After your two hour recovery period in the recovery room you will be moved to the post partum area where you will stay for 3-4 days. I will explain day by day what you can expect during this recovery period.
The day of your surgery
For the first few hours after your surgery your job is to rest and feed your new baby. You will be moved to the post partum area and will gradually get more sensation into your lower extremities. Your pain should be well controlled by Duramorph that has been place into your spinal or epidural and also an anti-inflammatory medication called Toradol that will be given to you through your IV. Your main priority will be to nap and nurse your baby. Please be sure to tell your nurse if you are feeling any pain, nausea or vomiting. There are medications that can be given to help with these issues. Usually by 10-12 hours your intestines will begin to recuperate from your surgery and you will begin to pass gas. This is a good sign that you can start to eat again safely. Usually your nurse has you sitting on the edge of your bed and if you are not dizzy you may be able to move and sit in a chair. The first night after your C-Section we keep the catheter in your bladder so that you do not have to worry about urination and you can sleep without too much interruption. Your midwife will come and visit you about 6 hours after your surgery to make sure you are pain free and also to make sure you are stable. We check your intake by IV and also how much urine you are putting out of your body through your catheter. We listen to your heart and lungs and also make certain that your dressing is dry and that you are not having any bleeding. Often times you eat a normal dinner the first night following your surgery. If the C/S was unexpected we can spend time with you at any point during your stay or after you go home to help review what happened and why. Birth processing is very important but the timing need or “readiness” to do this varies from person to person.
Day #1
The first day after your surgery you will be up and walking around! Your job is to walk at least 3-4 times that day. (But not too much or too far!) This helps your intestines work better, helps to prevent blood clots and helps your body recover. Your nurse will remove your catheter and you will be urinating on your own. You will be nursing and the nurses, lactation consultants and midwives will help you with breastfeeding if you need support. This first day is about rest and resuming normal but limited activity and also resuming normal bodily functions. The nurse will give you pain medication to take. Usually we give you Ibuprofin and Vicodin unless you have allergies to these medications. Your IV is discontinued and you have more time to rest and receive important information about care for yourself and your baby. Often times we discover that you are anemic from blood loss during your surgery. We will often offer you a iron pill with stool softener on this day. If you are RH negative blood type and your baby is Rh positive we will give you a Rhogam shot within 24 hours of your birth.
Day #2
This day is an adjustment day. You get to shower and rest. This day is usually in preparation for leaving the hospital. You continue to have a lot of nursing and lactation support and you begin to feel more rested and ready to go home.
Day #3 and #4
This is typically the day you go home! We take out your staples and put some strong supportive tape on your incision called steri-strips. This tape will be taken off at your 2 week follow up visit at our clinic. We give you prescriptions for pain medications so that you will be comfortable at home. We will offer you a flu shot if it is flu season and also TDAP to protect you and your family from Pertussis or Whooping Cough infection. Whooping cough is epidemic in our country and especially high in Boulder County. If you are not immune to Rubella you will be offered a MMR vaccine prior to discharge as well. We review carefully the signs and symptoms of baby blues and postpartum depression prior to discharge. If you have concerns about this we can offer support and referrals. We also review with you what it will feel like when your milk comes in (engorgement) which usually happens at day 3 or 4 of birth.
At Home: The most important thing to remember after a C-Section is to rest! We always recommend that women go home and get in bed for 10-14 days and rest and nurse their babies. The incidence of postpartum depression decreases if women can be taken care of during this critical period. You should not do too much activity. Avoid stairs and driving for at least 2 weeks. No baths, hot tubs or swimming for 6 weeks. Also, it is important to avoid intercourse for the first 6 weeks post C-Section. When you come into the clinic for your 2 week visit we will review birth control options with you.
You live in a community that is very supportive of VBAC (Vaginal Birth After Cesarean). Please try to give your body and uterine scar at least one year to recover prior to repeat pregnancy. This will be good for you and your baby and your uterus! About 90% of mothers who attempt VBAC at BCH deliver vaginally. Know that if you choose to have Trial of Labor After Cesarean (TOLAC) you will be well supported. We will have a surgeon and anesthesiologist immediately available for your next labor (should you choose) and also request that you have IV access and continuous monitoring. If something were to go wrong with your your uterine scar you baby’s heart rate is usually the first indication.
Congratulations on your birth! Cesarean Birth is a birth of a baby! Please, please feel blessed that you live in a day and age where you can have access to this life saving surgery! You are healthy and so is your baby thanks to C-Section and our wonderful surgeons!
I always share with people who have cesarean section that they are in very good, competent hands. The OB/GYN doctors who do surgery for us (Boulder Women’s Care) are very experienced and safe. The anesthesiology group that contracts with the hospital is also excellent. We all know that this was probably not in your birth plan to have surgery but I encourage people to be grateful that they live in a day and location where they can birth their baby safely. Cesarean birth is a life saving surgery.
The Surgeon will announce your name and what it is that is happening in the O.R. This may seem very silly but it is a safety measure to make sure that you are in the O.R. to have a baby! The purpose of this announcement or “time out” is to avoid the wrong surgery on the wrong patient.
We then place a sterile drape over your body and in front of your face. You can have your partner or support person sitting next to you and holding your hand. You can also have music of your choice playing in the operating room. The surgeon will then test your abdomen to make sure that you are numb and do not feel any pain. The anesthesiologist is monitoring your vital signs, making sure you are comfortable and will help you if you are having any pain, anxiety, nausea or vomiting. The surgeon will begin by cutting the skin low, near your pubic hair line. Your midwife will be there to assist the surgeon and will talk with you through your surgery. We work through the layers carefully and make certain that any bleeding is minimal. You may hear some noises, smell the cautery (which is an electrical way to minimize bleeding) and feel some tugging, pulling and pushing when the baby is close to being born. If you want to see you can often see the surgery occurring by looking up at the glass panels on the ceiling. You can often see a reflection in them! After a very brief 5-10 minutes your baby will be born! Happy Birthday! The midwife will gently put pressure on the baby’s bottom (or head in the case of breech) once the doctor has a good grasp of the baby’s head (or bottom). The baby usually comes out quite easily. The doctor or midwife will announce if your baby is a boy or girl if you would like us to otherwise your partner can look and tell you the surprise! The nose and mouth are suctioned, the cord is clamped and cut and the baby is handed off the sterile field to the nurse practitioner. The NNP (Neonatal Nurse Practitioner) will dry and assess the baby and bring the baby to be near you for a brief period of time. Your partner is welcome to go immediately over to the warmer when the baby is born and talk to your baby and see and touch him or her. After you have had time with your baby the baby will be carried out of the cold operating room to be skin to skin (usually with your husband or partner) until you can be reunited in about 45 minutes. If your baby was in a breech presentation often the legs are bent with the feet up by the baby’s face! The hips relax usually within one day and the legs return to a normal position.
The surgery finishes quite quickly once your baby is born. Your placenta is removed (be sure to let us know if you want to take it home and your nurse will put it in a tupperware container for you). The uterus is wrapped in sterile, moist cloths and a double layer of suture is placed on the uterine muscle. The surgeon usually orders IV pitocin after the placenta delivers to help prevent blood loss. The body cavity is cleaned with sterile water to remove any blood clots that may have developed. Your surgeon and midwife will continue to close the layers and monitor any vessels for bleeding. Often the anesthesiologist will talk with you and can administer medications if you are nauseated or anxious. You will have staples that will close up the skin layer that will be removed 3-4 days after your surgery before you go home. (The staples are replaced with steri strips which are a strong tape.) The doctor will push on your uterus after the staples are placed and expel any clots vaginally that may be present in your uterus. Your body is cleaned with cloths and dried. A sterile dressing is then placed over your incision and taped. We then cover you with warm blankets . We work as a team to carefully transfer you off of the operating room table with a roller board and onto a bed. We then take you to the recovery room where you can breastfeed and spend time as a family. The nurse will monitor your vital signs and well being for approximately 2 hours and then you will be moved to the post partum area where you will stay for 3-4 days. For the first 24 hours you are usually pain free because of morphine that was placed into your spine. This medication is safe with breastfeeding. We also keep compression stockings on your legs to help prevent blood clots from developing. If you are in any pain you should tell your nurse right away. We keep the catheter in your bladder for 24 hours so you do not need to worry about getting up to urinate. We wait to give you regular food until we hear bowel sounds and know that your intestines are working well after your surgery. Usually 8 hours or so after your surgery you are having a normal meal. Your job for the first day is to rest, breastfeed (if you choose) and enjoy your baby!
Part 3 and the last part of this blog will discuss your recovery in the hospital for 3-4 days and also explain what you can expect for the first 6 weeks postpartum.
I want to begin this blog with a beautiful piece of artwork by Amy Swagman entitled “First Kiss”. This piece of art is a mandala that shows a woman on an operating room table kissing her baby after birth. http://themandalajourney.com/2010/09/10/first-kiss/. Cesarean Section is a miraculous mode of birth. It should be celebrated. The art depicts what women go through for their children in order to have health and life. Amy writes below:
About the piece…
I wanted to do a piece to honor women who have given birth by cesarean. These women are strong mothers who have given much for their children.
Imagery for this piece was very difficult because there are so many different kinds of cesarean experiences, from the traumatic to the tearfully thankful. I asked many cesarean mamas, both friends and members of ICAN (Int’l Cesarean Awareness Network) to share their stories with me and looked for common elements. I decided to focus on the elements of the cesarean itself instead of the reasons and experiences behind it.
I used a three-dimensional approach to have the figure floating above the base representing the strangeness of the anesthesia. Many moms told me how they felt disconnected to their bodies by the drape, the tugging of the procedure, etc. This is why I segmented the figure into thirds where the sterile drape and the incision would be. The belly is exposed to show a shadow of a baby that was just there, the birth had just happened. It is like an echo of a baby.
I set everything on top of a Chartres Labyrinth to symbolize the journey women take to arrive at this place. At the center of the labyrinth there is the shadow of the baby, symbolizing the baby’s experience of the journey as well. Some cesareans are planned, some are not, but every woman has a unique web of experiences and situations that bring her to this birth. Sometimes we know the reasons, sometimes we never know.
The central imagery for this piece came from a friend of mine. She told me about her cesarean and how after her son was born her arms were tied down and she didn’t know what to do. “Kiss him” said the nurse and that was the first interaction she had with her son. This is why I decided to title this piece “First Kiss.”
***Again, I want to stress that this is not *all* cesareans, just a representation of common themes. If you’d like to process your own birth, cesarean or not, through art please contact me at amy@birthingbody.org to talk to me about commissioning a piece.
Cesarean Section delivery is never in someone’s birth plan when they come to Boulder Nurse Midwives unless women know that they are wanting a repeat C-Section. ACOG Statement RE: VBAC is linked below:
There are inherent risks to having surgery and it is less risky for the mom and the baby a majority of time if the baby can be delivered vaginally. The reality, however, is that some babies must be born by C-Section in order to have a healthy mom and baby. The statistic with our practice is somewhere between 10-15% of babies are born via C-Section. (Last year rate was 11%)
I always tell women to be grateful that they live in a day and age (and location) where they can have an option for surgery to deliver their baby safely. If families choose to have another baby at Boulder Community Hospital and with Boulder Nurse Midwives it is an option to have VBAC (vaginal birth after cesarean). The success rate of VBAC at Boulder Community Hospital is about 90%!
I was told by a patient that she felt completely unprepared for what cesarean section meant and what to expect should that happen to her. This blog is to give people who are interested, an understanding of what to expect during surgery and then day by day during recovery. This patient has helped to edit this blog and has given feedback so it is also from a patient’s perspective!
The following is a list of reasons why a woman may need C-Section:
- Breech presentation
- Fetal intolerance of labor (usually a long labor, short cord, cord compression, low amniotic fluid, placental pathology)
- Malpresentation (usually occiput posterior or acynclitic) Which is why we teach OFP-Optimal Fetal Positioning!
- Contraction inadequacy that can result from a fatigued uterus from a labor that has lasted a long time, meconium staining that causes the muscle to not contract affectively or polyhydramnios (excessive amniotic fluid), fibroids or uterine malformation Septated Uterus.
- Choosing repeat C-Section
Now we will walk through what happens during the surgery.
If a woman needs a C-Section we will call in our back up Obstetrician MD or DO who is on call. The on call doctor is usually in her office or in labor and delivery with a patient. They will assess the situation and usually agree with the midwife of the necessity for surgery. They will go through the risks of C-Section which include:
bleeding, infection, bladder, bowel or internal organ damage and death (which is an extremely rare event of any surgery.) Very rarely, complications can lead to a need for hysterectomy (removal of the uterus)
If you do not have an IV in place one will be started. You will be given antibiotics through the IV (usually Ancef unless you are allergic) to help prevent infection. We also need to know that you have adequate platelets for spinal anesthesia so if you do not have a recent CBC result blood should be drawn. A doctor of Anesthesia will come and talk to you. If you do not have an epidural he/she will discuss a spinal for you if your platelets are high enough. If it is a true emergency general anesthesia will be necessary.
Spinal anesthesia. If you do not have an epidural and are in need of spinal anesthesia this is what you can expect:
You will be sitting and usually pushing your lower back out (like a mad cat). The anesthesiologist will cleanse your back after a sterile drape is placed over your back. They will numb the back with lidocaine which is the most uncomfortable part. This usually feels like bee stings (although, compared to contraction this does not usually cause discomfort). The spinal space is found gently and carefully and a one time injection is placed into the spine to cause sensation to go away from the nipple line down. The MD usually uses a medication called Duramorph which will give you good pain relief for 12-24 hours and then oral pain medication will be available to you. After the spinal is in place you will be helped into a reclining position with a pillow under your head. You will be bumped off of your spine, usually with a pillow to help with good blood flow. (for the same reason we do not want you to sleep on your back during pregnancy!) The nurse will then put on a grounding pad, called a bovey pad on your thigh. This is applied because the surgeon will use cautery during your surgery to help prevent too much blood loss from vessels. You may smell this and it smells a little like smoke. The nurse will also place a catheter into your bladder (a tiny tube that goes into the urethra to keep your bladder protected and empty) once you are numb. This will stay in place for about 24 hours so you do not need worry about urinating. You will also have compression stockings placed on your legs to ensure that you have good circulation in your lower extremities to help prevent a blood clot. The nurse will then wash your belly with an antibacterial soap (usually blue in color) to help prevent infection. This soap needs to dry for about three minutes. We usually listen to the babies heart beat before cleansing your abdomen. We can turn on music if you would like to listen to music. The baby warmer will get turned on so the baby can be dried and wrapped up in a warm blanket immediately following birth because the operating room is cold to help prevent bacteria growth. Your baby can be near you for a short period following birth but then it is recommended that the baby leave the O.R. to be skin to skin with your husband or partner in the recovery room where the temperature is warmer. (You will be right behind your baby and will be nursing in approximately 30-45 minutes!)
Part II will continue with “The Birth!”
Illustration by Jenny Kostecki-Shaw
Most common reasons for Induction:
- 41-42 weeks gestation (you will hear this called, ‘post dates’)
- Pre-eclampsia
- IUGR (intrauterine growth restriction)
- Prolonged rupture of membranes
There are other reasons why women may need to be induced but the above are the most common.
We do everything that we can to make inductions as gentle as possible and try to make them mimic a normal labor. When we consider induction we always consult our back up obstetricians and weigh the benefits of the baby being born vs the risk of the baby staying inside the uterus. We assess the cervix and determine if the cervix “ripe” and ready for labor. A bishop’s score is a score that assesses your body’s readiness for labor. The bishops score assesses dilation, effacement, softness of the cervix, position of the cervix in your pelvis and how low your baby is in your pelvis.
When cervices are not ripe or ready for labor (the bishop score is under 6) then we discuss ripening agents to help prepare the cervix for labor. In our practice, if the cervix is slightly dialated, we like to use a Cook Catheter or Foley Catheter which is basically a water balloon that we put into the cervix over night (usually 12 hours). The Cook Catheter allows us to put 80cc in the cervix and 80cc vaginally and can often dilate the cervix to 4-5 cm in 12 hours. The Foley Catheter allows 30cc and usually a woman will dilate to 2-3 cm in 12 hours. The risk with the Cook Catheter can be urinary retention so we advise women to let the nurse know immediately if they are unable to urinate and we can then remove some of the water from the catheter. Cramping is not an uncommon side affect. We will offer women medication to help them sleep during the night should they need this. Rarely, but on occasion, the catheter alone will put people into labor.
The other ripening agent that we will use is called Cervidil. This is a medication that inserts similar to a tampon with a string attached. It sits behind the cervix and has a slow release of prostaglandin. This is a prostaglandin that can work overnight and help the cervix soften, thin and dilate. Occasionally Cervidil will put people into labor. If contractions become very close together with this medication we will pull in out prior to 12 hours.
Usually the Cook Catheter, Foley Catheter and Cervidil are followed by Pitocin use the following morning. (See Pitocin below)
Sweeping Membranes. If the cervix has a good bishop’s score and is considered ready for labor we will sometimes try to sweep the membranes. This is done only if a women’s GBS status is negative. Sweeping membranes is basically a vaginal exam where by the midwife goes into the cervix with her fingers and moves the membranes away from the inside of the cervix gently and carefully. Occasionally this will cause rupture of membranes but usually the bag of water is strong enough to stay intact through this procedure. This can often cause the women to release hormones to begin labor if the body is ready for labor.
Acupuncture. Acupuncture is another method to induce labor and can be very effective for some women. We often recommend acupuncture and membrane sweeping on the same day. We give referrals to local acupuncturists and now refer women to the community acupuncture clinic in the Boulder Birth Community Classroom in an attempt to lower out of pocket cost.
Castor Oil. Castor oil is sometimes recommended prior to pitocin use. Castor oil can be extremely effective if the body is ready for labor. Castor oil causes intestinal cramping, loose stools and usually diarrhea. The body has a vagal response where the uterus then begins contracting too. If used in recommended dosages Castor Oil should not cause dehydration or incontinence of stool. There is some thought that it may increase the incidence of meconium stained fluid. I have not seen this correlation with my practice but it is in some of the literature. I think it is hard to determine if the meconium is caused by a deteriorating placenta or Castor Oil ingestion.
Pitocin. We will occasionally use pitocin to get women into labor. We give women just enough pitocin to achieve regular uterine contraction. Pitocin is administered through a pump so that we give small but adequate amounts of this drug. Sometimes we need to use an IUPC (Intrauterine Pressure Catheter) in order to know precisely how strong the uterus is contracting. The IUPC measures the uterine muscle in mm of mercury. We can then titrate the amount of pitocin we give so that it is not too much or too little. With pitocin women need to be on continuous monitoring but fortunately Boulder Community Hospital has telemetry monitoring so that women can have good mobility. The telemetry monitoring is also water proof so women can be in the jacuzzi tub while on pitocin.
Breaking the water. When a woman’s body is extremely ready for labor and the head is low in the pelvis sometime AROM (artificial rupture of membranes or breaking the water) will be enough of an intervention to get someone into active labor. If the baby is not low in the pelvis this would not be advised due to the risk of cord prolapse or the possibility of the baby settling down in the pelvis in a less than optimal position.
Our practice does see natural childbirth when induction is needed but know that if you want epidural anesthesia, we can call an anesthesiologist in at any time. The other pain management option is Fentanyl IV. This IV pain medication can help contractions feel less painful and can “take the edge off” the contractions.
If you should need to be induced, remember the goal is to have a healthy mom and baby. C-Section risk does increase slightly with induction of labor. Remember that we are lucky to live in a day and age where Cesarean Section is an option for birth when it is necessary. Our Cesarean Section rate in 2011 was 11%. The World Health Organization recognizes this as a healthy rate. This is how some babies need to be born!
I also tell women and their families that induction can often take several days and this can be mentally challenging. If attempts for induction are not successful after the first day we often stop and allow for food and rest. On rare occasions we will stop attempts of induction and send people home for a few days to allow more time as long as there is no immediate health risk to the mom or baby.
What can you do about low milk supply?
1) Have your prolactin and thyroid levels checked
2) Use Fenugreek (Available at Pharmaca, Rebecca’s Apothecary, Vitamin Cottage or Whole Foods)
3) Use Goats Rue (Available-same as above)
4) Acupuncture (Acupuncture Clinic BBCC Mondays 11:30-2:00p.m.)
- Cost: $40
- Contact: Kate Blalack, L.Ac. 303-545-5792 x 107 kblalack@ChineseMedicineDoc.com to make an appointment or with questions.
5) Visit www.lowmilksupply.org and www.mobimotherhood.org
6) Get more information from these books
Mother Food by Hilary Jacobson and
The Breastfeeding Mothers Guide To Making More Milk by Lisa Marasco
7) Visit www.mobimotherhood.org and learn about the “power pumping” technique described below:
Power pumping is a technique that can be helpful in building a milk supply. For more information on basic pumping techniques, see the pumping section below. Here is a brief explanation of power pumping.
Power pumping involves using regular pumping techniques and setup, but in a unique way. The idea is to mimic a baby who is nursing frequently to increase a mother’s supply, as is common in the nursing relationship during a growth spurt. To power pump, hook-up as you would for a normal pumping session, pump for 10-20 minutes, rest 10 minutes, then pump another 10 minutes, then rest for 10 minutes, then pump again for 10 minutes. The mother does this for about an hour, once per day, to increase supply. At other pumping times during the day, routine pumping is used. It can take about a week to see an increase, so don’t get discouraged.
Some mothers prefer to concentrate their efforts and have a power pumping weekend, called “Power Pumping Boot Camp” by some lactation consultants. They power pump at each pumping for a couple of days before returning to routine pumping.
Lactation Support:
Stephanie Moore – Becoming Mothers. 303-546-MAMA
Chandra Ruiz, CLEC – lactivistmama@gmail.com. 520.225.7626 ($120/2 hours home visit)
Amanda Ogden
Nichole Didelot, CLC – joyfulmidwife.com. 303.669.9605 ($75/ home visit)
Darcy Kamin, RN – dkbabylove@gmail.com. 303.447.2609
9) Friday Afternoon Breastfeeding Club at BCH 720-254-7834 www.bch.org
Tuesday Afternoon Breastfeeding Club at BBCC (Boulder Birth Community Classroom) Drop-in 1:00-2:00
Prior to beginning any treatment for infection you should always be evaluated by your midwife to be sure that you do have a breast infection and not something more serious.
Suggestions for prevention or treatment of a mild case of yeast
1. air dry your nipples after each feeding
2. avoid plastic lined breast pads that trap milk and irritate skin
3. change nursing pads after each feeding
4. wear cotton bras and wash them daily in very hot water
5. thoroughly wash pump parts that come in contact wit your breasts and boil them in water for 5 minutes daily
If the above suggestions have not prevented or provided relief, try the following:
*Grapefruit Seed Extract, take as directed. This comes in a liquid tincture found at nutrition stores or pharmacies: Whole Foods, Pharmaca and Vitamin Cottage. Adding suggested amount of drops to juice will make it taste better!
*Acidopholus or Pro-Biotics, take as directed, available in nutrition stores and pharmacies
*Gentian Violet Daily-swab nipples and babies mouth (different swabs), once at bedtime for four days only.
*One dose of 200 mg Diflucan followed by 150 mgs by mouth for ten days. If no relief in 48 hours it is probably not fungal and is most likely bacterial. Diflucan is prescription only.
*All Purpose Nipple Ointment (30g) (APNO). Apply after each feeding. Rinse nipples before & after feedings with a warm washcloth. APNO is available at Walgreen’s Pharmacy at Boulder Community Hospital, Pharmaca on Pearl Street and Pharmaca at Table Mesa. This ointment is prescription only.
Here are some suggestions that may help turn your baby to head down!
Most babies are head down or “vertex” at 30 weeks gestation, but not always. At Boulder Nurse Midwives we begin checking the position of your baby at 30 weeks gestation and every visit thereafter. We use a technique called Leopold’s maneuver which means that the midwife will feel your baby’s position with her hands. Baby’s can be breech for a variety of reasons. The baby may not be ready to turn head down yet! This may be very normal and usually babies will turn head down by 35 weeks all on their own. Breech babies can also be in this malposition because of the woman’s uterine shape or there may be a septum or fibroid in the uterus that prevents the baby from rotating. Usually, if the reason is septum or fibroid related, we know this already by ultrasound diagnosis, but not always. Sometimes breech position is related to a short umbilical cord or how the baby is entangled in the cord. If we suspect that your baby is breech at 32-33 weeks we will suggest that you try the following to help your baby rotate:
- Frozen fruit or vegetables applied to the baby’s head. This does not hurt your baby but they sometimes move away from the cold.
- Acupuncture (Moxy)
- Chiropractic (Webster Technique)
- Deep water swimming doing flips or hand stands in the swimming pool. (The theory is that the bottom can come out of the pelvis and this helps the heavier head be able to rotate downward).
- Pelvic tilts (Laying on your back and lifting your hips above your shoulders)
- spinningbabies.com
- Please ask your Nurse-Midwife for referrals to acupuncturists and chiropracters who have experience working with pregnant women.
If your baby has not turned by 36 weeks gestation you will be offered to schedule a ECV (external cephalic version)
This procedure is done at Boulder Community Hospital at approximately 37-38 weeks gestation. The ECV involves an attempt to externally turn the baby under the direction of an OB/GYN MD & Nurse Midwife. We have women be NPO (nothing to eat or drink except sips of water) 8 hours prior to the procedure. Upon admission to the hospital we will confirm position via ultrasound and make sure there is adequate amniotic fluid. The nurse will monitor your baby’s heart beat with a non-stress test and start an IV with a blood draw for a current CBC, platelets and T&S. If there is an emergency, the anesthesiologist needs to see the platelet number in order to safely administer spinal anesthesia for an emergency Cesarian section birth. We give women a medication called Terbutaline to help relax the uterus for the procedure. This medication makes your heart feel racy like you would feel if you had drunk a couple of cups of coffee. It can also cause some women to have a little headache. We watch the baby’s heart rate carefully with ultrasound throughout the procedure and if the baby’s heart slows we stop the procedure immediately and let the baby recover and stop all attempts to turn the baby. We put oil on the belly and the CNM usually lifts the baby’s bottom out of the pelvis while the OB/GYN attempts to move the head downward. We usually try a front flip or back flip or both depending on the baby’s position. Some women want this procedure done under epidural anesthesia to help with discomfort but the procedure is very short in duration so it is usually very manageable with breathing techniques. The pressure and pain from the ECV is no worse or long in duration than a labor contraction.
The risks include placental disruption possibly leading to abruption and fetal intolerance from cord entanglement leading to a potential emergency C-section. If there are signs of fetal intolerance we stop the procedure immediately.
You will be monitored for about 2 hours following the procedure to ensure that your baby looks well oxygenated on the monitor. The statistic that we typically quote for success with this procedure is 50%.
If the procedure is unsuccessful we recommend scheduling a C-section between 39-40 weeks. We do not recommend vaginal breech birth even with providers who feel skilled in this area due to increase risk to your baby.
If your water breaks and your baby is breech this can become an emergency because the cord is more at risk of prolapsing. The head usually acts like a cork on the cervix in vertex presentation and prevents this from happening but with breech babies the bottom does not tend to settle down in the pelvis as easily. This is why we recommend C-section between 39-40 weeks and to call immediately should labor begin or if your water breaks.
Talk with your Nurse-Midwife if you have additional questions or concerns. If you feel a big rotation with your baby please call the clinic and we can check to see if the baby has turned. If your baby is now head down you should obviously stop all exercises to turn the baby from breech to vertex and begin focusing on Optimal Fetal Positioning exercises to now attempt to get the baby in a good Occiput Anterior position!
Merrilynn Artman, CNM, MS
This article will explore the benefits of doula care in conjunction with midwifery care. The combination of midwife and doula services are beneficial and offer the same philosophy of care without being redundant.
Some women will come to me and ask the question, “should I hire a doula?” Boulder Nurse Midwives believes in labor support during labor and delivery and we do what we can to be present during a majority of the labor and delivery process. We (the midwives) provide comfort measures and suggestions that help the labor process to include rest, hydration, nutrition and change of position. We have jacuzzi tubs in every room and also birthing balls. Aroma therapy is available and we also provide acupressure and massage when needed. The nurses in labor and delivery are also very supportive and some of the best “doulas”. Your midwife may, however, need to leave your room on occasion to answer a page, discharge someone from postpartum or we may have multiple people in labor. We do have a back up midwife call system in case people are needing constant labor support from the midwives. We ask that women and their families are vocal about their needs for support.
The benefit to doula care is the constant support and expertise that doula’s can provide to you at home and in the Boulder Community Hospital Birth Center. Doula’s are able to go to your home and be present with you in early labor and the midwives are unable to provide this service. The doula then advises you to come to the Birth Center in a timely way and she stays with you at the birth center providing comfort measures along side the nurse-midwife. When doulas are present the nurse midwife often takes the “back seat” in providing comfort measures but is still involved and present.
The other question that arises is “If I have a doula do I still need a midwife?” The answer is yes! The benefits of midwifery care during pregnancy are many. Our appointment times are long and we have plenty of time and availability to make sure all of your questions are answered and that everything is progressing normally with your pregnancy. We believe in non intervention unless it is necessary for the health of the mom and baby so you will often see less unnecessary interventions with a nurse midwife practice. When we need to open our “tool box” we use the least interventive methods first. (Please see our article on The Art of Labor Induction and Augmentation.)
There are also doulas who provide support postpartum. This service can also be very beneficial to women. Postpartum doulas help women with breastfeeding, nutrition, rest and monitor for signs of postpartum depression.
Some women do not have the resources to pay for doula care and if this is an issue for women, we offer referrals to doulas who have a sliding scale or that want to volunteer their time to support laboring women. There are studies that show that constant labor support is beneficial and leads to lower Cesarian section rates and less interventions.
It is important that you feel comfortable in your environment and with your labor support group in order for your body to labor well and effectively. We recommend that you interview doula groups similar to the way you interview your midwife or doctor providing you care so that you feel that the group is a “good fit”. Our resource page is growing and offers contact information for various doula groups at http://boulderbirth.com/resources.html