Being a pregnant woman in the Boulder area is a good thing these days – you have many choices and options for your prenatal care, birth preparation, birth location, and postpartum support. If only all women were so lucky! With this good fortune, however, comes the burden of having to make decisions, important decisions, in all of those areas. It can be overwhelming to sift through so much information, all the while, hearing advice and getting input from friends, relatives, and folks in line at the grocery store. Of course, you want to make the best choices – the ones that will best serve you, your partner, and the baby. But how are you to know?
Coming from my experience as a mother of three (ranging in age from 6-14), as a doula and a mentor for hundreds of expectant couples in my Birthing From Within classes over the past decade… I suggest you start with this question (and really take some time to feel into it…) “What is it that I need to know in order to give birth to this baby?” That might sound obvious, but so often, newly pregnant women, especially those expecting their first child, get swamped with input about what OTHERS think she NEEDS to know in order to give birth to her baby. It can get muddied and difficult to separate out what she thinks she should do, or learn, or believe from what she instinctively or intuitively is seeking.
So, what is it that YOU need to know? For many newly pregnant women, the immediate thoughts that arise might be along the lines of “what do I need to do in order to have a ‘natural birth,’” or a “pain-free birth”, or “an intervention-free birth”. But the truth is, there is no magic answer to those questions, and it’s not something that one class or another could ever guarantee. Birth is unpredictable, and, even with the best laid plans and intentions, each birth unfolds in its own, unique way – with twists and turns, ups and down, and round abouts. Just ask Pam England, the author of Birthing From Within – she was a homebirth midwife, who “ate tofu and did yoga”, and planned to give birth in a tipi. In the end, she gave birth to her first child by cesarean. So, birth preparation is not about learning how to avoid a certain kind of birth or certain interventions, but truly, it is about asking: “What do I need to know and do so that I may be present for myself and for the birth of my child as it unfolds in its unique perfection and glory?”
Birthing From Within classes are unique in that they address what we call “The Three Types of Knowing”: Primordial, Modern, and Knowing Thyself. The first kind of knowing is primordial knowing: the innate maternal instinct. Women have this knowing in their bones! And they are in this knowing when they are not in their thinking mind. However, social conditioning has taught us not to trust or act on our gut knowing–until we have “thought it through,” researched it, second guessed it, or checked with others about what they think or would do. One task for newly pregnant women is to first learn to feel their gut instinct and to distinguish this feeling from fleeting fear (or the contagious fear of others). Another task for newly pregnant women is to awaken the fierce protective mother within and learn to boldly act on their gut instinct. Instead of trying to “get it right” (which is impossible!), mothers need to learn (or remember) to act from a place of love, doing what needs to be done in the moment, without attachment to outcome.
The second kind of knowing is modern knowing: which includes learning the nuts and bolts of labor, birth and postpartum. Modern knowing includes holistic preparation for all kinds of possibilities, including inductions and cesarean births. It also means preparing for how to navigate the postpartum journey. This kind of knowing helps parents make informed and empowered decisions as they arise along the way.
The third kind of knowing, knowing thyself, is the most important. Pregnant mothers need to take time during pregnancy to deeply dive into this kind of knowing as they prepare for birth as a rite of passage. Knowing thyself is a priority in my birth classes. Before a woman can know where she is going in birth and beyond, she needs to know from where she came and where she stands now. It is helpful for expectant parents to become aware of what is motivating them to learn more; to choose or to avoid certain things; to act or to freeze, so that they can shift old patterns that don’t serve them anymore and instead move from a place of inner knowing and guidance.
In a nutshell, my Birthing From Within classes are interactive and dynamic, and offer a safe and nurturing environment for pregnant mamas and their partners to explore the these three kinds of knowing and for their unique birth journey. In the class we explore the nuts and bolts about labor, birth and postpartum, learn pain-coping practices, prepare mentally and emotionally for birth using Birthing from Within processes, discover how to deepen relationships with birth partners, envision a space that will help you open in labor, and create community with other parents through lively discussion and sharing. Birthing From Within is an accessible birth preparation philosophy that meets the needs of a wide variety of parents – not just the ones for whom self-exploration comes naturally, or the ones preparing for a natural birth, or the ones with lots of complicated issues to work out… but all parents who are on this journey. So, what is that YOU need to know in order to give birth to this baby?
Erika Primozich, As Colorado’s first Certified Birthing From Within Mentor, I have taught BFW classes for over ten years, and I am also an Advisor for new BFW Mentors . As a mother of three children, I believe strongly in each woman’s innate ability to give birth and I enjoy guiding parents on their journey. I feel the power of birth and believe in the magic and miracle of it. I also have witnessed the incredible unpredictability in the way each birth manifests. Because of this, one of the main goals of my classes is to prepare parents not for the “perfect” birth, but instead, to be present for their particular birth experience as it emerges and unfolds in its own uniqueness and beauty (whatever that may look like!), one moment at a time.
info@diveintobirth.com; 303-746-0267; www.diveintobirth.com
Classes currently being offered at the BBCC taught by Erika Primozich:
Emerging Mothers: Early Pregnancy; A monthly gathering for newly pregnant mamas to learn, share and grow together. This class may be taken on its own, or as a part of the “Birthing From Within Bellies to Babies Circle” (which also includes the Birthing From Within birth preparation class and Mother’s Rising, a post-partum group); 1 2hr.class per month for three months.
Birthing From Within: Birth Preparation; The goal is to prepare parents to be mindfully present as their child’s birth unfolds, rather than holding on to ideas about how it should look/feel/progress etc… The class covers the nuts and bolts about labor, birth and postpartum; pain-coping practices, as well as deeper, holistic processes to expand parent’s emotional preparation and their relationships with birth partners. 7 week sessions
Birthing From Within: Birthing Again! ; A three-session class designed for parents experienced in birth who want to: reflect on and learn from their previous birth(s), dust off old pain-coping techniques that worked and learn new ones, prepare siblings for birth and the new baby, take time to enjoy this pregnancy and connect with this baby. 3 week sessions.
This incredibly heart-warming show provides a glimpse of the world of midwifery in East London in the 1950’s. The story is told through Jenny, a young midwife working amongst an Order of Anglican nursing nuns. We see the midwives travel the cobblestone streets of East London by bicycle to the homes of the impoverished, urban community that they serve.
The stories and characters in Call the Midwife! are captivating. Whether it’s following the love life of Chummy, an awkward huge-hearted midwife, or getting absorbed into the heart-wrenching accounts of preeclampsia, preterm birth, and postpartum psychosis, the rich stories and characters will capture your heart.
So check out Call the Midwife! on PBS and let us know what you think HERE!
by Susan Mitchell Student Nurse Midwife
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.
At $300 or Less Why Not Use a Doula?
Women have unique needs before, during & following childbirth. A doula’s support is in addition to their medical care and the love & companionship of their partners.
Numerouse clinical studies (http://www.dona.org/mothers/why_use_a_doula.php) have found that a doula’s presence at birth tends to result in:
- Shorter labors with fewer complications & greater confidence
- Reduced request for pain medication
- Reduced need for medical interventions
- Greater success with nursing and adjusting to new family
- Decreased postpartum depression
Doulas Provide:
- Prenatal visits (discuss birth preferences, explore questions, practice what you’re learning)
- Information and education
- Non-medical physical comfort (massage, positioning, breathing, aromatherapy, hydration, and more)
- Presence & support tools for birthing mother & birth partner
- Consistent, continuous reassurance, emotional support & encouragement
- Respect for all types of families, birthing experiences preferences & circumstances (single, multiples, natural, medication, epidural, vaginal, VBAC, Cesarean)
- Documentation of your birth (depending on what you decide: birth story, timeline, photographs)
- Support during early bonding after your birth (including breastfeeding & infant care)
- Post-Natal visits (nursing, infant care, self-care, processing the birth story, resources, tips)
You Deserve and CAN Afford a Doula!
Instead of paying the ‘going rate’ for a doula in Boulder ($500-$1500), you can interview and hire a trained, certifying area doula at a discounted rate (free-$300). Trained doulas are required to complete 3-6 births before their certification is complete. These woman are educated and independent birth professionals, trained by nationally recognized doula training organizations (DONA, CAPPA, ToLabor).
Interested? Questions? Email your name and due date to AffordableDoulas@gmail.com.
Sponsored by BoulderBirthCollective.org
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!”
Outrageous Baby
“When my mom was pregnant with me we did some outrageous things! We loved to kayak. I would awaken to my mom skillfully navigating through the rapids. We would surf, bobsled, mountain bike, ski, climb, even participate in the local rodeo.
These outrageous activities were of course all in my mom’s imagination but we will do all of these things together when I grow up.
On the day I was born, my mom called her nurse midwife who told her how strong she was as she gave birth to me. She said mom deserved a gold medal for her labor marathon.”
Outrageous Baby
Outrageous baby is a unique story for moms and their unborn children.
Pregnant women will love to read this story to their children because it is about pregnancy, women’s changing bodies and changing activity levels during this amazing time of growing a baby.
One goal of this book is to help women through this beautiful and challenging time of body transformation and to realize that giving birth is perhaps the most spectacular physical activity in a woman’s life.
Pregnancy is a precious and temporary state. You may be bobsledding again soon.
Written by Merrilynn Artman, a Certified Nurse Midwife in Boulder Colorado and Illustrated by Laura Ziebarth, a Neonatal Clinical Nurse Specialist in Madison Wisconsin.
Both remember what is like to share a body with an outrageous baby.
To order your copies of Outrageous Baby contact Laura Ziebarth at Ziebarth@charter.net or Merrilynn Artman at martman@boulderbirth.com.
Checkout this article in the Boulder Daily Camera featuring the Boxing Workout Class For Moms at the Family Garden non-profit, resource center in Longmont.
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.
This post is written by Erica Moss, the community manager for the online Masters in Nursing degree program at Georgetown University, offering one of the nation’s leading nurse midwife programs. She’s also passionate about photography and meeting new people.
Midwifery is an often misunderstood profession that encompasses far more than assisting with childbirth. The history of the midwife stretches back through centuries and has involved periods of rapid change as well as controversy.
The role of the midwife in society has often been recognized as vital, and midwives even received priority passage to the colony of Massachusetts. At other times, midwives have been marginalized or persecuted because of their role in providing reproductive health care for women and/or because they have approached women’s health care differently than other facets of the medical establishment. Today’s midwives are certified health professionals who provide comprehensive care for women.
Education
Midwifery is a professional designation in the United States and requires certification from the Accreditation Commission for Midwifery Education (ACME). All midwives must complete an educational program and pass the same national certification exam. However, two classifications of midwife exist: Certified Nurse-Midwives are registered nurses who have also earned midwifery certification, which allows them to practice as midwives in all 50 states; Certified Midwives come from many different educational and professional backgrounds related to health care, and must pass the same certification exam as CNMS. Certified midwives can currently practice only in New York, New Jersey, Rhode Island, Delaware and Missouri.
The Midwife’s Role in Childbirth
Midwives are most widely known for their role in supporting and caring for women during pregnancy, childbirth and the postpartum period, as well as caring for infants during the first 28 days of life. Midwives differ from obstetricians in their non-interventionist approach to
childbirth, which primarily consists of waiting, observing, supporting and coaching women through the process. Midwives receive training in handling many complications that may occur during pregnancy and labor in a non-invasive manner. A midwife may also consult with or provide care in tandem with an obstetrician, depending on circumstance, the patient’s wishes and medical factors.
The Midwife’s Roles Beyond Child Birth
Though the popular imagination tends to depict midwives as appearing at a woman’s side only during the final moments of pregnancy, midwives often provide general care for women from adolescence through advanced age. Midwives perform physical examinations, prescribe medications and provide gynecological care, as well as act in educational and therapeutic roles. Philosophically, midwives tend to approach health care from a woman-centered perspective, emphasizing female empowerment and human rights, as well as prioritizing the construction of a healing and communicative patient-caregiver relationship. Midwives may also treat men for sexually-transmitted infections.
More than 5,000 Certified Nurse-Midwives currently practice in the United States. Though the profession has evolved considerably since the days when midwives practiced folk medicine and were sometimes hunted as witches, what has remained constant is the principle of a healing human presence in the lives of women. In a medical establishment, which is increasingly technological and bureaucratic, as well as historically male-dominated, midwives play a vital role in ensuring that women have access to comprehensive, non-invasive general and reproductive health care. The medical education that midwives receive and the rigorous standards of certification they must maintain both support this profound perspective on women’s health.