. “Sarah, the Pitocin isn’t working and I need to see this bleeding go down quite a bit more before we send you to mother baby. Do you consent to Cytotec?” Oh gosh I thought, not THAT drug! I have always been terrified of that drug. (Remember how I said I know too much earlier, this is one of those cases where it is both a blessing and a curse….) I asked her if there were any other options and she calmly stated that short of a D&C or another drug that had worse side effects she would strongly suggest this drug. She gave me all of my options, but urged me to make a choice quickly. I elected to go ahead and take the cytotec and within minutes my bleeding slowed down to an acceptable level. I was safe now and I could relax with my baby by my side. David was able to breathe a sigh of relief too.
Everything from there was routine as usual. I was weaker than I had been after giving birth to Nathaniel. Most likely due to the blood loss and the length of my labor, but recovery was easy. I had very few problems nursing, although baby took some time to learn how to properly latch, Samuel still did well. I was treated with respect and even though it wasn’t where I wanted to be, I was able to appreciate that I needed to be in the hospital.
I learned from Sammy’s birth that we can often plan all we want, but that births will go differently than we planned, no matter how picture perfect your labor or birth is. I also learned that we are given instincts for a reason. We may not always know why they are there, but that trusting those instincts can be crucial. I also learned that trusting your care provider is critical as well. We have to work together as a team and if you can’t trust them, then it may be wise to consider other options. I trusted Kim’s opinion all throughout my pregnancy, labor and birth and because of that I was fully supported when it came time to transfer to the hospital. I also learned that pride about a previous birth experience does not guarantee where you will give birth. And I learned that a doula is an absolute must in the birthing experience! Especially when things do not turn out the way you planned them!
All in all my birth experience, while long, was exactly what I needed. I learned just exactly how strong I am and I learned that not all hospital births are bad. While my first birth shaped my second birth, my second birth equally shaped this one. Because of Allie and Nathaniel’s births I can proudly say “I had a C-section, a home birth after cesarean and a home birth transfer.” All three of my birth experiences shape me as a mother and hopefully will continue to shape me as a doula, adding humility in there as well.

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Congratulations on your little Sammy and thank you for sharing your story about being flexible when it comes to birth!

All Rights Reserved, Kimberly Sebeck, Knoxville Doula, 2015

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A Cautionary Tale for Doulas About Giving Medical Advice

Doulas who attend trainings with a doula organization are taught to not speak against medical provider advice. We are told that we aren’t to get between the clients and the medical providers. Yet, it happens. Usually it’s a very subtle thing, like our client calling us first to ask what to do if her water is broken. The proper response would be to ask their provider, of course, but perhaps we first offer some helpful tips like putting a pad on and seeing if it’s urine or letting them know the smell and color of amniotic fluid. Perhaps their provider suggests a procedure and they call us to get more information about the procedure such as what it is for or if there is an alternative. I like to think that these conversations are about helping the client educate themselves and get evidence based information so as to go back and have an empowering discussion and decision with their provider. What I would choose to do is not relevant and not only do I say that but I encourage the woman to listen to her gut feelings and ask for as much information and clarification as she needs.

Have I seen things that have given me pause? Of course. Have I felt like I would make a different choice at times? Yes. But none of that matters — it is not my birth. I am there to support decisions and facilitate the birth process no matter the circumstances. Now I will tell you about a recent scenario, with some details changed and names left out. Even after 15 years of being a doula, I am always learning.

One morning I receive a text from the client’s husband saying the amniotic fluid is very low and baby needs to be born and an induction is going to happen immediately. I text back and say ok, let me grab my stuff, call me when you can and give me details and how low is the fluid. I am told the level of fluid is an 11.  I won’t go into great detail over what is considered low and the fact that many providers perhaps are a bit overzealous with inductions for low fluid. In my head I thought the level is an 11? That’s not that low — but I correctly assumed that I was missing vital pieces of information. After a little while another text comes that the OB is recommending a cesarean. This really made me pause — why not an induction and trial of labor first? Again, I remind myself that I must be missing information as I know this provider and truly do trust his opinion and judgment and the fact he is called the male midwife in our area. I receive a phone call from the clients and get a little more information as I am driving to the hospital. The fluid was so alarmingly low that the ultrasound technician said there was none and as the OB explained to them that with there being no dilation or effacement of the cervix even past the edd that he was leaning towards a cesarean to safely deliver baby, but it was their choice.

I am confused, I admit it, but I keep it to myself.  My client is being sent straight to the hospital for monitoring and to make her decision about induction or a cesarean that afternoon. I assure them I am on my way and we will sit and discuss all the details so she can make a decision. When I arrive we sit and talk extensively. I ask the client what her gut feeling is. She says to do a cesarean, for a variety of reasons. She cries, we hug, we grieve a bit. Then we sit and discuss what she can expect for a cesarean. She is concerned that she has to wait a few hours but I assure her she is being monitored and if anything adverse happens that she and baby will be well taken care of. We spend the next few hours making sure the father gets all their stuff from home and gets something to eat and just going over things.

When it is time for the cesarean we are all prepped. This OB happily allows doulas or birth photographers in the OR. I have never been in the OR at this hospital with this OB — this is how rarely one of my client’s under his care gets a cesarean. I talk to the father while we are not allowed in for those few moments and keep him company and give him some advice for post cesarean care. We go in and the cesarean begins and I snap photos. Mama looks gorgeous despite the circumstances and I take some photos of her and speak reassuringly to them.

Beautiful baby girl is born in minutes, quickly taken to the warmer, and then given to Daddy for skin to skin. In moments we discover why the cesarean was an excellent decision. The placenta has already previously torn away in a partial abruption. There is virtually no amniotic fluid. An infection is suspected. The OB graciously shows this to me and we nod at each other over our masks. The surgery goes well and baby is given to mama on the way back to the room and we almost immediately initiate breastfeeding.

I stay for a few hours and we discuss what a good decision was made. I know that it’s a whirlwind of activity at this time and I offer to come back the next day to help process and give cesarean care tips. Unfortunately we had a huge snowstorm that night so I speak to them on the phone and come the following day. All is going well. We discuss the partial abruption and later we find out that the amniotic fluid level was not an 11 but instead was declared a 0.

Would it have been possible to have a successful induction? Maybe. Maybe not. No one is concerned about that any more because the decision has been made and it was an empowering and successful birth even if it wasn’t an unmedicated vaginal birth.

I am reminded yet again why we don’t give advice counter to medical advice. Doulas are not OB’s or midwives. We are not even labor and delivery nurses. There had been no symptoms of a partial abruption — no bleeding, no pain, no contractions. There was no fever to indicate an infection. Baby’s heart rate was good on the monitors. The week before the amniotic fluid had been at over a 20 level, then went to virtually none. Sometimes you take the signs, symptoms, and trends and have to make a tough decision.

I am reminded yet again why it’s important to have a birth team that you trust and also for my clients to trust their intuition. As we discussed while she was making the decision — no one could give her a guarantee either way of the best call. You make the best decision you can with the information you have at the time. Hopefully you have an OB like hers who doesn’t unnecessarily frighten or make you feel you don’t have a choice. She had a choice and the risks and benefits of both were clearly outlined. Yes, mother and baby were both fine and healthy but the bonus was that my clients felt empowered in their decision and were supported all the way and their emotional health was considered and supported.

Being a doula is a precious role and one that should stay within the proper scope of practice of non medical advice while offering emotional and physical support.

All Rights Reserved, 2015, Kimberly Sebeck, Knoxville Doula