(Trigger warning: discussion of maternal and infant mortality rates)

Or maybe you’ve heard this one, “Healthy baby, healthy mama. That’s what counts.” Are these platitudes true? I think they are absolutely true. But are they really all that matter?

Do Birth Plans Work?

Many people go into birth with a plan. You might have preferences and intentions that you and your care team work to make happen, but the reality is that in birth there are detours. Birth plans are a great way to get you prepared for labor and birth, and have many benefits, but they can not guarantee perfect outcomes.

Sometimes the detours are simple and easy to work around. Other times, they can be very scary and some people have an experience that feels not only like one that is not what they originally planned for, but one that can feel traumatic. Some people end up feeling like birth became a rip current that pulled them off their feet and underwater only to spit them out 50 yards down the beach. I’ve heard many women describe feeling out of control, confused, sad, overwhelmed, and guilty. They might be wondering, “What if I had done something different…”

Am I Wrong for Feeling Like This?

I want you to know that it is absolutely normal to be feeling and thinking ALL the thoughts and feelings you are having—the guilt and sadness, the confusion and feelings of being totally overwhelmed. It’s all so very normal, and it’s also specific and highly personal. It’s a very big thing that your body and brain and emotions are trying to process.

Even more, you might compare your situation to those of others and try to talk yourself out of some of these emotions by thinking, “Well, at least we are safe and healthy now.” That might be true, but it is also very true that a big thing happened and that your feelings are totally valid.

Those feelings, especially the guilt, do not mean that you deserve blame for anything. You did the best you could in each moment on this journey with the information and support that you had. You are here just because you are here, and NOT because you did anything wrong.

You may never know the reasons for everything, so it’s important to feel those feelings, let them move through and out, and then move forward knowing that difficult things just happen sometimes, and you are going to keep doing the next right thing as you know it. No one can do any better than that.

You might also be made to feel that you are ungrateful if you share that you’re not OK about your birth experience as long as everyone is healthy. You might feel pressured to shut up, shake it off and move on, ”At least I have a healthy baby.” When someone makes you feel bad about the feelings you are having, it’s usually not about you. They have their own issues that are coming up for them. They may have had a traumatic experience that ended badly, or maybe they never did and can’t understand what you might be feeling.

Use it for Good

Hopefully you can find some compassion for those people who aren’t able to sympathize. And hopefully you can find plenty of compassion for yourself. Compassion is a very positive feeling!

And remember that you’ve gone through difficult things before. For me, it helps to remember those times and recognize that I did get to the other side of it. I also like to remind myself that, in many ways, I am now better, stronger, and wiser for having lived it. This is one of those moments. You are already stronger and wiser, and you can get to the other side of this too.

Racial Disparities

The difficult emotions might be felt even more in certain racial communities. There are big disparities in care in the United States. The risks of pregnancy and birth are higher for black, brown, and indigenous people, and especially for black women. This is caused by a combination of factors, with systemic racism and implicit bias being the foundation of it all. This should not be happening. This is preventable.

For many of these families, finding out they are pregnant can bring an even greater range of emotions. They might be very happy to be pregnant and expanding their family. They also might feel afraid for their lives or their baby’s. So many more black families fear death as a result of birth than any other racial group, and with good reason. In this case, when they survive the experience, they might feel especially relieved and grateful. But does this mean that they received excellent care and feel completely positive about their experiences?

What to Do?

I encourage all families, and especially black families, to find a supportive care provider, maintain good prenatal care, hire a doula, take birth classes or educate yourself about labor and birth, and make a birth plan. I want everyone to feel empowered going into their birth. That should help you feel less afraid. It’s important to understand your body and your options, and it’s important to have support and an advocate.

It’s About More Than Just Survival

I also want ALL families to have the expectation that they will more than just survive their birth experience. You can and should expect more. Birth can be a positive experience, even when things don’t go exactly as planned. When it’s not a positive experience, it is your right to question that, remembering that it was not your fault. What went wrong? Were there missing pieces in your care? Were you given true informed consent at every step? Do you feel like you were not just a patient, but a true partner and leader in your health care? It’s important to ask those questions out loud. I recommend talking to your providers, and also using the Irth App to share your experiences, good and bad.

And please try to remember this. While there can be other complications, most everyone does survive pregnancy and birth. It’s true that the United States has some of the highest maternal mortality rates in the world compared to most high resource countries. And mortality rates are more than doubled for black families than for white non-hispanic families, and this is unacceptable.

But for your peace of mind, remember that the absolute risk for mortality is still very small. For black women, the risk of death is .05%. For white women, it’s .019%. So, while there is some risk, and there is increased risk for black women, it does not mean that you are most likely to have a bad outcome. You are most likely to have a good outcome.

It’s important to maintain this perspective, so that you can enter your birth time with more confidence and peace. High levels of stress can contribute to complications, and that is definitely not the goal. Keep this perspective while you educate yourself and build your excellent care team. This kind of preparation will help you navigate your labor and birth with more presence and resilience and will also help lower your risks.

We all want healthy bodies and healthy babies, and we all deserve that and more. You deserve to survive and to feel good about your experience.

References:

• Timing of maternal mortality and severe morbidity during the postpartum period: a systematic review
• Maternal Mortality Rates in the United States, 2022.
• Systemic racism: individuals and interactions, institutions and society | Cognitive Research: Principles and Implications
• Systemic Racism
• American Black women face disproportionately high rates of maternal mortality | PBS News
• What is the difference between absolute risk and relative risk and why on Earth should I care?
• Relative vs Absolute risks: Why Relative Risks Are Misleading, and How To Communicate Absolute Risks

When people register for my birth classes, there’s a question on the form that asks what they’re most hoping to learn about. One of the answers I see most is about breathing during labor. We hear A LOT about the importance of breathing techniques for labor. Maybe you think about breathing for pain coping, or maybe for helping you stay relaxed. (class spoiler: relaxing DOES help with pain!) Whatever the reasons are for wanting to know more about breathing during labor, I want to answer this question.

Where did Breathing Techniques come from?

Who knows! I’m sure even very primitive people figured out that breathing in certain ways was helpful during childbirth. A lot of people figure this out through trial and error during their own labors even when they don’t get to take a birth class.

You might have figured out that breathing well helps you in other situations. Maybe you’re a runner, and you recognize that the way you breathe makes a difference when you’re running. Maybe you’ve been injured or experienced pain in other situations where you noticed that you were holding your breath and that made things feel worse. It goes WAY back and it comes from within. BUT that’s probably not why people keep asking about it on birth class registration forms.

In 1960, both the International Childbirth Education Association and Lamaze International were formed in response to a new “Natural Childbirth” movement in the United States. Up until the 1950s birth was still often at home, or in hospitals under extreme sedation and often with unnecessary and dangerous surgery.

Mortality rates actually did not go down when hospital birth rates increased until the late 1930s when sulfa drugs were developed to treat infections. Many hospital birth practices were being reconsidered as unethical and even harmful, and many people were afraid after seeing some of those birth outcomes.

Grantly Dick-Read was an obstetrician from the UK who wrote a couple of groundbreaking books in the 1930s and 40s, including Natural Childbirth and Childbirth Without Fear. It was the right time in the United States for those books to take hold, and they helped create a movement toward better birth care.

Additionally, Dr. Fernand Lamaze from France introduced his “natural birth” method in 1951 which formed the basis of the “Lamaze Method” of childbirth education.

These new childbirth education organizations began taking the messages of Grantly Dick-Read and Fernand Lamaze to the general public mostly through hospitals. You may have heard of Lamaze breathing! Lamaze did put a lot of emphasis on breathing techniques in their classes. Lamaze is still around today, and is one of the leading methods for unmedicated childbirth education. Things have changed some though. We still understand the importance of breathing well during childbirth, but the focus has shifted.

How does breathing help?

When I teach birth classes, I DO discuss the importance of the breath. There are a lot of things that breathing well can help you with.

• lower blood pressure and heart rate
• lower levels of stress hormones
• reduced lactic acid build-up in your muscle tissue
• balanced levels of oxygen and carbon dioxide in the bloo
• increased physical energy
• increased sense of relaxation
• improved relaxation and/or engagement of the pelvic floor and other muscles

All of these things can be really helpful when you’re in labor and giving birth! Unfortunately, so many of us do not know, or don’t remember, to focus on breathing.

FIRST get conscious!

Even if you don’t learn anything else about breathing during labor, this one thing will probably help you.
Take your breathing from unconscious to conscious. This means that you will start by making your breathing conscious. We don’t usually think about it, it’s unconscious. We just breathe. That’s usually a good thing. We wouldn’t want to forget to breathe! But the fact that breathing is usually unconscious can sometimes lead to problems.

In preparation for labor, start by just paying attention to how you’re breathing. You might not need to do anything about it at first. Just practice bringing your attention to how you’re breathing. Practice doing that often. It might still be involuntary since you’re not really controlling it yet, but now it’s conscious.

Then get voluntary

Once you’ve gotten pretty good at observing yourself breathing, you might start to use some breath control techniques. You’re going to work on taking your breathing from involuntary to voluntary. When your breathing is conscious, you may notice that you’re not breathing in a way that is most beneficial to you. When you can catch that, you can do something about it. Here are some things you might try instead.

• Natural breathing: I like to imagine that my body is a balloon. Air goes in, and the balloon gets bigger. Air leaves the balloon, and it deflates. When you’re breathing in a healthy way, that’s what it should look like. Sometimes when we’re under stress, we do the opposite. This is not the best way to oxygenate, and it’s also sending a signal to the brain that something stressful is happening. This is especially bad for labor, because it might mean that your labor slows down or stops. This is a protective mechanism. Your brain knows that a baby shouldn’t be born into a threatening (stressful) situation. What if there was a predator?! Shifting to a natural breath pattern might be all you need to do to feel much better.
• Deep breathing: You might take it a step further and breathe in and out more deeply. Each breath takes a little longer when you do this.
• Diaphragmatic breathing: Taking it a little further still, you can practice directing your breath all the way down into your belly. You breathe in while you focus on making just your belly bigger and rounder. You breathe out, and your belly deflates. This technique gives your big breathing muscle, the diaphragm, a chance to go through its full range of motion. This also causes your pelvic floor to contract and release in response. It’s great to use this technique before labor to get in some pelvic floor familiarity and training, and also during labor! Relaxing your pelvic floor can help reduce discomfort.
• Relaxation breathing: This is a way to reduce your stress. If you notice that you’re getting really anxious, try it. All you have to do is make your exhalation longer than your inhalation. You probably breathe in and out about evenly normally. When you’re just starting to drift off to sleep, your exhalation gets a little longer. When you can do this consciously and voluntarily, you might feel very relaxed, just like when you’re starting to fall asleep. This is a great technique for reducing anxiety because you’re telling your brain that everything is SO OK here, that you’re even able to fall asleep.

There are a lot of other breathing techniques you might be able to look up or learn about in a class. They might be helpful in some situations. I chose these few, because I think they’re pretty universal. You will most likely benefit from using these at some point during your labor. They are not the most complicated, and usually don’t take too much practice to master.

I DO recommend practicing these techniques before you go into labor. This will benefit you during pregnancy, but will also be great preparation for birth and useful during labor. The more familiar you are with the techniques, the more likely you remember and use them. If you get the time to take a comprehensive birth class or a pain coping class before labor, you’ll likely learn some breathing techniques and a lot more. I highly recommend a class for so many reasons, but a big one is so that you can lower your stress levels now and feel more confident going into labor that YOU CAN DO IT.

Reference

https://www.sciencedirect.com/science/article/abs/pii/S0014498307000241?via%3Dihub

If you’re wondering whether you should tour your hospital before you go into labor, my answer is YES! If you can only do a virtual tour, do it! If you can go in person, that’s even better. If you can do it before choosing a location, that’s best.

Choosing a Location

It’s important that you feel comfortable and safe in your birth setting. Labor is a very hormonally driven bodily function, and stress hormones can interfere with its safe and easy progress. However, it’s not possible for everyone to have choices. There are parts of the country where there might not be ANY maternity hospitals, or where the nearest one is uncomfortably far away and the next nearest one is twice the distance. It’s possible that the nearest hospitals don’t provide excellent care or have a NICU. Your insurance might also limit your options.

Some people might opt for a home birth or birth center setting instead, and that could be the right thing for you, especially if the hospital option causes you significant difficulty or stress. In this case, there are likely midwives with good experience and credentials, and you’ll want to make sure you do your homework when choosing your provider just like you would a doctor or hospital.

For others, the idea of a birth center or home birth is stressful. Some people feel most safe in the hospital setting, and will choose it regardless of any difficulties. In this case, people who live very far away from their nearest hospital might decide to stay with family or friends nearby, or rent a home or hotel in the days or weeks leading up to their due date. This actually happens quite often, and might be a good choice if it gives you peace of mind. Keeping those stress levels down can be really helpful!

What to choose first, provider or hospital?

Remember that if you have chosen a specific doctor or midwife that you feel very safe and comfortable with, you will most likely only have one option for your birth location. So if you don’t want to have to switch providers, you’ll need to go wherever they attend births.

Some people choose the hospital first, provider second, other people do the opposite. Either way works as long as you feel like it’s the right thing for you.

Getting a Feel for the Best Location

If you’re in a situation where you have multiple good options, visiting the locations can help you choose. It’s best to schedule a tour with the labor and delivery unit if you can, or you might just go visit the hospital on your own if that’s not offered. You can read about all of the options and amenities on the websites, but visiting the hospital can give you a feel for what it will be like to be there as a patient. Even when you’re choosing from several excellent hospitals, each one will have its own personality, and one might feel more or less right for you. As long as the other things that are important to you, such as doctor availability, cesarean or episiotomy rates, distance from home, etc. match up pretty closely, it’s great to go with what feels right.

Reasons to Tour

There are a lot of very good reasons to tour the facility whether you’re still undecided or whether you have chosen already.

1. Parking: It can be stressful to find parking at a hospital. At some facilities it’s very easy, but others have a more complicated set up, so going there and actually driving around can help you feel more at ease and prepared for the real thing. If you find that the parking situation is too stressful for you, you might instead plan to get a ride to the hospital. You can ask a family member, friend, or neighbor to be on call for you, or you can hire a rideshare or taxi service.
2. Hospital navigation: Some hospitals are HUGE or complicated. Some are big enough to have multiple elevators that don’t all go to the same floors so even finding the right elevator to get you to the right floor can be tricky. Some hospitals have lots of good signs to help you find the right department, but others don’t. Going there and getting familiar with the layout can help you feel more sure of yourself for finding the right place during labor.
3. Personality: Each hospital has its own personality. It might be very bright and cheerful. It might be more elegant and serene. How do you feel when you walk in? If the hospital matches your personality, you’ll probably feel better being there.
4. Amenities: It might be helpful to see all of the available amenities at a hospital. You can usually expect to be a hospital patient for about 3 days in the case of a quick vaginal birth and as long as 6 days or more with complications, a long induction, or surgery. A hospital stay can be more pleasant when the rooms are bigger and when the facility has some conveniences like good food nearby and comfortable waiting rooms or family areas.
5. Information: Guided tours can offer lots of great insider information about the hospital. Make sure to take ALL of your questions and take notes. Depending on your tour guide, you can expect to come away with a lot more information than you might get just from reading the online materials. Here are some examples of questions you might want to ask if it’s not covered during the tour:

• • Will it help to call ahead when I’m in labor? Will someone meet us outside?
  • What’s the best way to handle parking/getting in?
  • How long does the triage process usually take and what all is involved?
  • Is there ever a waiting time to get into a delivery room?
  • I’m interested in using these (insert your favorite things such as balls, showers, bath tubs, wireless monitors, squat bars, warm compresses, etc.) tools for labor, do you have them here? Or do I need to bring my own?
  • How much of the time will I have a nurse with me in direct care?
  • I get hungry often and I’m nervous about not being able to eat. I’d like to bring some of my own healthy snacks from home. How is that usually handled during labor?
  • I’m interested in using peanut balls during my labor. Is everyone here comfortable with helping me use them?
  • I might like to try multiple positions for pushing during labor. Will I be well-supported?
  • What is the policy for cervical checks here?
  • How often do you see episiotomies happen here?
  • What is this hospital’s cesarean rate? (It’s also important to ask your own doctor for their cesarean rate if you have that concern. Even if the hospital has a higher rate, your own doctor’s might be especially low and that might be even more important.)
  • How long does it usually take to get an anesthesiologist here for epidurals? I’m planning to have one and just want to know so I can decide when to ask for it.
  • I plan to breastfeed exclusively. How will I be supported toward this goal? Immediate skin-to-skin? No separation from my baby? Delayed procedures?
  • Can I expect to visit with a lactation consultant at some point? And when?
  • If I can’t be with my baby for any reason, can I expect help expressing breast milk and getting it to my baby?
  • Is donor breast milk available if I can’t provide milk for any reason?

How to Tour

You might call the hospital labor and delivery unit to set up a tour, or you might set it up through your obstetrician’s office. It’s a good idea to ask about this during one of your prenatal visits. They will likely be able to steer you in the right direction.

Once you have it set up, I love to encourage people to do a dry run. Pretend that you’re actually in labor. Of course, you probably won’t know exactly which day of the week or what time of day you’ll be needing to head to the hospital, so it’s fine to do this at any time.

Parking

You might time how long it takes to get there and find parking. If the parking situation is tricky, ask someone about what you should do when you’re actually in labor. Sometimes they’ll offer an easier suggestion such as temporarily leaving your car near a particular entrance while you get to the right place in the hospital and then letting someone take your car to an appropriate parking spot. As long as parking is fairly simple, I do like to recommend that everyone park and walk in together. I don’t like the idea of dropping off the laboring person in front of the hospital to wait or find their own way in.

Drop Off Procedures

If you need to do a drop off because of a complicated parking situation, I recommend doing this in a modified way. You can probably find a place to safely leave your vehicle for a few minutes with the hazard lights on until you can be escorted to the right area or handed off to someone who knows where they’re going, preferably a doula or nurse.

Things to Pay Attention To

While you’re touring, imagine what it might be like to be in labor and in recovery there. What kinds of things will you want or need? Consider some of these things:

• How’s the lighting?
• Is it noisy or quiet?
• Is the bed comfortable?
• Is there a bed for your partner and is it comfortable?
• Do they have the tools you might like to use during labor and for postpartum such as:
  • birth balls
  • peanut balls
  • squat bars
  • wireless monitors
  • pads
  • gowns
  • etc
• What is the bathroom like?
• How’s the storage? Will you find places for all of your things?
• Is there room to move around?
• What about for the baby?
  • blankets
  • diapers
  • bed
  • clothing
• How about towels and bedding? Do they work for you, or will you want to bring your own?

You might feel a lot better after taking a tour. Most people have never seen a live birth and when you’ve never given birth yourself either, it’s very hard to know what it will be like. Doing a dry run and getting to know your facility can remove some of the mystery and stress. You’ll have a place to visualize, and can do some things to prepare for your experience in that place. Everyone could use a little more peace of mind leading up to their first birth and parenting experiences, so do this for yourself!

Birth plans can be a surprisingly controversial topic. A lot of people think they are a great idea and even essential. I sometimes work on birth plans individually with families and have had people tell me that their doctors have even required that they bring a birth plan to their next prenatal appointment!

Other care providers don’t like them. They might argue that birth is unpredictable and it doesn’t make sense to set up unrealistic expectations with a birth plan. The intention behind this advice is to avoid making a birth plan so people can avoid disappointment if things don’t go as planned. Others might say that a birth plan is an indication that a person is less concerned about health and safety and overly concerned about having a particular kind of birth “experience”.

Some of that makes sense, although I think it leaves some things out. First, I’ve worked with dozens of families in making birth plans, and I know for sure that none of them were more concerned about having a certain kind of experience over their health and safety or their baby’s. Everyone’s first priority is health and safety, but it’s also important to recognize that that is just a baseline. We should have the expectation of health and safety when we choose a good location and provider and because birth is inherently normal and safe. Birth is not, in essence, a medical emergency. It’s a healthy person experiencing a normal function of their body.

It’s more than OK to aspire to more than just surviving birth. I would even argue that it should be a high priority of care providers and facilities to aspire for more. Of course mothers and babies should survive the birth, but we can also help them have a positive experience and thrive.

Family Centered Care

An important piece toward that goal is providing family-centered care. That puts the family in the central decision-making role, with their care providers offering guidance and support toward their goals. For a family to be able to make decisions, they need to be informed, that’s true. But there are other considerations too. A person’s upbringing, culture, religion, values, and past traumas all have to factor into their decisions. That’s the only way to know what their true preferences might be, and how they might be able to have a healthy AND positive experience.

So, I think that, YES, you should make a birth plan! I encourage you to think of it more as a list of birth preferences. When I talk to classes and individuals about the birth plan making process, the leading thought is “As long as all is going well and everyone is healthy and safe, here are my preferences.”

How are Birth Plans Helpful?

The following list shows how to make a birth plan, but also how birth plans are beneficial.

STEP 1: I recommend that people start by taking a birth preparation class of some kind, or finding another way to learn the basics of birth.

STEP 2: As you are learning more about the birth process, you might start to develop some ideas about what it might look like for you. The next step to making a birth plan is to develop your birth vision. You might just talk it through with a trusted person, or you might write it down, draw it, or even just imagine it. Once you have a solid vision, you can start making your birth plan. The process of developing your birth vision is one of the things that makes birth planning so valuable! A lot of people never do this, and they go into labor without a clear vision. That can definitely make things feel more out of control and scary. When things feel out of control, if you are faced with a decision, you may decide not to participate. Birth can feel traumatic when you believe that everything is outside of your control, and when you don’t decide on or understand what is happening to you.

So, even if you stop here with your birth plan, you’ve done something positive for yourself. But I encourage you to take the next step!

STEP 3: Once you have a rough draft of your birth plan completed, the next step is to take it with you to prenatal appointments with your care provider. Most people have the experience of going in and out of those appointments very quickly. You do the basic assessments, and then your provider likely asks if you have any questions. So often we leave without asking anything, only to remember later that we did have questions! So next time, go in with your birth plan. It can be a great communication tool. You can go over it with your provider and ask any questions that it might bring up. They can even help you refine your birth plan since they know a lot about the facility where you’ll be giving birth and your medical history.

STEP 4: Once you have a final draft, you can take it with you at birth time. I recommend having several copies since there could be staffing changes while you’re there. You might even want to tape one to the door of your room. This is for all the people who haven’t met you yet. There may be nurses, doctors, midwives, or even interns visiting with you, and it can be helpful to give them some guidance for helping you.

Birth Plans and Breastfeeding

Of course I couldn’t complete this article without mentioning the importance of birth plans for breastfeeding success. There are some birth practices that can make breastfeeding more or less difficult. If your goal is to get started with breastfeeding most quickly and easily, and then continue to breastfeed, it’s important to learn about some of those things and incorporate them into your birth plan. Some examples include:

• Recognizing the potential impact of IV fluids on breastfeeding or avoiding IV fluids except when necessary for safety. A lot of fluid can cause issues with swelling and engorgement which can interfere with breastfeeding. It’s good to recognize that if you do get IV fluids during labor, it’s possible that your baby’s weight will be a little higher due to the excess fluid. Some recommend using a day-two weight instead of the birth weight as a comparison point when assessing weight loss or gain.
• Avoiding early induction when possible so that the baby is born fully developed with a coordinated suck-swallow-breathe pattern.
• Refrain from certain medications during labor that can cause sedation in the newborn, preventing early breastfeeding.
• Epidural anesthesia itself is not likely to cause a problem, but has shown to increase the risk of forceps or vacuum assisted deliveries which can lead to an interference with early breastfeeding if the baby experiences some distress and needs time to recover.
• Encouraging immediate skin-to-skin contact with mother. This provides closeness and some physiological cues to the baby and to the mother’s body that can increase breastfeeding success.
• Aim for little to no interruption of skin-to-skin contact. That usually means delaying procedures and keeping the baby on the birthing parent’s body even through delivery of the placenta. It’s best to delay an interruption until at least after the baby has had a successful first feed.
• Encourage early initiation of breastfeeding. When the immediate skin-to-skin contact time is uninterrupted, it’s likely that the baby’s first hunger cues will be recognized and acted on immediately, ensuring the best outcomes.
• Avoiding cesareans when possible, because surgery can make breastfeeding more complicated. But there are some things you can do to make things go as smoothly as possible including:
  • Immediate skin-to-skin contact in the operating room.
  • No mother/baby separation and help with early initiation of breastfeeding in the operating room.
  • A gentle or family-centered approach can offer a less stressful environment for families, making breastfeeding easier.

If you’d like assistance making your birth plan, we offer a class to help you put your wishes for your special day into words. Check out How to Make a Birth Plan!

Resources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3868283/

https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/15-analgesia-and-anesthesia-protocol-english.pdf

https://www.bfmed.org/assets/7%20ABM%20Model%20Maternity%20Policy%20Supportive%20of%20Breastfeeding%20English.pdf

https://evidencebasedbirth.com/iv-fluids-during-labor/

https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-015-0043-8

Traumatic childbirth is something that happens. Sometimes that’s because of truly life-threatening situations, but more often it’s other things that happen. Those things might be perceived as life-threatening, even if they’re not, for any number of reasons. Those things might even be reminders of something scary that happened in the past. A lot of times, these situations get out of hand because people don’t have a proper understanding of what is happening, or because they don’t have a good support system. 

The term “trauma” gets tossed around a lot in common conversation, especially lately. Some people have a very broad understanding of what it is while others have a very narrow definition.

What is Trauma?

An official dictionary definition says that trauma is “a deeply distressing or disturbing experience.”

That is pretty broad, actually. And it can mean very different things to different people. One person can experience strong turbulence on an airplane as no big deal while another person on the next row may experience extreme distress. It might be that person had been on a plane that crashed before, or they lost a family member to a plane crash. The reasons don’t really matter. What is most important is how that person feels at that moment.

They will have physiological symptoms with this level of distress. They may experience heart palpitations or a rapid heartbeat, trouble breathing, raised blood pressure, sweating, blurred vision, muscle tension. They may have the unshakable belief that they are about to die. The present experience may not be enough to cause an initial trauma for most people, but for someone with a past trauma, it is a problem. This is why we can never decide what is or isn’t traumatic for someone else.

Triggering Past Trauma

These situations where someone re-experiences a past trauma can have a big impact on their current and future experience. They may develop associations between that sense of their mortality and anything related to that flight. It might be the sights and sounds of an airplane. It might be the smell of the perfume that the person sitting next to them was wearing. Any similar sights, sounds or smells might produce some of those same physiological effects. Any of those things may forever trigger panic for that person. If a nurse at the hospital is wearing the same perfume, it might trigger a response that they then associate with their experience of being in the hospital for labor. That new situation becomes something stressful just because of that association.

Now imagine being someone who was sexually assaulted or molested as a child. Imagine being someone who experienced waking up during a surgery. Imagine being someone who watched a loved one die while getting medical care in a hospital. These and SO MANY other situations can cause trauma. Then imagine getting pregnant and knowing that you are facing maternity care and a hospital stay. These people may have triggers that can be very easily touched during labor and birth.

Trauma Informed Care

Trauma-informed care is what all health care providers should aspire to give. There are many training programs out there that can help health care providers avoid re-traumatizing their patients.

The very good news is that even though you can’t always predict what will trigger someone, it doesn’t take much to prevent most of it. A lot of it is already the kind of care that is required by law. The “law” or practice of getting informed consent says that health care practitioners must provide complete information to a patient about an intervention and then wait for consent before administering the treatment or assessment. That means that they should have a detailed conversation with their patient. They should tell them about what it will be like, how long it will take, the benefits and risks. They should also go over alternative options if their patient is unsure. Just the process of having this informed consent conversation might be enough to avoid triggers and keep away panic.

Birth Trauma

Statistically, about 70% of people have experienced some kind of trauma that could cause distress during the labor and birth process. Sadly, that’s a very big number.

Some examples include:

• Rape
• Sexual assault
• Assault
• Sexual harassment
• Domestic violence
• Child abuse and neglect
• Child sexual abuse
• Serious injury and hospitalization of self
• Serious injury and hospitalization of a loved one
• Surgery
• Assault by a medical care provider
• Medical related trauma

There are a lot of things in a hospital or birth setting that could trigger memories of these traumas or a trauma response. The following is not an exhaustive list but includes some of the more common and obvious situations that could cause trauma in the birth setting. When someone who has had one of these traumatic experiences gets pregnant and needs to receive prenatal care and hospitalization for labor and birth, these are just some of the many things that are common triggers.

Some of these things include:

• Cervical checks
• Being touched in any way, but around the genitals especially
• Being confined to bed with restraints such as arm straps or stirrups
• Feeling out of control
• Lack of privacy
• Not having an understanding of what is happening to their bodies – lack of communication
• The sound of codes being called over the speaker system
• Needles
• Sharp objects for cutting
• People wearing lab coats or scrubs or other safety equipment such as masks or gloves
• Beeping machines
• The smell of disinfectant
• Nudity
• Blood

The list could go on. It’s clear that maternity care settings may offer many triggers for some people. It’s very important to understand your particular situation and what your triggers might be. Good communication with your care providers might be helpful, but you are under NO obligation to share more than you’re comfortable.

Birth Plans

Making a birth plan is a great way to start. You can do this yourself, with a loved one, or with a doula. It’s best to start by taking a childbirth preparation class. This will help you understand the process of labor and birth better so you’ll have some reasonable expectations. It’s also a great idea to take a tour of the facility where you’re planning to give birth.

On a birth plan, you can list all things you’d like to focus on and all the things you’d like to avoid. You can go over that with your care provider at prenatal visits to see what they might be able to help you with and to make sure all of the things are available in your birth setting. Again, you may like to explain why you need certain things, but you don’t have to. Good trauma-informed care also means accepting the preferences of their patients without having to be convinced of the validity of those preferences.

Therapy and Support

In addition to having a solid birth plan, it can be a great idea to look into therapy or support groups. You can talk to people who have had similar experiences and have similar concerns. You can talk to a professional with the skills to make you feel more confident about your pregnancy and upcoming birth. They can offer suggestions for things you can do to keep anxiety levels down as you prepare for birth, and possibly even some things you might like to add to your birth plan.

If you have a supportive partner, they may be able to help you in many ways. If you feel comfortable talking to your partner about your concerns, it might help to verbalize those things to a safe person.

Whether you’re able to share details or not, a supportive partner can be a great advocate for you. They can help you make a birth plan, and even more importantly they can learn it. They can memorize that plan because they understand it’s very important to you that certain things happen or don’t happen. They can be vigilant during your prenatal care and labor so they can catch any issues that might come up and handle it in a way that means you don’t have to.

For example, if you are aware that cervical exams are triggering for you, you might include a line item on your birth plan that says you’d like to minimize those checks to only those that are absolutely necessary. Your partner can be on the lookout for any unnecessary cervical checks. During a check that you consent to, your partner may also step in and ask questions so the provider understands that you’d like to know exactly what is happening during the procedure. They might ask questions for you like:

• How long will this take?
• What positions are available for this procedure?
• What are you going to touch first? And then?
• What will this feel like?

Having your partner ask questions can sometimes prompt the provider to be very communicative during the procedure. For a lot of people, this level of communication can prevent triggering the trauma response. It can reduce the feeling that you are not in control while someone is touching your body. It can remove the sense that something is happening that you don’t understand. That can be very comforting to people dealing with certain types of trauma.

Trauma Response Symptoms

I think it’s great to recognize that there are so many ways to help you move through the experience of pregnancy and birth without feeling overly anxious or traumatized. With great support and some preparation, this is definitely possible. It’s also great to have some tools available to you in the case that you do get triggered. It’s important to recognize what happens when you’re having a trauma response. Some of the more common signs include:

• Freezing
• Withdrawal
• Inability to communicate or make decisions
• Zoning out
• Flashbacks or feeling disconnected from the present moment or reality
• Anxiety symptoms
• Irritability or anger

If you know how you tend to respond or how you might respond, it’s great to communicate this with someone on your team if you can. It can help them to know what to look for so they can be available to help change the situation with you. Some tips for stopping the trauma response include using physical cues to draw you back to what is actually happening. These might include:

• Smells that are calming to you
• Being touched in a particular way
• Squeezing a toy or someone’s hand
• A certain song or sound
• A cold or warm compress or drink

Postpartum Responses

Since it’s not always possible to avoid being triggered, it’s also great to recognize what might happen later and seek help. If your birth experience does feel too hard or even traumatic, you may experience some symptoms afterwards. Some of the symptoms of trauma can resemble postpartum mood disorders such as depression, anxiety, and OCD. For birth-related trauma, AND for postpartum mood disorders, it’s a great idea to get help from a perinatal mental health professional. They can help you distinguish between a mood disorder and a trauma response. They can help you process any trauma, and that can go a long way in helping you achieve some peace and continue your parenting with more ease.

Breastfeeding and Trauma

Breastfeeding can sometimes be triggering too. If you’re concerned about this, it’s a great idea to be thinking about it. Taking classes to prepare might be helpful, but it’s also sometimes a ‘wait and see’ sort of situation. For a lot of people, actual breastfeeding is not as triggering as the thought of breastfeeding was.

If you visit with a lactation consultant, they should offer good trauma-informed care so that your visit is less likely to be triggering. They should offer plenty of explanation and communication about what is involved in a consultation beforehand and as the session progresses. They can either not touch you at all if you prefer, or only touch with permission and lots of communication. You should also have as much privacy as you need.

The good news is that birth, babies, and breastfeeding can often change things for the better. Pregnancy, birth and having a baby might provide an alternate way of viewing your body. It can be triggering, but it can also give you a new perspective. Your body does something new and amazing. You become a parent. All of this can help develop a new kind of self-confidence which might help you work through past traumas and move forward with a renewed sense of strength, purpose, and belonging.

View our full interview with Lacey Castilleja Fisher, LPC-S, RPT-S, PMH-C below for more information.

Resources

Postpartum Support International
Postpartum Health Alliance of Central Texas

Open Heart Counseling ATX (Lacey)
Open Heart Counseling on Instagram

National Maternal Mental Health Hotline (FREE AND CONFIDENTIAL – 60+ LANGUAGES)
Call or Text 1-833-TLC-MAMA (1-833-852-6262)

Resources:

Maternity Care in the United States compared to 10 other Developed Countries
Midwifery credentials in the U.S.
2023 JAMA Network Article Maternity Care Deserts in the US
2022 March of Dimes Report on Maternity Care Deserts
History of midwifery care in America

This is one of my favorite topics to talk about, write about, and even teach about. I’ve been teaching birth classes since 2014, and it honestly never gets old. HOWEVER, it’s definitely fun to find a new topic or new angle for a class. A little more than two years ago, I developed a class for birth partners and it has become my favorite class to teach.

Why is Learning About This Important?

As a childbirth educator, I see mostly couples in classes. While I do see a variety of combinations of couples in my classes including mother/daughter, pregnant person/doula, etc., it’s usually the pregnant woman and her husband or partner attending my birth classes. I hear these partners expressing certain thoughts and feelings about their role in the birth. Some of the common things I hear include:

• I’m afraid for the safety of my loved ones.
• I’m afraid of seeing my loved one in pain
• I’m afraid I won’t know what to do if something happens.
• I don’t know how to be useful.

If you’re a partner to someone facing labor and birth soon, you may be having some of these feelings too. This can definitely be true for ALL partners regardless of sex, gender, or relationship status and sometimes even more because of less traditional gender roles. But 95% of the birth partners in my classes identify as male.

It was a relatively recent change in human history when men were allowed into the birthing space at all, first as medical care providers and then as partners. In the U.S., it wasn’t until the 1960’s that fathers were regularly allowed in the room during labor, and not until the 1970’s or even 80’s that they were allowed to stay for the birth.

Now, partners can be just about anywhere their pregnant partner goes. But I also hear another message loud and clear: partners want more. They want to be included in more ways than just being let in. They want more than just to be “allowed” and barely tolerated. And this desire should be nurtured!

We know that when partners go “all in” and families have two engaged parents, things are better in so many ways. The financial picture is better, mental health is better for everyone, and the kids benefit from having more adults in their lives who are caring for them. Partners are often struggling to wiggle out of a traditional partner role that is usually very limited and often unsatisfying for everyone. Partners no longer need to be the sole breadwinner, the hunter or gatherer, and the protector. Partners can share those responsibilities and take on other roles which can be equally or even more rewarding. They can be comforters and cleaners, boo-boo kissers and snugglers, advice givers and planners.

It’s true that the pregnant person bears most of the burden of ensuring a healthy pregnancy and birth, but research also shows that having supportive partners during pregnancy and birth can have significant impacts on health outcomes. There are studies showing that when pregnant people are well supported by their partners, there are lower rates of premature birth, low birth weight babies, birth complications, cesareans, and postpartum depression and anxiety. Research also shows that supportive partners can mean better breastfeeding rates and improved partner and parenting relationships. This says a lot about your value as a partner and also means there is a lot of responsibility you are taking on too.

How to be a Great Birth Partner

Partners first need to understand that they are essential and wanted. Just you being you means that you are needed. You don’t have to know how to do anything to be useful. Your presence is comforting and that is a critical piece. Staying actively present and engaged makes a big difference in your partner’s pregnancy, labor, and birth experience, even if you’re not actually doing anything.

That doesn’t mean that you can’t also get a little more prepared to take an active role in the pregnancy and birth. It’s true that some people prefer a more hands-off approach from their partners during labor, but there is a lot that a birth partner can do to help in most situations.

The Birthing Partner Prep class at Breastfeeding Success offers MANY suggestions for you, but here are a few basics to help you get started:

1. Stay connected NOW. Find ways to be involved during pregnancy. The more you do, the better connected you stay with your partner. That connection will make you feel like a co-parent and help minimize your partner’s stress levels. This is really important for a healthy pregnancy and birth.
2. Help create then MEMORIZE THE BIRTH PLAN. When you know your partner’s preferences, you can stay aware of anything that might interfere with their wishes. Knowing what your partner wants and doesn’t want for their birth, and then making sure their wishes are respected, might be your biggest responsibility.
3. Hire a doula. A doula is there to help your partner, but also to help you be the best partner you can be. You are not expected to learn everything there is to know about labor and birth and then be able to put that knowledge into practice at the birth. Because of your special relationship, you can’t be the most objective. Your emotions might overwhelm you sometimes, and a doula is there to support both of you so you can be the best emotional support and comfort to your partner.
4. If you can’t hire a doula, do your best to BE a doula. Take a class, read The Birth Partner by Penny Simkin, or even attend a doula training! A fun tip is to pack a secret separate bag of supplies that a doula might bring to a birth. Getting some education will help you know how to use what’s on this list!

• • Water bottle with a straw
  • Electrolyte Tablets
  • Rubber band for hair
  • Massage tool
  • Essential oils
  • Lights and warm touches for the room
  • Lotion or oil for massage
  • Shower cap
  • Hand held fan
  • Roller ball
  • Rice sock or cold/warm packs
  • Battery operated candles
  • Music/sounds
  • Visuals. Something nice to look at.
  • Copies of the birth plan
  • Soothing teas
  • Mouth wash
  • Protein rich sandwich – for you!

5. Get a gift. Sometimes called a “push present”, the purpose of this gift is to show your partner that you SEE the effort they are giving to the pregnancy and bringing a baby into the world. This is no small thing. Pregnancy can be very difficult for so many reasons, and of course labor is just that…..labor. Hard work. This is a gift that shows that you know, and that you appreciate it.

6. After the baby is born, there is so much left to do. This can often be the most difficult time for partners. BE PATIENT. You will likely be needed A LOT. You will also have to share attention with the new baby, and possibly even with friends or family members who are volunteering to help out. This is all needed and important, but can feel really difficult for partners. Do your best to offer a massive amount of patience. There is A LOT of physical healing that needs to happen before your partner is feeling normal, and there is a lot of emotional upheaval that comes with this rite of passage into parenthood. Be together in this. Give your effort and focus to your partner and to your baby as long as they need it. You will all benefit from this in the long run and can possibly even make your family stronger and better for it.

References

• Biaggi A, Conroy S, Pawlby S, Pariante CM. Identifying the women at risk of antenatal anxiety and depression: A systematic review. J Affect Disord. 2016 Feb;191:62-77. doi: 10.1016/j.jad.2015.11.014. Epub 2015 Nov 18. PMID: 26650969; PMCID: PMC4879174.https://pubmed.ncbi.nlm.nih.gov/26650969/
• Paulson JF, Bazemore SD. Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. JAMA. 2010 May 19;303(19):1961-9. doi: 10.1001/jama.2010.605. PMID: 20483973.https://pubmed.ncbi.nlm.nih.gov/20483973/
• Kyei-Arthur F, Agyekum MW, Afrifa-Anane GF. The association between paternal characteristics and exclusive breastfeeding in Ghana. PLoS One. 2021 Jun 3;16(6):e0252517. doi: 10.1371/journal.pone.0252517. PMID: 34081726; PMCID: PMC8174696. https://pubmed.ncbi.nlm.nih.gov/34081726/
• Godbole NB, Moberg MS, Patel P, Kosambiya J, Salihu HM, Campos EA, Menezes L, Verma R, Wilson R. Paternal Involvement and Adverse Birth Outcomes in South Gujarat, India. Int J MCH AIDS. 2020;9(1):161-166. doi: 10.21106/ijma.348. Epub 2020 Feb 14. PMID: 32123641; PMCID: PMC7031884.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031884/
• Biaggi A, Conroy S, Pawlby S, Pariante CM (2016) Identifying the women at risk of antenatal anxiety and depression: a systematic review. J Affect Disord 191:62–77 – DOI https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4879174/
• Paulson JF, Bazemore SD. Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. JAMA. 2010;303(19):1961–1969. doi: 10.1001/jama.2010.605. – DOI – PubMed https://jamanetwork.com/journals/jama/article-abstract/185905
• Ghosh JKC, Wilhelm MH, Dunkel-Schetter C, Lombardi CA, Ritz BR. Paternal support and preterm birth, and the moderation of effects of chronic stress:a study in Los Angeles County mothers. Arch Womens Ment Health. 2010;13(4):327–338. [PMC free article] [PubMed] [Google Scholar] https://link.springer.com/article/10.1007/s00737-009-0135-9
• CLINICAL RESEARCH| VOLUME 34, ISSUE 4, P444-452, JULY 01, 2005, Precursors of Preterm Birth: Comparison of Three Ethnic Groups in the Middle East and the United States, Lina Kurdahi Badr, Bahia Abdallah, Ahalam Mahmoud DOI:https://doi.org/10.1177/0884217505276303
• Collins, N. L., Dunkel-Schetter, C., Lobel, M., & Scrimshaw, S. C. (1993). Social support in pregnancy: Psychosocial correlates of birth outcomes and postpartum depression. Journal of Personality and Social Psychology, 65(6), 1243–1258. https://doi.org/10.1037/0022-3514.65.6.1243
• Laura King, Hiding in the Pub to Cutting the Cord? Men’s Presence at Childbirth in Britain c.1940s–2000s, Social History of Medicine, Volume 30, Issue 2, May 2017, Pages 389–407, https://doi.org/10.1093/shm/hkw057
• Shots-Health News from NPR, A History of Dads, Remembering A Time When Dads Weren’t Welcome In Delivery Rooms, June 18, 20175:00 AM ET Heard on All Things Considered, DEENA PRICHEP
• Bohren MA, Berger BO, Munthe‐Kaas H, Tunçalp Ö. Perceptions and experiences of labour companionship: a qualitative evidence synthesis. Cochrane Database of Systematic Reviews 2019, Issue 3. Art. No.: CD012449. DOI: 10.1002/14651858.CD012449.pub2. Accessed 24 August 2022. https://doi.org//10.1002/14651858.CD012449.pub2
• Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub6. Accessed 24 August 2022.https://doi.org//10.1002/14651858.CD003766.pub6
• ACOG Committee Opinion No. 766: Approaches to Limit Intervention During Labor and Birth. Obstetrics & Gynecology: February 2019 – Volume 133 – Issue 2 – p e164-e173 doi: 10.1097/AOG.0000000000003074

I honestly didn’t know what my cervix was while I was pregnant and giving birth. Maybe that was covered in 6th grade health class, but I was not paying attention!

During my pregnancy, I didn’t think to ask questions about my anatomy. I’m not sure why. I don’t remember, but I might have been a little embarrassed that I didn’t know what those things were. I might also have just wanted to ignore as much as possible.

Like many of you probably are, I was nervous about what was going to happen and not all that excited to find out. I didn’t know that it might be helpful to understand more about my anatomy for pregnancy and birth.

Now that I’m a childbirth educator, I’m pretty amazed at the human anatomy that makes pregnancy and birth possible. I love talking about those parts and how they work, and the uterus is my favorite organ. The cervix is a very important part of the uterus.

What is the cervix exactly?

You can see the uterus in this drawing on the left. The part at the bottom that looks like a neck, or two thumbs pointing down, is the cervix. You can see in the picture that the color of the cervix is a little different from the rest of the uterus. There is no shading in the image. That’s because while most of the uterus is made of very strong muscle fiber, the cervix is not. The cervix is a little bit muscular but mostly connective tissue, so it behaves differently from the rest of the uterus.

What does the cervix do?

During pregnancy, the cervix stays long and firm and tightly shut and sealed. This ensures that your baby doesn’t come out too soon, and that nothing else can get in. As you are nearing the end of pregnancy, there will be some changes.

• Ripening: The cervix will soften in response to some hormonal changes. A very unripe cervix might feel like the tip of your nose. A very ripe cervix will feel more like your ear lobe.
• Effacement: As it softens, the cervix will begin to thin out and pull back from the opening. Effacement is measured as a percentage. 10% effacement feels like the cervix is that much shorter. 100% effacement means the cervix is completely thinned out and feels very short or on level with the rest of the uterus.
• Dilation: The cervix will open. As it’s opening, it might be compared to what it looks like when a closed eye opens gradually. Dilation is measured in centimeters. Fully closed would be 0cm, and fully open is 10cm. I just measured it, and that’s exactly the length of the mouse I’m using to write this article right now!

Some of these changes can start before labor, and sometimes they all happen during labor. Sometimes the changes are gradual and slow, but once the uterus is contracting strongly, the cervix might change very dramatically and very quickly.

It will get very soft. It will shorten until it barely sticks out at all. And it will open until it’s completely dilated. Once all of those changes are made, a baby can get through.

You’ll probably be asked to allow cervical exams during prenatal visits, and also to monitor the progress during labor.

How is a cervical check done?

A nurse, doctor, or midwife will insert two gloved fingers into the vagina and feel the cervix. They do not use a ruler or special measuring tool to assess the cervix. Some people have big hands, some have small hands. They have to estimate. This means it’s pretty subjective, and there is room for error. During a cervical check, one person might feel 80% effacement and 5cm of dilation, but another might say 70% and 4cm. So who do you believe? I think it’s safe to say you can believe whatever makes you happy!

Before any of that happens though, it’s important that you are informed about the procedure and that you give consent. In the best situations, you would hear all of these things:

• I would like to do a cervical check because……
• I’ll need you to get into this position…..
• Here’s what it might feel like……
• Here’s how long it will take……
• Here’s why I think it will benefit you…….
• These are some risks of doing this assessment……
• How do you feel about that? Do you want to go ahead?

Once you have all of the information, you can choose whether or not to go through with the cervical check. You have the right to give consent to or to refuse the procedure. You should ALWAYS be asked for your permission first.

It’s true that sometimes cervical checks happen without permission. It’s unfortunate, but sometimes it’s assumed that once you’re in the hospital or birth center, anything is allowed. That is not the case. Just being a patient doesn’t mean that things should be done without explanation and approval.

Also, hospitals can be very busy places. Sometimes care providers are overworked and hospitals are overcrowded. Unfortunately, this can create a stressful situation for the staff which sometimes means they have to move too quickly and might overlook things, even when they have very good intentions. Most of the time, checking without permission is an accidental oversight.

For a lot of people, it’s also helpful to get some narration during the procedure. “Okay, now you can let your knees relax open. I’ll insert 2 fingers now. It might feel a little cold. You might be feeling a little pressure. I can feel the cervix now. It feels very soft. It looks like you’re fully effaced and about 6 cm dilated. I’m all finished now.” It can be comforting to know exactly what will happen, and what is going on WHILE it’s happening too. It’s very reasonable to ask for that.

Do I need a lot of cervical checks?

The standard in hospitals used to be to perform a cervical check almost every hour. Evidence does not support this practice. Checking that often is not shown to improve outcomes.

Now the standard is to check less often, but it’s also good to know that most of them are optional. A cervical exam can really just tell you one thing, how your cervix looks RIGHT NOW. It can not predict what will happen next. If your cervix is fully dilated, it does not necessarily mean you’re ready to push and that your baby will be born in the next hour. If your cervix is not dilating much at all, it doesn’t mean that you won’t be giving birth in the next hour.

It’s true that it can help make better guesses, but that might actually make things harder for some people. It might be discouraging to find out that you’ve been laboring for 12 hours and that you’re “only” 3cm dilated. You might start to wonder if it’s really going to take four hours per centimeter! If that math is true, it would mean another 36 hours of labor. That would be very hard to hear.

Fortunately, that’s just not the way labor tends to work. For most people, the first 5cm take the longest. After that, dilation might happen at a MUCH faster rate. As your labor moves along, the contractions get longer, stronger, and closer together. Each contraction is doing something to make your cervix ready, so that means more progress more quickly. So, if you think you might feel discouraged knowing about the progress of your cervix, you might consider choosing them wisely.

A lot of people ask me which cervical checks are the most necessary. This is a hard question to answer, because it really does depend on each person and each situation. It’s best to talk it over with your care provider if a situation comes up where you’re being asked to consent to a cervical check that you’re not sure you want. They’ll be able to tell you if there’s a good reason.

In general though, I can think of four situations where you might like the idea of getting checked, even if you generally don’t want the exams. These may also be situations where you would be more strongly encouraged to consent to a check by your care providers.

1. Before admission to the hospital or birth center: When you show up at your birth place, they usually want to know if you’re having real productive labor. Sometimes people do show up in “false labor” or just way too soon to be admitted. Checking your cervix can help decide whether it would be a good idea to stay or whether you could benefit from going home. It can also help them know whether your doctor or midwife should be called quickly, or whether that can wait.
2. Before pushing: In most cases, feeling an urge to push means your body is ready for you to push. It’s a mostly reliable way to guide your pushing and birth. But in some rare situations, a person will feel an urge to push when the cervix is not ready to let the baby out yet. If you start pushing before the cervix is open enough, it can cause swelling and make things more complicated and difficult. This is why a cervical check might be strongly recommended before you start pushing.
3. Before getting an epidural or pain medication: If your goal was to avoid medication unless absolutely necessary, and then you reach a very intense point in your labor and want to ask for medication, it might be a good idea to ask for a cervical check first. Often, people feel the most intense contractions right before full dilation when it’s time to start pushing and give birth. If you get a cervical check and find out that you’re fully dilated or almost there, you might decide not to get the medication.Most people benefit from having medication most before it’s time for pushing. The pushing part is usually not when people most need the pain relief. It can take at least 30-45 minutes for an epidural to provide relief, and by then you may not even need it anymore. Also, it’s pretty common for people to allow the medication to wear off during pushing so they can have a little more muscle control and ability to move.
4. Before labor induction: If you schedule a labor induction, a cervical check is usually part of this process. There are many different methods that can be used to induce labor, and it can help your provider decide on the best course of action to know how ready your cervix is. They’ll need to do a cervical exam to find out.

Why not get cervical checks?

You may be perfectly happy getting many cervical checks. For some people they are not all that uncomfortable. Some people really like hearing about changes in the cervix, and it gives them some level of comfort.

On the other hand, you might feel very different. Sometimes checks are very uncomfortable or even painful. For most people, they’re at least a little bit uncomfortable. And some people have conditions that make any kind of penetration excruciating. If you’re in labor, it’s usually a good idea to get them in-between contractions instead of during a contraction to help with the physical discomfort.

For some people, they can also be emotionally painful. If you have experienced sexual abuse or trauma, a cervical exam might be extremely disturbing.

If you have any of these concerns, and want to limit cervical checks, that is absolutely reasonable. You can talk to your care team about which checks are most valuable or necessary before you decide whether or not to give consent. You can definitely share your concerns and difficulties with your care team, but you can also keep that information to yourself. You never have to justify your refusal with reasons. It’s OK to just say “No, thank you.”

Illustration: https://www.flickr.com/photos/internetarchivebookimages/20545021128

DOULA is an ancient Greek word that means female slave or servant. Yikes, right?!?!

Some more modern interpretations of the word accept the meaning as woman caregiver. In modern times, being a doula is a profession. A doula is a birth companion.

Birth doulas are hired to provide CONTINUOUS labor support. Postpartum doulas offer support AFTER your birth during the recovery period. Some doulas do both. They are called Full Spectrum Doulas. A lot of modern day doulas might actually consider themselves female servants in the most literal way. They are there to serve the woman. Most people don’t hire a doula or have even heard of a doula, but they do provide an essential service.

What Doulas are NOT

Doulas are not medical practitioners. A doula should not do any medical procedures or even offer medical advice. A doula also can not speak for you. A doula can find out a lot about you and understand your preferences and plans for your birth, but they can not step in and make medical care decisions on your behalf. A doula can offer you general information about birth related procedures and topics and offer you resources and referrals, but really should not make recommendations about your healthcare.

Doulas are also not babysitters or nannies. A doula is trained to support the pregnant, laboring, or postpartum woman. They are the doulas’ focus. A pregnant, laboring, or postpartum person needs plenty of support, and most often they don’t get enough. Babies are adorable, but they have parents AND other caregivers.

How Doulas SERVE

A doula knows a lot about pregnancy, labor, birth, postpartum recovery, and possibly even about baby care. They learn some of this from books and training, but they also know this from having the experience of being with other people on this journey. It’s usually a very deep and personal understanding.

Doulas usually feel called to the profession. Most doulas don’t do it for the money or the glory because there isn’t much of either! Most doulas are completely awed by and obsessed with pregnancy and birth. It’s a fascination that might have been sparked by their own birth experience or that of a loved one, or they might have been born with their passion!

The spark is usually fanned and fueled by a deep desire to help. Doulas understand what a special and complicated time pregnancy and birth and new parenting are in a person’s life, and they feel compelled and honored to help and participate in some way. Doulas also understand that the modern birth experience is often cold, disconnected and scary. They want people to feel nurtured, safe, and informed so that they can experience the joy in the process and the outcome.

Birth doulas help by:

• Being a touchpoint during pregnancy. A doula will listen and offer answers or referrals or moral support when you have issues or questions.
• Providing education. Some doulas will offer some childbirth preparation as part of their services.
• Making a birth plan. Some doulas will encourage you to make a birth plan and even help guide you through the process.
• Being on-call and showing up for labor and birth. Your doula will stay available for the time around your due date and make sure to answer your call when it’s time! They might come to your home or meet you at your hospital or birth center depending on the situation.
• Providing physical support for labor by offering touch or massage or help you get into more comfortable positions. They will encourage you to breathe effectively and stay well hydrated. They can make recommendations for how to position or move your body so your labor continues smoothly and with less pain.
• Providing emotional support. Labor and birth can be hard. A doula usually knows the right things to say and do at the right times to keep you feeling motivated and calm. They can help you understand that what you are experiencing is normal and that everything is OK.
• Being an advocate. A doula can not speak for you, but a doula can remind you and your care team about your birth preferences. If a problem comes up, a doula can’t make a decision for you, but they might be able to offer you information so that you can make a decision for yourself. A doula can be very observant about what is happening, and can bring your attention to anything that you might need to know about. “It looks like they’re about to cut the cord. Didn’t you say your partner wanted to do that?” A doula can help your partner to advocate for you when necessary. Your partner or family member can often speak for you when needed, and a doula can help them if they don’t remember some of your birth preferences or need more information. They can help you AND your partner know what questions to ask and how to advocate for yourselves.
• Facilitating communication. During your prenatal care, a doula can help you know what to ask about during your visits with your doctor or midwife. A doula can help you make respectful requests of your caregivers when needed. They can help partners communicate more effectively with each other so you can stay on the same page and set up healthy expectations.
• Helping your partner know how to best support you.
• Supporting your partner by giving them time and ideas for rest and rejuvenation. When your partner stays healthy, they can continue to offer good support for you.

Postpartum doulas help by:

• Offering some information and referrals (if needed) about baby care and feeding.
• Providing some baby care when you need to shower or get some self-care time.
• Helping you eat well.
• Helping you get plenty of rest.
• Doing light housework.
• Teaching you about your body changes and how to manage your recovery.
• Providing emotional support and comfort when things feel very hard and overwhelming.
• Offering information and referrals about complications that might come up during postpartum recovery including mental health issues.
• Being a touchpoint during your postpartum recovery. They can help you understand that what you are experiencing is probably normal and will pass. You are OK.

The Benefits of Doula Care for Birth and Beyond

Most people who have had doula care understand the benefits. I have very rarely heard someone say that they regret hiring a doula. Most people say the opposite. They can’t imagine having done it WITHOUT their doula.

Some people give birth without a doula first, then get a doula with a subsequent pregnancy. Most of these people say they wouldn’t do it again without a doula. It’s easy to hear THAT doulas are helpful, but HOW doulas are helpful is a lot harder to understand. Most people can’t really articulate WHY their doula was so important, just that she was essential. I also can’t tell you exactly why my favorite shoes are so helpful. I don’t know what it is about the design or features of these shoes that make them so special to me. I just know that when I don’t wear them, life is worse. My feet hurt. My ankles hurt. I’m just not as comfortable or energetic when I wear other shoes. A doula is sort of like having a really good shoe. Maybe it doesn’t sound all that glamorous, but it’s life-changing!

There is very clear and legitimate research showing that doulas actually make a very measurable difference in birth outcomes.

Research shows that doula care can:

• Significantly lower the risk of having a cesarean birth.
• Lower the risk for postpartum depression and other postpartum mood disorders.
• Lower the use of epidural medication.
• Make it more likely that people rate the birth experience as good.
• Increase the chance that people feel they coped well with labor.
• Make it more likely that people report that “labor had a very positive effect on their feelings as women.”
• Help people have improved perceptions of their bodies’ strength and performance.
• Increase breastfeeding success rates.

This is a HUGE and very significant list of benefits, and the word is spreading. Doula care is not universal, but it’s there! Many cities have a thriving doula community and there are plenty of doulas to contact and interview and hire. In other places, there are only a few. Doula care is usually not very expensive when you consider the amount of time a doula spends with you. Also, consider the fact that they have to reserve about a 2-week window around your due date to be on call for your birth.

Even so, doula care might not be in everyone’s budget. While doula care is not currently covered by most insurance plans, some are coming around. It seems like a no-brainer that insurance companies would want to cover a service that can have such a huge and lasting impact on maternal health.

Currently, Tricare covers doula services, and there are a few others. Rhode Island passed legislation REQUIRING doula coverage for both Medicaid AND private insurance providers. Nine states including Oregon, Minnesota, New Jersey, Florida, Maryland, Nevada, Michigan, D.C., and Virginia currently reimburse Medicaid clients for doula services. At least 17 other states are planning to implement something similar for Medicaid reimbursement. Five states are considering a Medicaid sponsored doula program. There is a pilot program in Texas that includes Austin through G.A.L.S., which is covering the cost of doula services for Medicaid clients. There are programs like G.A.L.S. Austin or Black Mamas ATX which provide low-cost or no-cost doula services for those who can’t afford to hire a doula out of pocket.

Another option to make doula care more affordable for you would be to hire a doula-in-training. To become fully certified, most doula certification programs require a student doula to attend at least three births. This means that the doula has taken the classes and done the reading and fulfilled other requirements, but now they have to get out there! They will probably need the clients and medical staff attending the birth to submit a short evaluation about the care they received. It can be hard for doulas to get invited to births before they’re actively working, so most doulas-in-training offer a very reduced rate for their certification births.

Doulamatch.net is a nationwide doula directory where you can see many of the doulas in your local area. The doulas can show that they have a certification. Doulas-in-training are easy to spot, because they lack a certificate verification and have no or limited experience. In my hometown of Austin, TX, the Central Texas Doula Association is another great way to find a doula.

If you do not have access to doula care for lack of availability, budget, or any other reason, your partner or another family member or friend can step in. Doulas are shown to offer the most benefits, but continuous labor support of any kind is beneficial. I would recommend getting some education about how to support someone through labor, so that your partner can provide the best support possible. We have a class for that! Birthing Partner Prep: The Manual For Labor and Birth Support. Another great resource is a book called The Birth Partner by Penny Simkin.

Resources

• Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching
• Effects of providing hospital-based doulas in health maintenance organization hospitals
• Impact of Doulas on Healthy Birth Outcomes
• Doula care supports near-universal breastfeeding initiation among diverse, low-income women
• Doula Services in Medicaid: State Progress in 2022

What will your baby look like at birth?

Cute? No, probably not. Sorry!

Pretty much everything they show on TV and in movies about birth and newborn babies is very wrong. Birth almost never happens like that, and babies don’t look like that as soon as they’re born. They use babies that are at least a couple of months old to play newborns in the movies. They’ve gotten over the worst of the newborn weirdness by then. There are some people who look at their newborn baby and think they are absolutely beautiful. Others of us (me included!) look at our newborn baby and think, “That can’t be mine! What’s wrong with it?!?!” Luckily, the answer is almost always, “nothing”. Your baby might not look healthy and fine, but they are!

How long will my baby be ugly?

Luckily, they start to get cute pretty quickly. A lot of the strangeness comes from being fresh out of the womb. They have been waterlogged for nine months. They have stuff all over them that has been protecting their tender skin.

Babies also get pretty squished during a vaginal birth, and that can leave some marks. Within a few hours, most babies will start to look a little more normal. This does not mean they will look completely normal in every way though. They do look better pretty quickly and we can stop worrying.

Unfortunately, most of the time weird conditions and behaviors will keep coming up for the next couple of months! By the time babies are about three months old, they should look like the cute babies we see on TV and out in the world. Most of us haven’t seen brand new babies. Most newborns don’t get out much, and when they do they might be all bundled up and in blankets. We don’t get to see the truth of newborn ugliness until we have our own.

What can I expect right after birth?

There are a lot of things we might see when a baby is first born that usually go away pretty quickly. There is a lot of variation. Depending on how quickly and easily the baby was born, the baby’s natural skin tone, and how long the baby was in there, you may or may not see some of these attributes:

• Blue, gray, or other weird skin colors – Until a baby is breathing well and has good blood oxygen saturation, their skin tone might be sort of pale or bluish. This usually improves within minutes. Once the baby is breathing well, the skin tone might STILL not look normal; it depends on the baby’s natural skin tone. Some babies will look pink, others might look bright red, or even purple! I have a darker olive skin tone, and my first baby was a very deep red color. It was pretty shocking! My second baby was mostly purple. I didn’t expect this, but I was reassured that they were normal and healthy. Their skin tone changed gradually over the next few hours and looked a lot more normal by the next day.
• Swollen face/eyes – A lot of babies will have a swollen face or swollen face and eyes. I remember thinking it looked like my daughter had gone a few rounds in a boxing ring! My son did not look very swollen at all. When a baby spends time in the birth canal, they get a little squished and this can cause some swelling. My son was born very quickly, so he was not as swollen. Also, babies tend to be a little swollen because they were submerged in water all those months!
• Hair – Some babies look very hairy when they’re born. It’s a soft fuzz that might cover a lot of their body. This is called lanugo. All babies have it in the womb to help protect their skin. A lot of it falls off before they are born. When a baby is born on the early side, they may have a lot more lanugo than a baby born later. Most of this body hair will fall off over the next few days and weeks.
• Skin goo – Babies are born with some goo on their skin. Some will have a little, others will have a lot more. Some of this is blood. It is very normal for the baby to have some of your blood on their skin. You might be bleeding for a number of reasons. It could be that you experienced some tearing on your baby’s way out. There is also blood in the uterus that needs to come out and will continue to come out vaginally over the next few weeks. This is completely normal and nothing to be worried about, although it might look sort of gruesome. They are also born with some white waxy stuff on their skin. This is called vernix. It is there to protect their skin from getting too waterlogged in the womb. The common practice now is to leave it on them or rub it in because it’s good for them!
• Swollen genitals – Your baby might have swollen breasts, labia, and/or scrotum. This can be shocking if you don’t expect this, but it’s very normal. This can be caused by exposure to hormones and also just the birth process.
• Cone head – Babies can be born with a misshapen head, and it’s most always cone-shaped. A newborn baby’s skull is not fused together yet so that it can mold to fit the birth canal for easier birth. The skull bones are actually multiple separate plates that can overlap each other as the baby’s head is squished and descending through the birth canal. This will normalize pretty quickly and your baby will have a nice round head soon!
• Crossed eyes – Newborns often have crossed eyes, but that’s nothing to worry about. Babies don’t see all that well at first and have a hard time focusing on things that are at certain distances, so they will look cross-eyed sometimes.
• Birthmarks – Some birthmarks are subtle and stay with you for life. Others are caused by birth and will go away with time. A lot of babies are born with red splotches or dark spots that will eventually fade and go away. Sometimes these are really big and dramatic.

What can I expect later?

Newborns do start looking cuter pretty quickly after birth, BUT then other stuff might start to happen. For the first three months or so, you’ll probably notice a lot of big changes, and some of those might look weird or even hideous. They are technically newborns until three months old, so just hang in there! Whatever it is, it’s probably normal and nothing to worry about. A lot of parents are taken by surprise when their baby doesn’t have perfect baby skin or they start to notice these other strange characteristics or behaviors:

• Dry, flaky skin – Babies will lose a layer of skin after they’re born. Remember they were soaking in fluid for a very long time, so it makes sense that the top layer would need to come off. There is no need to provide extra moisture or lotion if you don’t want to. It will stop once that layer is gone, especially if you don’t use drying soaps or shampoos.
• Yellow skin – Jaundice is a condition that babies are sometimes born with, but some develop it a little later on. This is usually just called breast milk jaundice and will go away if you continue to breastfeed frequently. It can make your baby look very yellow or orange.
• Acne – Babies can get acne! My daughter had breast milk jaundice and acne at the same time. She was a little bit ugly. Of course, by that time we were so in love with her that we hardly noticed. However, we didn’t print any pictures from that time! The jaundice went away after a few days. The acne was much better after a couple of weeks, and then she was REALLY adorable.
• Jerky movements and gestures – A newborn doesn’t have a whole lot of control over their body yet. Their arms and legs might flail around awkwardly. They might scratch themselves, hit themselves and you, wake themselves up with a big jerk of their arms. I like to imagine that some of this is just that they are using their little muscles and getting the hang of NOT being in water and crowded. Some movements are actually special reflexes that only newborns have. These are a couple of the more common and cute reflexes that newborns have and then LOSE once they get a little older:
  • The Moro Reflex – This is what we’re seeing when a baby is falling asleep and their arms start to relax down, but then they startle awake and jerk their arms forward like they’re trying to grab hold of something. They are! Humans and other primates historically tended to hold their babies A LOT, and babies are born with the instinct to not be dropped or fall out of a tree.
  • The Rooting Reflex – Babies will open their mouths wide like they are ready to eat when the side of their cheek is rubbed. Even if a baby just ate and isn’t hungry anymore, they will respond that way. Babies need to eat OFTEN as newborns because their bellies are tiny and because at first we only have a very small amount of milk released at each feeding time. This reflex helps the baby and the parent remember to feed more often and to help the baby open wide to get a good latch.
• Rude faces – Newborns tend to make a lot of funny faces and sometimes they look a little rude! They don’t have much control over their facial expressions yet. They might make a face that looks like they are trying to poop, but then you don’t see anything in the diaper. Sometimes when they ARE pooping, the facial expressions can seem pretty intense and we wonder if there is a problem. It’s most likely just that pooping is a new and strange sensation and your baby is reacting to that. Sometimes they look very surprised or disgusted for no reason. They might smile and look very happy when passing gas. They might look very focused and determined, or suddenly stick out their tongues. It can be endlessly entertaining to watch a newborn baby make faces.

Whatever your newborn looks like or is doing in those early weeks, just remember that they do change very quickly and most things are nothing to worry about. I know that a lot of times we are not encouraged to do an internet search for health conditions, but when it comes to newborn weirdness, it might be worth a quick search just to ease your mind a little. Doing a search for “My baby has acne.”, will show you that this is a very common thing and you can stop worrying. Most things are like that, so a quick search can give you some peace of mind. If you are concerned, it’s definitely a great idea to call your pediatrician or family doctor. Babies have so many visits at first, that it might also make sense to just make a list of all the weird things you’re wondering about so you don’t forget to ask while you’re there for a check-up.