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A Doula Helps Change Law about Mandatory Erythromycin Ointment

A Doula Helps Change Law about Mandatory Erythromycin Ointment

Recently, I wrote about the evidence for erythromycin ointment in newborns. In my review of the evidence, I found that erythromycin is used to prevent eye infections that are caused by sexually transmitted diseases– chlamydia and gonorrhea. There are several evidence-based alternatives to erythromycin– including prenatal screening for chlamydia and gonorrhea. However, both Canada and many states in the U.S. mandate the use of erythromycin, and some health care providers will threaten to call Child Protective Services if parents refuse to have the ointment administered.

Jodilyn Owen is a doula (now midwife) who was involved involved in changing the mandatory erythromycin rule in Washington State. I was intrigued by how she did this—how does a doula become involved in changing policies to reflect evidence-based practice? Why do care providers threaten to call Child Protective Services? Today, Jodilyn is going to share her testimonial about how she changed the mandatory erythromycin rule, and what she learned from her experience.

 Tell us a little bit about yourself.

Jodilyn Owen, CPM

I have worked in the birth and early parenting world as a doula, educator, and parenting center director since 2001.  I am currently a Certified Professional Midwife (CPM) but I do not practice midwifery in Washington State as I am waiting for my license. I am co-author of the upcoming book, The Essential Homebirth Guide: A book for parents planning or considering a homebirth (Simon and Schuster, coming out in February 2013). I love working with parents as they get to know their newborns and am certified in Newborn Observation by the Brazelton Institute. My passion was never hospital births or homebirths, though I have attended hundreds of each—my passion has always been mothers and babies: supporting them in their journey and helping parents gather resources and information as they make their way forward.

What inspired you to work on changing the erythromycin law in Washington State?

My inspiration was a family that had a massive blow-out with a provider they had grown to love. Towards the end of the pregnancy, they let her know that they would be refusing erythromycin for their newborn and why. She told them in no uncertain terms that they were putting her license at risk, that Child Protective Services (CPS) would have to be called, and that they were putting their child at risk for blindness. 

Prior to this experience I had witnessed dozens and dozens of “informed consents” about this treatment in a variety of settings. I never heard the same explanation twice!  Everyone was confused about the law and the erythromycin treatment. I just decided to get to the bottom of it—urgently so that this family would understand the issues at hand, and long term so that I could grasp what it all really meant and speak from an educated place. 

A newborn receives erythromycin ointment
Credit: G jewels

I had often done “recon” work for my dad when I worked for him in high school—gathering information about his competitors and generally acting like a teenage 007. This experience gave me the foundation for my research skills. Knowing which questions to ask and who to ask helped me as I began to slog through the mud of this issue.

How did you go about helping change the law? How long did it take?

If you told me when I first began to ask questions that it would take two years and discussions with people all over the state, country, and world to change 2 sentences in our code, I would have laughed in your face! I have a long history of accomplishing what I set out to accomplish, so I was surprised at my first real interaction with government bureaucracy. It really was as bad as “60 Minutes” says it is.

When a law is passed by the federal or state government, individual departments write “rules” or “codes” to fill in the details of the law. In Washington State, these rules are called Washington Administrative Codes (WAC). The actual law about the use of erythromycin actually worked really well. It was the language of the code that was so confusing. The Washington State code about erythromycin is just one in the chapter that addresses all aspects of provider’s responsibilities regarding sexually transmitted diseases. At the time, when I began to look into this, the code had not been updated since 1981.   

At that time, the details were written in a way that understandably led providers to believe that they would be held financially responsible if they did not install the ointment and an infection or blindness occurred. This is why care providers would call CPS when parents refused it—to protect themselves from a future lawsuit. When I read the code as it existed, I couldn’t really blame them.  But the intention of the original law was clear, and that gave me a lot to work with.

I called a variety of agencies and insisted on speaking to the top-dog. I spoke with CPS who told me that when they receive these complaints, they basically go into a box in a closet where no one ever sees them. The exception to this rule is if there are further sentences which indicate potential harm such as, “These parents refuse to let me put this medication in their newborn’s eyes and they are on crack-cocaine or the father is regularly hitting the mother.”

I spoke extensively with the Department of Health and finally got in touch with the woman who was responsible for making sure that our state rules work for providers. I spoke with professionals in other states, researches in this and other countries, and even the pharmaceutical company who makes the medication. I kept copious notes in an easy to read format so that I could easily share them with others.

As the months wore on I reminded myself often why the work mattered so much to me.  I never apologized for seeking information or working to affect change. I knew this medication was not always benign and that parents should be able to enact their right to refuse it when appropriate. As I attended births over those months and saw the confusion over this rule amongst providers, my resolve was strengthened. My contact at the Department of Health took everything I brought her and built a case for her superiors and the committee they worked with that this rule needed to be rewritten. 

In the end, parents had the right to refuse this treatment on behalf of their newborn all along. All I did was work with a Department of Health employee to rewrite the code language to reflect this. We took it to a committee meeting, where I presented it in front of a couple dozen members, including OBs, Midwives, hospital and insurance representatives, and state employees. They asked some questions, which I answered, and they approved the wording that is now on the books. It was then several months before it was put into practice. I requested that the department of health notify all hospitals and birth centers and the professional associations of providers that work with newborns. They did.  

Credit: peasap

I was like a preening chicken the first time that I was at a hospital birth where the nurse announced that they had a new form for parents to sign regarding this treatment. I saw my words printed on it, in clear and easy to understand terms. It was worth the wait. No more painful arguments in the first moments after birth, the nurses were happy and the parents felt heard and understood. As a doula I was thrilled—it was an exponential improvement for babies and their families.

The final wording of the code rule allows parents to refuse this medication on behalf of their newborns.  It also clearly tells providers what to do so that they are protected if parents refuse this treatment.

In addition to the clearer language, I was able to include an allowance that stretches the length of time from birth that a provider has to use this medication from one hour to two hours. I had tried for four hours because the medication instructions allow for that long, but the committee members did not want to stretch it past the normal time that mothers are in recovery before being moved to postpartum care.  

The final code reads:

“Health care providers shall: Instill a prophylactic ophthalmic agent into both eyes of the newborn as prophylaxis against ophthalmia neonatorum up to two hours after the delivery, whether the delivery occurred vaginally or by Cesarean section. Acceptable ophthalmic prophylactic agents are application of erythromycin or tetracycline. In the event the U.S. Food and Drug Administration declares a shortage of these prophylactic ophthalmic agents health care providers may substitute alternative prophylactic ophthalmic agents recommended by the Centers for Disease Control and Prevention. If the newborn’s parent(s) or legal guardian refuses this procedure, the health care provider will document the refusal in the newborn’s medical record.”

I want to be clear that I don’t believe that every family should opt out of this treatment—my work in this area was not about that. There are really legitimate uses for this medication. I do believe that families deserve actual information—not so that they will consent—but so that they can make informed, educated choices about the care their baby receives. Parents have to make these kinds of decisions over and over again throughout the first eighteen years of their child’s life. We need to model, during pregnancy and the early postpartum time, what it means to really investigate and purposefully decide. 

After you wrote your article, parents contacted you from all over the world about their experiences with erythromycin. What did you learn from this?

After I had done my research, and upon realizing that the process of making a change would take much longer than anticipated, I wrote a paper to explain the history, use, and rules regarding eye prophylaxis in Washington state. I put the paper on my website and encouraged my doula colleagues to share it with their clients.  The paper got a lot of hits which brought it to the top of search engines and I did hear from people all over the world. (To read Jodilyn’s paper, click here).

Interestingly, in the United States, in almost every situation, it was fathers who contacted me. They were usually told that their baby needed to have this medication because a father who had an affair may have exposed his wife to Gonorrhea or Chlamydia. On the whole, the fathers who contacted me were distraught when they called. They were upset by this suggestion, and they felt bullied and threatened into accepting a treatment they did not want. The threats made in other states echo those made here: that CPS would be called, that they were putting their provider at risk for liability, lawsuits and professional misconduct, and that they were breaking the law and endangering their child.

Credit: RobBixbyPhotography

So much of pregnancy is out of range for fathers—they can’t fix it or make it better or do it for their partners. But they can protect them from accusations of bad mothering and threats of jail time or massive fines. And they can protect them from providers who refuse to work with them if they continue on with their desire to make decisions about which medications their baby will receive.

I often just listen to their stories and we wind up spending more than an hour and sometimes several hours over several days talking through options and potential pathways. For me, this is about bringing fathers into the pregnancy and birth and early fathering experience in an active and healthy way. It is about letting them explore their new-found father voices and providing tools to create good outcomes for their family and meaningful change in their community. We are all citizens and we all have the right to participate in our political system.

I am thrilled when I hear from parents who don’t want to give up their rights, even if it means ruffling some feathers. It is meaningful to create change from the consumer end instead of waiting around for the big-wigs to figure out how to create best practice out of good science. Hospital administration and policy making are slow moving machines—meanwhile families are dealing with this and other issues like it every day, so why not move what we can forward? 

Povidone iodine is an alternative to erythromycin that is not available in the U.S. What did you learn when you looked into the option of povidone iodine?

This is a complicated issue—but to over simplify it I would say that there is a gentler, more effective agent called povidone iodine that is in use all over the world. (You can read more about it here) The U.S. Food and Drug Administration (FDA) and the Centers for Disease Control (CDC) are highly influenced by well-funded lobbyists who represent big pharmaceutical companies. The FDA and the CDC need the pharmaceutical companies to fund both the local clinical trials and the packaging of medications in order to consider approving them for use. These pharmaceutical companies made it clear to U.S. scientists that they would not fund the use of povidone iodine in America, because this drug would not be profitable enough.

Our system is broken and twisted and relies on financial gain instead of following good science into best practice. The story of povidone iodine illustrates the depth of this problem. Meanwhile, povidone iodine is used all over the world and has reduced the rate of blindness in developing countries, which is great news.

What advice would you give to parents who would like to refuse the erythromycin ointment?

I encourage parents to gather the facts about what this treatment does and does not do, and find out how it affects newborn babies and their mothers. Have a frank discussion between partners about sexual history and activity so that you have all of the information you need to make a good decision.

If you decide to use erythromycin, push it off until after the first hour and as far into the second hour as possible. Those first moments are a time of intense coming together for mother and for baby and indeed for the whole family. It is a multi-sensory experience. Smell your baby, gaze into her eyes, hold her so that her skin touches yours, and breathe slowly. This is sacred space in my opinion, and it should only be invaded for procedures which are life-saving, such as a mother who is bleeding too much. Finding out his weight, sharing pictures with family and friends, inviting visitors into the room, or giving him that eye medication can wait.

In the first hours after birth the hormones that pulse through your body are designed to help you get to know each other and form those initial impressions and bonds which will carry you through your early parenting experience. It is not about all or nothing—it is about finding a balance that honors the built-in design that attaches us to our young, while providing the best individualized care for each family.

Jodilyn’s work has helped parents in Washington so that their choices to use or not use erythromycin are now based on informed medical decision making, instead of coercion or fear. Thank you, Jodilyn, for sharing your experience with us!

Do you have any thoughts or questions for Jodilyn? Please feel free to leave them in the comments below.

You can also reach her at EssentialBirthandFamily [at] Gmail [dot com].

 

Did you like this article? Then you may also like: 

A doula facilitates skin-to-skin in the operating room

A first-time mom shares her quest for evidence-based fetal monitoring

What is the evidence for doulas?

For a sample “baby plan” that includes declining the ointment, click here.

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Finding a Care Provider who will Support Upright Pushing Positions

Finding a Care Provider who will Support Upright Pushing Positions

Last month, I published an article about the evidence for various pushing positions. The best quality medical evidence shows that women should push in whatever position is comfortable for them. Some moms find that upright pushing positions are more comfortable. However, only a small minority of women in the U.S. (4%) give birth in upright positions.

Erin, a first-time mom from Ohio, shares her testimonial about how she found a care provider who supported her desire to push in an upright position.  

Erin, a first-time mom, and her new baby Rosalie
Copyright: Evidence Based Birth

What kinds of positions did you push in?

I was able to labor in many positions – for me the most comfortable was on my hands and knees with my head down – similar to the yoga “downward dog” position, but with my knees on the bed.  I tried to labor while standing, but baby’s head was pushing against something down there and that hurt a bunch!  Being on my hands and knees really helped to alleviate that pain.  When it came time to push, I went with what felt natural to my body.  In a previous life I trained in weight lifting. Squatting is very natural to me, so squat I did!  Squatting is great because it opens up the hips. Also, because I was squatting while pushing, I was in the perfect position to help catch baby. Rosalie was able to take to breastfeeding right after she was born. Jared, my husband, was a great coach and labor partner!

How did your care provider react to your desire to push in upright positions?

Erin preferred to squat while pushing
Copyright: Evidence Based Birth

My husband and I decided to change care providers at 36 weeks.  I really enjoyed my first doctor, but I just had a feeling that I would not be given as much freedom as we were looking for in our birth experience.  At the recommendation of friends and family who are nurses, we looked into the Family Beginnings Birthing Center located inside Miami Valley Hospital in Dayton, Ohio.  There are two practices in Dayton that see patients who would like to give birth at Family Beginnings.  They were willing to take me on at 36 weeks because we had made the decision to birth at Family Beginnings.  These docs are great.  They are supportive of what moms would like to do.  At one point I asked my doc what her role would be during birth.  She replied that she would just be checking in occasionally, but that for the rest of the time it would be just me and hubby in the room working to labor. 

Erin was in the perfect position to help “catch” her baby!
Copyright: Evidence Based Birth

There are three docs at the practice.  I saw one during labor.  He stopped in and asked how it was going.  We said great and he left.  The next time I saw a doc was when he was there to deliver baby.  We were at the hospital for about 6 hours before baby was born.  During that time a nurse would come and check baby’s heartbeat with a Doppler but I only remembered her checking about 3-4 times.  Needless to say the docs and nurses were very supportive of whatever position we felt comfortable with for pushing.

What advice would you give to other women about pushing positions?

The biggest recommendation I can give is to find a care provider that is willing to work with you.  You want to have the support of your birth team during labor and pushing.  If you feel that your care provider is not going to be supportive it is totally okay to shop around and find a new one.  I would also recommend that moms and dads get informed about the options that are available.  We took a Bradley Method class and loved learning about all of the options that were available.  Knowing why care providers run certain tests and why they might make different suggestions was invaluable information. 

Finally, I would encourage women to find what positions work for you.  I tried a bunch of positions before we went into labor, but found that only two really worked for me.  Having a support person (my husband Jared) who had gone through the birthing class with me was also great.  When I couldn’t think straight he was there to help me out!

Jared and Erin with new baby Rosalie
Copyright: Evidence Based Birth

Thank you, Erin, for sharing your story! Do any of you have any tips on how to figure out ahead of time whether your care provider will encourage you to push in whatever position is most comfortable for you?

 

If you liked this article, you may be interested in:

A mom shares how she pushed during 3 different births

A mom describes what it is like to do immediate skin-to-skin after a C-section!

A new mom shares her quest for evidence-based fetal monitoring

 

 

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Posted in: Pushing, Testimonial

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Testimonial: Push in whatever Position feels most Comfortable

I recently published the evidence about pushing positions during birth (click here to read the article). The take-home point of the research evidence was that women should push in whatever position feels comfortable to them– there is no need to stay continuously upright or continuously lying down during the pushing phase. Today, Krista, one of my readers, shares her testimonial on how she followed this evidence-based practice with each of her three childbirth experiences. Her first-hand account helps bring evidence based birth to life!

My name is Krista and I currently live in Key West, Florida.

Krista and Madeline

My daughter, Madeline, was my first baby and was born in a military hospital at Fort Lewis, Washington. I pushed in almost every position you can imagine. When the initial urge hit me I was standing next to the bed. The nurse had raised it so that it was more comfortable to rest my chest on the mattress as I breathed through contractions. I was pretty comfortable standing, but both the labor and delivery nurse and my midwife suggested that I get into the bed so that my legs did not get too tired. They raised the head of the bed so that I could kneel and kind of hang over the end. This was comfortable for awhile, but kneeling actually made my legs hurt more than standing. I pushed on my side for awhile before kneeling again and then lying down on my back.

I preferred standing and leaning on the bed. After a lot of pushing I ended up giving birth flat on my back with an episiotomy. My care providers, both the labor nurse and my midwife, were very supportive of me pushing in upright positions. They were open to any position I felt comfortable in and were helpful in suggesting positions that might move things along or alleviate some of the pain. In the end I was flat on my back because we had tried almost everything else and I was exhausted. At that point it was the most comfortable position for me.

Krista laboring in the tub at Houston’s birth

My second baby, Houston, was born in the same hospital as my first. When I was pregnant with him I learned that the tub for laboring was now also a tub for laboring and birthing. The episiotomy I had with my first had extended to a fourth degree laceration and I was determined to avoid another tear, so I knew I wanted to try for a water birth. I pushed in an upright position while sitting in the tub. I pushed for a very short time, so I never really adjusted my position.

My midwife was extremely supportive and entirely hands off. She never asked me to switch positions and even advised the labor nurse to skip a heart rate check because getting a good read with the doppler would have meant me shifting and adjusting my position. It was my second baby, so I knew what to expect and had the confidence to do what felt right. My midwife sensed that and never intervened until my son was pulled out of the water. I cannot say enough about the benefits of laboring and birthing in a tub of warm water and would suggest that any woman desiring an intervention free birth and who has it as an option take advantage.

Krista and Houston moments after his birth

Benjamin is my third and was just born in July 2012 at a private hospital in Key West, Florida. My research indicated that this hospital did not support upright pushing positions, and that they used constant monitoring and other policies not based on evidence. I was afraid these policies might inhibit my ability to birth my baby vaginally and without pain medication. I arrived at the hospital fully dilated and ready to push. I was lying down in the bed for initial monitoring and that’s where I stayed. I had hired a doula for this birth, and between her and my nurse I could have switched positions and been more upright. I started to sit up, intending to squat on the bed, but it was actually more painful. I was having a lot of back pain, but for some reason the angle I was in on the bed made lying down more comfortable. I rolled onto my left side when I heard the monitor slow down. By switching to my side, I hoped to get his heart rate to pick up and avoid too much premature concern about his well being. It worked and that’s where I stayed. I pushed him out about an hour after I arrived.

The best advice I can give a woman about pushing positions is to really do what YOU feel is comfortable. When I was given the suggestion during my first birth to get in the bed and kneel rather than stand I went against my gut and got in the bed. I didn’t feel too tired to stand, but this was my first baby and I figured the nurses had to know something that I didn’t. Unless someone is advising you to adjust your position because there is a problem, trust your instincts. Even if you’ve never had a baby before you know more about how to do it than you realize.

Krista and Benjamin

All of my births, the last one in particular, have taught me that you never know exactly what is going to work and be most comfortable. In addition to trusting their instincts, I would advise women to avoid getting too wed to the idea of pushing in a particular position. Before I labored with my first baby I thought for sure that I would push from a squatting position. Ultimately squatting was never a position that I really felt comfortable with. With my third I was very concerned with not letting anyone dictate my position and I had prepared myself to avoid lying down in the bed at all costs. Imagine how surprised I was when lying down on my back/side was more comfortable that being upright.

Set yourself up for success and choose a supportive environment for your birth. Do not consent to interventions that might inhibit your movement when it is time to push. You might be moving around a lot and switching positions, so you want to maintain the ability to move about freely.

 Thank you, Krista, for sharing your testimonial on Evidence Based Birth! Readers, what do you think? How many of you had care providers who actively encouraged you to push in whatever position you felt most comfortable?

For more testimonials from Evidence Based Birth readers, click here!

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A Doula Facilitates Skin-to-Skin in the Operating Room

A Doula Facilitates Skin-to-Skin in the Operating Room

Today’s interview is with Sharon Muza, a certified doula, lamaze certified childbirth educator, and birth doula trainer. This interview is a follow-up to my evidence-based article on skin-to-skin after a Cesarean, which you can read here. Sharon offered to share with us her thoughts on how doulas can advocate for and help facilitate skin-to-skin in the operating room/theatre after a Cesarean.  

Tell us a little bit about yourself. 

I am a DONA certified birth doula and  birth doula trainer, and a Lamaze Certified Childbirth Educator teaching independent birth classes through my practice, New Moon Birth.  I also train childbirth educators through Passion for Birth and am a co-leader of the Seattle chapter of ICAN (International Cesarean Awareness Network.)  I live in Seattle, have been doing birth work for about 10 years and have two daughters and a crazy golden retriever.  I also am the community manager over at Lamaze International’s Science & Sensibility blog.

 When was the first time you saw skin-to-skin care in the operating room after a Cesarean? What was it like?

Twins by planned Cesarean. Kristine is skin-to-skin with first twin Zoe moments after birth. (Permission is NOT granted to copy or use this photo).

As a doula working with women whose birth may have ended up in a cesarean, and those working towards a VBAC, I frequently heard the women state that one of the biggest “losses” they felt was that they were unable to have immediate skin to skin with their babies.  Their hopes were always to have that opportunity when they birthed again.  I knew the benefits of immediate skin to skin, and when I was invited in the operating room to support my client, I thought we might be able to offer this to mothers as long as everyone is stable.  The first  few times I tried it with mothers, at the beginning of my doula practice almost 10 years ago, it was awkward until I started “perfecting” the approach.

How can other doulas promote skin-to-skin care after Cesareans in the facilities where they practice?

Doulas can do two things, 1) they can promote skin to skin in the operating room “birth by birth” when they are able to go in with the mother during the procedure.  Here in Seattle, many hospitals allow two support persons in the OR, so whenever I am in with my clients, and the mother is open to trying immediate skin to skin, and the baby is stable, we give it a shot.  2) On a larger scale, doulas can offer to meet with leadership at their hospitals, and do a presentation on the potential benefits and help the hospitals to figure out how everyone’s needs can be met; the mother, the baby and the facility, who has safety and logistics at the forefront, as they should.  I would enlist the hospital lactation consultants, midwives on staff, if they practice there and even the hospital ombudsman, who would be delighted to know that women are more satisfied with their experience when they have this immediate skin to skin opportunity.

Partner Dawn brings twin Milo (swaddled) to Kristine– twin Zoe is already skin-to-skin on Kristine’s chest. (Permission is NOT granted to copy or use this photo).

Additionally, this could be a “marketing” advantage for a hospital, if they could state that they regularly promote this immediate interaction between mothers and babies.  Certainly, if I were a mother who was deciding between two facilities for my hospital birth, this could be one of the things that swayed me to choose the hospital that offered this, just in case I should have a cesarean.

When I have a positive experience getting baby skin to skin in the OR and the health care providers, (doctors, labor and delivery nurses) comment on it, I take a moment to share how this could happen with many cesarean births, with a little dedicated energy by the staff in the OR, and that I am happy to share some ideas if they are interested.  Every time it happens, I am  “modeling” this possibility for future births.

What is the doula’s role during the skin-to-skin care after a Cesarean? Is this considered part of the doula’s scope of practice?

Let me take a moment to share how I go about setting the mother up for success in getting her baby skin to skin if she were to have a cesarean. (I also talk about this during childbirth classes, so all the families can plan for it.)

  1. I discuss this when I meet with my clients prenatally. When we are going over their wishes during the birth, and covering the Cesarean portion, I explain that this might be an option and ask if they might be interested.  I note their preferences for myself and encourage them to include this in their birth wishes they share with the health care provider.
  2. I also share that partners may also have the option to have skin to skin time with their baby, if the mother is unwilling or not able to do it.  I invite them to consider that as well, and also encourage them to have baby get some skin to skin time after the birth, after mom has “had her fill.”
  3. I encourage them to advocate for having two support people in the OR, if the decision is made to proceed to a cesarean, so I can help.
  4. As the mother is getting ready to be taken back to the OR, I make sure she is wearing only her gown, and that her bra, camisole or other clothing has been removed.  I encourage partner to be wearing an old t-shirt under his or her OR clothing, that can be cut or ripped to make room for baby if that is what they wish.  If I am not able to go back to the OR, I am giving partner tips and reminders in the moment about how to get the mother-baby dyad together skin to skin as soon as possible.
  5. I remind partner in advance that after the baby is born, they will/can go over to the warmer and advocate for getting baby to mom ASAP, delaying things like weight, diapering, swaddling, eye antibiotics, vitamin K etc, until back in the room, unless there is a medical reason to do something immediately.  Mom can also ask for her baby to be brought to her ASAP.  The baby is usually over to mom in less than 5 minutes if everything is stable when that is the wishes of the parents.
  6. In the OR, I sit or stand behind mom/partner until the baby is born.  When the baby is born, the partner goes over to the warmer and I step in closer to mom, usually holding her hand and encouraging her to talk to her baby.  I ask partner to share what is happening and details about the baby.
  7. Partner is handed the baby, hopefully as soon as possible after the baby is dried, determined to be stable and the first set of vitals has been taken.  In the meantime, I have unsnapped mom’s gown on both sides and am ready to pull it down to the drape, when the baby comes over.
  8. When the baby is brought to mom, I help partner unwrap/unswaddle the baby, pull down mom’s gown and place the baby chest to chest (face down with the head turned toward mom) with mom, usually across both breasts.  We cover the baby/mom pair with the baby blankets and I see that partner (or I if necessary) keeps at least one hand on baby, to be sure it stays on mom’s chest.  Mom is usually able to use one hand to touch and stroke baby as well.  Sometimes the baby is nearer the nipple or sometimes just across the chest.  I am sure to respect the surgical drape that hangs across mom’s chest and keep baby “upwind” of that drape which designates the sterile field.
  9. Baby can lick, smell, move its head, taste, touch, see and hear mom.  Sometimes the baby will show signs of wanting to eat, and we gently locate baby as close to the nipple as possible, in case baby will want to latch on.  Sometimes the baby is just content to lay there taking it all in.  I make sure that the baby is well covered with heated blankets and that someone besides mom always is holding the baby in place.
  10. Usually the anesthesiologist is also up in the space by mom’s head, but s/he is doing her business and tends to leave mom alone unless necessary.
  11. If mom is not stable in any way, panicky, upset or feels nauseous, then I wait until mom is stable before encouraging skin to skin.  Sometimes, the mother asks for the baby to be removed, if she is starting to feel unwell.
  12. I find that having the baby skin to skin helps the rest of the surgery go smooth from the mother’s perspective.  She seems less anxious, is engaged with her baby and enjoys that time with her partner and baby while the surgeons finish the procedure.
  13. If the mother cannot have the baby skin to skin, then I ask partner/mother if partner wishes to do so.  If yes, I help partner to unswaddle baby and slip the baby down skin to skin under their shirt and gown/scrubs.  Sometime the neck of their shirt needs to be ripped or cut.  I encourage partner to stay close to mom while holding the baby skin to skin.
  14. If I am not allowed in the OR, then I hope that the instructions I have given the parents prenatally, and before the surgery, will help them to achieve the results they want.
  15. The OR staff seem to consistently leave the mother and baby alone, and may not even be aware that baby is skin to skin.  Once, a baby was making loud nursing noises, and the OB commented, asking what that was.  The mother responded “My baby is nursing!” and the OB replied “Wow, I didn’t know that was possible during a cesarean.” everyone laughed. Anything IS possible!
  16. I work hard to blend in, be supportive of everyone, respectful of everyone and have mother’s voice be heard.  It not my place to ever be pushy and domineering about what needs to happen.  It is the parent’s responsibility to advocate for their own wishes, I just gently encourage that by staying close and supportive.

In all the times that I have been able to be in the OR with my clients, there as never been any concerns, comments, or pushback by staff when mother has been skin to skin.  There are a couple of hospitals that occasionally do this with cesarean mothers, even when a doula is not present.

Dawn skin-to-skin with twins Zoe and Milo. (Permission is NOT granted to copy or use this photo).

To answer the question of whether this is within the doula’s scope of practice; I feel that if this is the mother’s wish, she has made an informed choice and both mother and baby are stable, then supporting the mother’s wishes and helping her and her partner to ask for what they want is certainly within my scope.

Which experience seems to work best for your Cesarean clients– immediate skin-to-skin (within a minute or two after birth), very early skin-to-skin (within 30-40 minutes ater birth), or early skin-to-skin (anytime after 40 minutes)?

In my experience, skin to skin in the OR is the ideal situation if everyone is stable and mother is willing.  Luckily, in Seattle, where I practice, stable babies stay in the OR room and both mothers and babies return together to the labor room from the OR.  Mothers do not go to “recovery” and stable babies do not go to a nursery or observation area.  If skin to skin in the OR is not possible, then immediately upon returning to the room is second best, provided that mother is stable, which is normally the case.  It is very rare to have the mom not be able to go skin to skin within the first 30 minutes.  Even in some cases, when mother has been very out of it, due to medication or exhaustion, it has been possible to get baby skin to skin with her and breastfeeding, back in the room, with my support.

“As I carried two bundles out of the OR after years of frozen sperm and fertility treatments, an emotionally stressful twin pregnancy, and a planned c-section I felt relief and then panic because I wasn’t feeling love for the babies.  They weren’t my flesh and blood…I started to fear I wouldn’t love them.  Back in the room, Sharon encouraged me to open the button down shirt she suggested I wear and I held the twins skin to skin.  In an instant the panic and fear were gone and I knew I loved these tiny, vulnerable creatures in a powerful and life-changing way.  I’m sure I would have gotten to this point eventually but what a gift to have only wasted an hour in doubt.” ~Dawn

What differences do you see between moms and babies who have immediate skin-to-skin after a Cesarean and those who don’t?

Dad (Jeremy Levin) is carrying a naked baby Natalie directly from the warmer so she can do skin-to-skin with mom (Dahlia Levin) after an unplanned repeat Cesarean. (Permission is NOT granted to copy or use this photo).

In my experience, the mothers that get skin to skin contact with their babies during the Cesarean, have a higher degree of satisfaction with the surgical procedure, even if a Cesarean was not wanted nor planned.  It makes for very positive early memories of connecting with their babies, they seem less “disturbed or anxious” about the surgery and even report less discomfort during the rest of the procedure.  They are very distracted from the surgery by engaging with their newborn in this way, and tell me in a postpartum visit how much they appreciated having this component of connection, even when they did not have the birth they were planning.  Women who have missed this opportunity share with me that they are disappointed in not being able to spend skin to skin time right away.  As I mentioned earlier, those women planning a VBAC often state that this missed opportunity with their previous birth is one that they felt very impacted by and would like to change the next time around.

“Immediate skin to skin made a difficult & unwanted situation (repeat c-section) bearable. It was night & day from my first c-section where I was separated from my newborn for several hours after birth (baby was taken to the newborn nursery with dad while I was in the recovery room by myself until I could feel my legs). It was healing and allowed for immediate bonding between the baby and her parents. It also facilitated getting breastfeeding off to a good start. Sharon was amazing at helping us cope with the reality of having another unwanted c-section and making the best of the situation by helping us bond with our baby almost as if it had been a vaginal birth.” – Dahlia and Jeremy Levin

Jeremy places baby Natalie skin-to-skin on Dahlia’s chest in the operating room. (Permission is NOT granted to copy or use this photo).

In my review of the literature, I noticed that very little research has been done on skin-to-skin in the OR after a Cesarean. What research questions would you like to see answered about skin-to-skin care after a Cesarean?

I would love to have an assessment of the newborn when placed to skin to skin in the OR compared to when the baby is just swaddled and held by partner.  Do they stabilize quicker?  Does their body temperature remain stable, are they calmer? Do mothers routinely feel more positive about the experience?  How do partners feel?  How does this affect newborn stress levels, breathing and other vital signs?  Can it be routinely done safely at every facility?  What risks can be identified if any?  Is there a long term impact on breastfeeding when this happens?  Some of the concerns I have read about immediate skin to skin in the OR is that baby will get cold, as the OR is a cold place.  Can this be compensated for by warm blankets routinely being available?  Who is responsible for the baby during skin to skin to assist the mom, assuming the doula is is not able to help? Is there an available pair of hands from a staff member?  What barriers exist in having skin to skin routinely in the OR and how can they mitigated these issues so both the staff and the mother’s concerns and needs are being met.

Dad (Jeremy) takes a turn doing skin-to-skin in the operating room. (Permission is NOT granted to copy or use this photo).

Is there anything else you would like to add?

The reality is that 1 in 3 women will have a baby born by Cesarean in 2012.  Who knows what that rate will be in the future, though my wish, of course, is that this rate is at the zenith and we see a downturn in this number.  I would like every mother’s experience to be positive, to have her feel that her voice was heard, her wishes were respected and that she got to connect with her baby in a way that felt good to her as soon as possible.  Certainly, we can figure out a way to have this happen without compromising safety of the mother or baby, making the hospital staff feel comfortable at all times and respecting the research that says that “first hour” is of critical importance to the mother baby dyad.

A mother (anonymous) does skin-to-skin with her newborn in the operating room. (Permission is NOT granted to copy or use this photo).

Doulas (and childbirth educators in the classroom teaching expectant parents) can and do play a critical role in making every birth the best that it can be.  I invite anyone who would like to discuss this, brainstorm or who has more questions to comment here, or contact me by email so that we can continue the conversation and I can offer support in whatever way I can.  I want to thank Rebecca for putting this conversation out there, examining the limited research and giving us all this forum to discuss it.

I encourage doulas who are paving the way in getting mothers and babies skin to skin in the OR to always be respectful and cooperative while supporting their clients.  The OR is not a place to alienate staff, or create division or argument but should be a place where good doula behavior is “modeled” for everyone to observe.

Please share your thoughts, comments, and questions with Sharon!

If you liked this article, you may also be interested in:

The Evidence for Skin-to-Skin after a Cesarean

A Woman’s Experience with Immediate Skin-to-Skin after a Cesarean

A First-time Mom Shares her Quest for Evidence-Based Fetal Monitoring

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A Woman’s Experience with Immediate Skin-to-Skin after a Cesarean

A Woman’s Experience with Immediate Skin-to-Skin after a Cesarean

My main goal for Evidence Based Birth is to provide summaries of the latest evidence on birth practices for both consumers and clinicians. However, I will continue to present interviews with women, family members, and clinicians who have put evidence-based birth information into practice. Although individual experiences are perhaps the lowest acceptable form of scientific evidence, these interviews are a very helpful way for consumers and clinicians to share with others how they have put evidence into actual practice. Personal stories and testimonies can be an effective way to promote changes in practice.

This interview is a follow-up to my evidence-based article on skin-to-skin care after a Cesarean, which you can read here.

There are 3 main types of skin-to-skin that can take place around the time of birth. Immediate skin-to-skin starts in the first minute after birth. Very early skin-to-skin starts within 30-40 minutes of birth. Early skin-to-skin refers to any skin-to-skin that takes place in the first 24 hours.

The research we have so far demonstrates that there are many benefits to skin-to-skin care for all moms and babies after uncomplicated vaginal births and Cesarean births. Conversely, there are NO benefits to routinely separating a healthy mother and child after an uncomplicated vaginal or Cesarean birth. Many women are interested in requesting “immediate” skin-to-skin care that takes place in the operating room/theatre after a Cesarean. Although the research on this technique is limited, researchers so far (from one randomized controlled trial and 2 quality improvement studies) have not reported any adverse effects from immediate skin-to-skin care after uncomplicated Cesareans.

V.F. wanted to share some pictures of her immediate skin-to-skin time after a Cesarean, and I asked if she would be willing to do an interview to accompany her photographs.

Tell us a little bit about yourself and your pregnancy.

My name is V.F. I live in Australia, I’m studying to be a doula and have a one year old girl. I have a neurological condition which causes muscle weakness and requires me to use a wheelchair. The pregnancy was not easy – I had a severe case of morning sickness (aka hyperemesis gravidarum) for the first few months, the weight of my belly affected my mobility further and I had excruciating pubic symphysis pain for the last couple of months. I had a plan and every intention to have a natural birth but on my due date exam my daughter was in a funny position (sitting with her shoulder/neck to the cervix, possibly caused by a severe scoliosis I have) and after considering all risks (including possible cord prolapse as head wasn’t fixed in the pelvis) and much deliberation, I agreed it’s safer to go with my doctor’s suggestion to have a Caesarean. I insisted on having the surgery be as family-friendly as possible and my daughter was born 3 days after her due date.

When did you first hear about the possibility of doing skin-to-skin in the operating room (theatre)?

I can’t remember when exactly. Birth and pregnancy were an interest of mine for a while before getting pregnant, and I used to regularly read online articles on the subject. I think it was in one of them that I heard about it first and I thought if I ever have to have a Caesarean, I’d definitely want to have the skin-to-skin contact and not be separated from my baby.

Was this a routine procedure for your hospital?

As far as I know, the hospital practised skin-to-skin for Caesareans but only if the parents asked for it. I talked to my doctor and he said it’s not a problem. The way it’s routinely done is that after a baby is born, it’s taken to a little station where it’s wiped, checked, weighed and wrapped, then placed on mum and unwrapped while both baby and mum are under warm blankets. My doctor is up to date with latest research in the field and a fan of skin-to-skin, so he suggested we go a step further and have the baby given to me immediately, before the cord is even clamped.

Tell us about the experience of doing skin-to-skin right after your baby was born. What was it like?

Just before the surgery my doctor suggested a different way of doing the skin-to-skin to minimise exposing baby to the cold air in the theatre and to allow for amniotic fluid to go on my skin – something that helps with establishing breastfeeding and bonding. The procedure would involve lifting the surgical sheet covering me so the doctor could slip bub on my belly as soon as she’s pulled out. A midwife would then reach for the baby from the other end of the sheet and pull her up to my chest and in doing so still maintain sterility of the surgical area. It all went as planned. As soon as she was on my chest, we had warm blankets piled on us.

the doctor lifting my daughter out of my belly and is just about to slide her up on my abdomen under the surgical sheet (another doctor is seen lifting the sheet up).

The obstetrician is lifting the baby out of her belly and is just about to slide her up on her abdomen under the surgical sheet (another doctor is seen lifting the sheet up). (Permission is NOT granted to copy or use this photo).

I was ecstatic having my daughter on me – the feel of her warm, wet, soft body on mine, the distinct smell of the amniotic fluid, the feel of her little hands reaching up on my face and her body wriggling on me – it was just heaven. I hugged her, kissed her and tried to take it all in! She didn’t have her nose and mouth suctioned, so they drained on their own as she lay on me. She was making quiet whimpers from time to time but not really crying, it was obvious she was calm and happy. She stayed like that throughout the surgery with a small break in between – my blood pressure dropped at one point, I felt faint and struggled breathing with bub on me so I asked that my husband take her for a bit, four minutes later I felt better and she was back on my chest.

We had our first breastfeed while I was still in theatre. Skin-to-skin contact continued in the recovery area as well, where we had another breastfeeding session. All in all, it was great being able to have that contact, despite not being able to have a natural birth. It helped with bonding, decreased stress and was just a beautiful experience.

Here you can see the midwife adjusting her on my chest, after pulling her up. We were immediately covered in warm blankets to preserve body heat (as the operating theatre is quite cold). (Permission is NOT granted to copy or use this photo).

A barrier to skin-to-skin after a Cesarean for some women is that there needs to be more than one nurse present– one to watch the mom and one to watch the baby. How did your hospital handle this?

During recovery, there is typically only one midwife who looks after both baby and mum. She’s the one who pulled my daughter up on my chest (you can see her hands in the photos), she made sure baby was well positioned on me, warm enough and well covered, she also helped me with the breastfeeding.

How did the skin-to-skin impact your recovery?

Not sure if it affected my recovery on a physical level, but mentally and emotionally it was huge for me. I was feeling really down for not having a natural birth and I’m sure that would have spiraled into a depression if it wasn’t for the joy and bonding that the skin-to-skin contact brought. When I think back of the birth, it’s all that I remember – the contact with bub, how we snuggled and all the love, as opposed to details about the theatre, doctors, the stress and surgery in general.

What advice would you have for families who desire immediate skin-to-skin after a Cesarean?

Talk at length to your doctor about what you want and how you want it. If they say it can’t be done, ask them why and show them proof that yes, it has been done and it’s not a problem. If they are still hesitant or resistant, get a new doctor!

One of the first kisses I gave to my daughter. (Permission is NOT granted to copy or use this photo).

Do you have any questions for V about her experience? Also, I know that some of you live in areas where there are NO surgeons or hospitals that provide this option. Does anybody have any suggestions for women or care providers living in those areas who would like to implement this?

 

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A First-time Mom Shares her Quest for Evidence-Based Fetal Monitoring

A First-time Mom Shares her Quest for Evidence-Based Fetal Monitoring

In my last post, I discussed the evidence for fetal monitoring. To sum up what I found, evidence clearly shows that intermittent auscultation (listening to the baby’s heart rate while feeling the mom’s contractions with your hand) is the best way to monitor baby during labor. However, only 3% of women in the U.S. receive this care. The other 91% receive electronic fetal monitoring, which increases the risk of Cesarean delivery. Many women are led to believe they have no options in regard to electronic fetal monitoring. However, this is one of the least helpful interventions for birthing that actually has proven risks. For women who birth at home, intermittent auscultation is the standard of care. On the other  hand, it can be extremely hard for women who give birth in hospitals to receive intermittent auscultation. But– it can be done.

I’d like to introduce Sarah, one of my readers, who recently succeeded in being the first woman (that she knows of) in a large teaching hospital in her town to receive intermittent auscultation. Her quest was not without struggle– when she went into labor, she ended up spending 2 hours in triage because of push-back from the on-call OB regarding 3 items on her birth plan: intermittent auscultation, no saline lock/IV, and letting the placenta deliver on its own. Here is my interview with Sarah. If you’re interested, you can read Sarah’s birth preferences (aka birth plan) here. It’s a great example of a low-intervention or “natural” birth plan.

Here is my interview with Sarah.

Tell us a little bit about yourself and your pregnancy.

As soon as I found out I was pregnant, way before you’re ‘supposed’ to be planning and celebrating, and way before I knew about possible birth preferences, I began putting together my birth team. The first person on my team was my birth partner—my extremely supportive husband.

We knew we wanted a doula because of the success many of our friends had with them and I quickly found a respected and experienced doula with availability around the time I had calculated would be full term.

Next, we chose a doctor based on a recommendation from a friend who had been given time to have her baby (she was 42 weeks) and had a low intervention birth. The doctor was in the OBGYN practice at the university hospital where I also teach. He was about our age and spent a lot of time with us at each visit. We thought he was great, though we knew that the possibility of actually having him on the date of delivery was slim.

Around 20 weeks into my pregnancy, I attended an open discussion group offered by a local maternity resource center. I had come to ask one question: “So, as long as I have my husband and my doula, it doesn’t matter who’s catching the baby, right?” The moderator offered a long and kind response outlining the reasons why this was not the case. At the end of the session, I was given the name of another care provider in Family Medicine at my university. My husband and I met with her briefly and immediately made her our care provider and switched practices altogether. As you’ll read below, this became an extremely impactful decision we made for having the type of birth we wanted, which was one with as few medical interventions as possible.

Tell us about your requests for intermittent auscultation, declining a saline lock, and allowing the placenta to be delivered without Pitocin. What made you interested in including those things on your birth plan? How did your chosen care provider respond?

I’ll start with declining the saline lock, since to me it felt like that decision was the cornerstone of our birth preferences. For me, the saline lock represented an anticipation of fluids and drips that I knew would not be part of our birth. And, it represented a hospital experience where I was a patient with a condition, rather than a healthy woman in an uncomplicated birth. Declining a saline lock guided the direction of our low-intervention birth.

As for intermittent auscultation, I was over 40 weeks into my pregnancy before I knew this was a possibility. Until this point, our birth preferences read: ‘We prefer intermittent monitoring.’ I learned about intermittent auscultation in passing from a friend. I looked into it using online resources and made the easy decision to change the birth preferences to read: ‘We prefer intermittent monitoring with a handheld doppler monitor’. I was very interested in this because of the mobility it offered. As opposed to electronic monitoring, where I would have been belted and attached to a machine, the handheld doppler didn’t disrupt me at all– I didn’t have the discomfort of something strapped around my belly, and I was allowed to change positions even during monitoring. The other research I found was alarming, particularly the rate of inaccuracy and false-positives (as in, a reading that indicates a problem when there is not one). Again, I wanted to eliminate hypothetical situations during the birth.

Finally, my opting for physiological third stage (natural delivery of the placenta) over active management (placenta delivery with Pitocin) was based on allowing my body the time it needed to complete the birth process. This decision didn’t go as smoothly as the other two. I was told in triage that third stage could not exceed 30 minutes (see below) and therefore I felt very anxious during this time, worried that I was on the clock. Additionally, in the 12 hours following the birth, I had more clotting than the hospital wanted me to have and I chose to have a shot of Pitocin at this time to reduce bleeding. Ultimately, even this was part of my birth plan since I wanted to avoid anticipated issues and only intervene when medically indicated, which in this case it was.

By the time we brought our birth plan to our Family Medicine health care provider, we had already completed our Hypnobabies birth education course and had done additional research using online resources. Our doctor still took the time to discuss risks and benefits of each of them, which we appreciated since we very much valued her perspective. She also let us know that there may be some issue with the hospital adhering with some of the points of our plan, particularly intermittent auscultation. She, my husband, and I determined that it was important to all of us to try to push through hospital policy, particularly if it meant that somewhere down the line it might pave an easier path for someone else requesting intermittent auscultation.

What was it like trying to get the hospital to follow through on these birth preferences?

This is where the importance of choosing a supportive care provider came to fruition. After arriving at the hospital with four copies of our birth preferences, we began getting push back from the OB on duty and she came into triage to discuss the risks of our birth preferences with us. According to the OB, the risk for intermittent auscultation was the fact that there was no paper trail of complications should there be an emergency where they may need the record for diagnosis. The risk of declining a saline lock was in case of emergency Cesarean. She was ‘fine’ with the placenta being delivered without Pitocin unless it took longer than 30 minutes to deliver due to the risk of postpartum hemorrhage. I was surprised by her repeated use of the term C-section and at one point in her explanation she mentioned NICU. In my deeply focused state (at the the I was somewhere between 5 cm and 6 cm dilated), I thought for a split second that the OB was jumping to the worst case scenario to frighten me out of our decisions. Then, I realized that thinking toward the operating room was just her training.

We told the OB that we appreciated the hospital’s position but that we were going to stay with our birth plan. In the end, it was our family medicine care provider, and my husband, who advocated on my behalf. At the end of the night, I realized that if I had stayed in the OBGYN practice, that this particular OB would have been caring for me that night. If that had been the case, my experience would have been dramatically different from the wonderful birth we had.

When you finally got past any barriers, how did using intermittent auscultation contribute to your overall birth experience?

I don’t have electronic monitoring as a comparison to my experience, but like I said, one of the decisions to use intermittent auscultation was based on having mobility, which I certainly got. I was allowed and encouraged to be in whatever position felt natural to me. I spent time on a birthing ball, in the bathroom, and on a bedside toilet with the bottom removed, and wasn’t near the bed until I was ready to push.

What I hadn’t anticipated was a sense of calm that came with intermittent auscultation. The monitoring felt very organic, different hospital staff held the Doppler at different times, and there was very little monitoring in the beginning, more near the end as my baby was moving through my pelvis. I was sometimes aware that my baby was being monitored and I’m sure sometimes not aware since the disruption was so minimal. Because I couldn’t hear the pulse constantly or see any flashing lines, I couldn’t jump to conclusions about how he was doing. What I could do was cue off of my care provider’s reaction, which was always very calm, so I never had even a moment of concern. I do distinctly remember feeling the monitor going on lower and lower at the end, which was very exciting.

Sarah, her husband, and her baby right after birth

What advice would you have for other moms who might want to request these things in a hospital birth setting?

Make sure your birth partner is on board and is as educated as you are about the risks and benefits of your birth preferences as you are, since you may not be able to be ‘present’ enough to deal with adversity. Choose your care provider based on their commitment to your plan. If they have a ‘we’ll see what we can do’ response to your birth preferences, consider changing care providers or even changing practices. It’s never too late to find someone with whom you share mutual respect, who makes you feel comfortable, and who wants to work with you. And yes, the right care provider for you is out there! If you make your decision early enough in your pregnancy and you know that there are parts of your birth plan that don’t follow standard protocol for your hospital, see if there are any hospital personnel with whom you could discuss your birth plan to avoid push back when you arrive in labor. Come to the conversation with them educated and with confidence.

Sarah’s happy little baby boy

(This is Rebecca again) I think Sarah described her experience– and her insights– beautifully. I think we can learn a lot from her story about how to request evidence-based monitoring at birth.  And I am so thankful to her for paving the way for women in her community to receive evidence-based monitoring at that particular hospital. For women who are birthing at home or in birthing centers, you probably don’t need to worry about monitoring since intermittent auscultation is already standard in those settings. But for women who are giving birth in hospitals and want to receive intermittent auscultation, I’d like to suggest a potential plan of action. (But FIRST, read my Disclaimer). Of course, as Sarah pointed out, some of these action points may or may not be feasible, depending on how close you are to your due date.

  1. Have a pleasant discussion about intermittent auscultation with your care provider. State that you are really interested in intermittent auscultation. Emphasize that you want intermittent auscultation with a handheld Doppler—not an intermittent electronic fetal monitor. Find out from them if intermittent auscultation is used at your chosen place of birth.
  2. If your midwife or doctor is interested in helping you out with this, but they are not familiar with the method, give them the intermittent auscultation guidelines from the American Congress of Obstetricians and Gynecologists , the American Academy of Family Physicians, the American College of Nurse Midwives, and the Association of Women’s Health, Obstetric, and Neonatal Nurses (all freely available onlnie). Likewise, if your care provider is NOT interested, you can also hand them these same guidelines.
  3. If you meet with extreme resistance from your care provider, and if this is really important to you, then you might either A) consider choosing another care provider or B) let them know that you are thinking about refusing consent for the EFM and that you would like to choose intermittent auscultation instead. They may not “let” you do this or state that this is not “allowed,” and threaten to fire you from their practice. I would hand them the ACOG guidelines. And reconsider again whether you want this care provider at your birth. If you have no other option and “have” to stay with this care provider, weigh the benefits and risks of creating adversity with your care provider versus your desires for intermittent auscultation. Is it worth it to create adversity for this particular cause, or not? Adversity can be a bad thing in a birth setting. Also, you need to ask yourself, is this a warning sign that this particular care provider might not honor any of your other requests related to birth preferences?
  4. If you are going to be a trend-setter, or one of the first people at your hospital to receive intermittent auscultation, I would contact the nurse manager of the labor and delivery unit where you will be birthing, and set up a meeting or phone conversation with them to discuss your care. To set up this meeting, you can call the labor and delivery unit and ask to speak with the manager. At your meeting, make sure you bring the guidelines listed above. In particular, the American Academy of Family Physicians guideline has a helpful segment on how to implement intermittent auscultation in a hospital that is not used to using it.
  5. In the month before your birth, confirm that someone who will be at your birth (your doctor, midwife, nurse manager, or nurse) is comfortable, trained, and experienced at intermittent auscultation with the handheld Doppler or fetoscope, and willing to provide this care. You do not want to get there and have nobody that knows how to do this.
  6. Ask your care provider to write “intermittent auscultation” in your orders and notify the hospital so that when you arrive this wish is honored. Have your birth plan signed by your doctor and already placed in your chart. The hospital staff might think you are weird or crunchy or a crazy natural birthing mama. But you know what? This isn’t weird or crunchy stuff. It’s evidence-based stuff.
  7. If you meet with EXTREME resistance from your hospital about intermittent auscultation with the handheld doppler, you could request that they hold the electronic monitor to your abdomen for intermittent auscultation—instead of having it belted around your waist. Auscultation is an option the staff can select with most electronic fetal monitors. That way you can be in whatever position you want to be in, and they bring the monitor to you, and hold the sensor up to your abdomen, listen to the baby’s heart rate, ande palpate your contraction. This will also allow them to “capture” the brief reading on their computer in case of a lawsuit (which is mostly what they are worried about).
  8. If you meet with extreme roadblocks along the way, I would write a letter to hospital administrators. You can usually find out their names and sometimes their emails on the hospital’s website… if not, call “Information” at the hospital main number and ask for “patient relations.” Once you get someone on the phone from patient relations, ask them to pass along your letters to these people. You could include copies of the ACOG, AWHONN, ACNM, and AAFP guidelines (links above) with your letters. Send them to:
  • Chairperson of OB/GYN
  • Nursing Manager of Labor & Delivery
  • Chief Nursing Officer
  • Chief Medical Officer

In the end, there are several ways to obtain evidence-based maternity care when it is not routinely offered. You can be strong, determined, and resourceful– like Sarah– and fight for it on your own (with help from your birth partner and your care provider). Women like Sarah are birth “pioneers” and we need more women like her! However, I would also like to suggest an additional way that we, as women, could get this evidence-based care. We can fight for it together. We can join together with Improving Birth to rally on Labor Day for evidence-based care for women. Look for an article about Improving Birth’s mission, coming soon!

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Diagnosed with Gestational Diabetes? It’s not the end of the world.

One of my readers would like to share her story about being diagnosed with gestational diabetes. I found her story very inspirational! Please read about how she coped with the diagnosis, managed to keep her blood sugars under control, had a healthy and low-risk pregnancy, and got the un-medicated, evidence-based birth she wanted (minus a little unnecessary bedrest).

Read her story about being diagnosed with gestational diabetes here.

And her inspirational birth story is here.

Stay tuned– I plan to post more about gestational diabetes later this summer. Does gestational diabetes always mean big babies? Does it always mean induction? Does this mean you are now considered “high risk?” Should you be worried about getting Type II diabetes after your baby is born?

To read about the glucola test and how women are diagnosed with gestational diabetes, click here.

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Dr. Shannon’s Tips for a “Natural” or Un-medicated Birth

Dr. Shannon (a family medicine physician) just prepared this handout for patients in her practice who want a “natural” or un-medicated birth. Although she believes in the ability of all women to give birth normally, Dr. Shannon knows firsthand that a little bit of preparation goes a long way. Here are her tips for those of you who want a natural birth! If you are a doula, childbirth educator, midwife, doctor, or nurse, you can access a free, printable version of this handout here for your clients.

Dr. Shannon’s Tips for an Un-medicated Birth

© 2012 by www.evidencebasedbirth.com

If your goal is an un-medicated birth/natural vaginal birth…read below!!!

  1. Prepare and Practice! You wouldn’t run a marathon without training, would you? Labor and birth can be long and hard. Take a natural birth or Hypnobabies class at an independent childbirth education center NOT affiliated with a hospital. If you do this, you won’t even need to read the rest of the list! You will already know it all! :)
  2. Practice your relaxation exercises every night. Get your partner involved.
  3. Hire a doula. This is a woman who provides continuous labor support. They are trained to provide encouragement to you and your partner as well as massage, instruction on labor positions and help in navigating the medical world of labor and delivery. In research studies, doulas decreased C-section rates and epidurals and shortened labor duration, even when a supportive partner was present. They are worth every penny! For a list of doulas in the area, contact your local independent childbirth education center.
  4. Exercise, eat a nutritious diet and gain the appropriate amount of weight during pregnancy. Go to prenatal yoga classes or rent a prenatal yoga video.
  5. Visit http://spinningbabies.com/ to review healthy sitting positions for the third trimester and exercises that are vital to getting your baby in a good position before birth. Do 40 “Cat-Cow” poses every day!
  6. Read as much as possible on natural birth. These books are often available at your local library or for cheap at www.half.com:
  • Ina May’s Guide to Childbirth, by Ina May Gaskin (strongly recommended)
  • The Official Lamaze Guide: Giving Birth with Confidence by Lothian
  • Husband-Coached Childbirth by Robert Bradley
  • Your Best Birth by Ricki Lake
  • Birthing from Within by Pam England
  • Birth Matters by Ina May Gaskin
  1. Do not watch television shows (A Baby Story) or movies that show negative birth experiences. Do not read or allow people tell you hospital horror birth stories. It is important for you to develop a confident mindset that birth is normal and healthy.
  2. Write down your birth preferences and give them to your partner, doctor, and nurse.
  3. Avoid an induction unless it is absolutely medically necessary.
  4. For every intervention that is offered, ask, “Is mom okay? Is baby okay?” Then use the BRAND acronym:
  • What are the Benefits?
  • What are the Risks?
  • What are the Alternatives?
  • What if we do Nothing?
  • Give us time to Discuss and Decide.
  1. If this is your first baby and your provider says it’s okay, stay at home as long as possible during labor! If labor might be starting, try to ignore it. Walk, eat, stay hydrated, and relax. If it is nighttime, sleep, and if it is daytime, go about your normal activities. Try to keep moving during labor and avoid lying on your back. (If your water breaks, ask your provider what they recommend.)
  2. Be flexible! Every baby has its own timing and way of being born. Try not to get too worried about having a specific experience. Just try and make you and your baby as healthy and as ready as possible!

Have you used any of these suggestions before? Do you have any additional tips you would like to share with readers?

If you liked this post, click here for more articles featuring Dr. Shannon

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Testimonial: A Positive, Low-intervention Hospital Birth Story!

Last fall I took a Hypnobabies course. In that course my eyes were opened to the fact that people (especially in the United States) are very afraid of childbirth. That shouldn’t come as a surprise to you– just think about all the movies that you’ve ever seen that depict childbirth. Think about the show “A Baby Story.” Almost all of them are full of people screaming, and crying, and writhing in pain– or numbed and paralyzed from the waist down with an epidural– pushing on their backs with their feet in stirrups, with many of them rushed to “emergency” C-sections because their bodies were just not meant to give birth. You know what I’ve learned? Birth doesn’t have to be like that. Our bodies were made to do this. And if you are pregnant, I believe that one of the most important things you can do is to re-set your mind and avoid watching any movies or television shows that depict childbirth, and refuse to listen to negative birth stories (there are plenty of them out there, given that our maternity healthcare system is so messed up).

So I decided that one of the things I want to do with this blog is to regularly share positive birth stories. For example, with my second baby I had an almost completely painless birth that was the single most empowering experience of my life. And I have had other friends who have had amazingly easy births that I find so inspirational. So from now on,  check back here every  Wednesday for a mid-week positive birth story. Our first guest writer is Sarah, a friend of mine and client of Dr. Shannon’s. Sarah had her first baby this past fall in the hospital. Enjoy her story! ~Rebecca

When Rebecca asked me if I’d be interested in writing a guest post about my experience birthing in a hospital, I was very excited to share my experience! I often feel that as a non-medical professional I can’t have much of an impact on something I feel very passionate about (low intervention and natural birth) but hopefully my positive story can provide some encouragement!

Soon after I got that plus sign on my home pregnancy test I called Dr. Shannon to ask for recommendations for a good OB. I was surprised when she said, “You can come see me in Family Medicine!” It had never occurred to me that I could go to Family Medicine for prenatal care. So I made my first appointment and started seeing her around 8 weeks. During one of my first visits Dr. Shannon asked me if I thought I would have an epidural. I said, “Yes!” right away without thinking about it. Because that’s what you do when you have a baby, right? But then I started reading. The first book I read was Ina May Gaskin’s Birth Matters. The positive natural birth stories and the outline of risks involved in interventions had me second guessing my desire for an epidural. So I signed my husband and myself up for a natural birthing class in the area.

The class was at an independent childbirth education site (not affiliated with a hospital), and it was taught by a midwife. She went over all the possible interventions and instances where they would be needed or necessary—to emphasize that they really can be a good thing—when used for the right reasons! The most valuable thing that I came away with was that contractions were usually 45-90 seconds in length, that they had a peak about halfway through, and that if I took it one at a time I would get a chance to rest in between. Which was totally true. It wasn’t constant pain, like people think. She also talked about walking around or being on your side during labor and how being on your back was probably the most painful for most people. She gave us a hand out of different labor and birthing positions.

After taking the class, I wrote my birth plan. I will share it with you all in case you would like to see an example of a low-intervention hospital birth plan:

Birth Plan for Sarah

Doctor: Dr. Shannon

Due Date: November 5

I wish to have the following people at my birth:

  • Nicholas – Spouse
  • Courtney – Doula

I prefer the following general medical procedures:

  • Have saline lock
  • Have no IV fluids
  • Few vaginal exams or by my request
  • Intermittent external monitoring
  • Avoid Pitocin unless absolutely medically necessary

Pain Management:

  • Offer pain medication only if I request it
  • After medical guidance for pain relief, I would appreciate some private time with my partner and doula to discuss which pain management technique or medication I would like to use.
  • I would like to be free to move around

During the pushing stage:

  • Push when and how I feel is right
  • In any position that I feel is right for the time
  • As long as we both are healthy, no time limitations on pushing time
  • I prefer to tear, no episiotomy

Once the baby is born I would like:

  • The baby immediately place on my abdomen
  • I would like skin to skin contact before baby is taken for routine care
  • Breastfeed as soon as possible
  • Delay all other routine baby care until after breastfed

Routine baby care:

  • You can administer all newborn immunizations
  • My baby is to be exclusively breastfed.

At 36 weeks  I woke up one morning feeling a bit crampier than normal. I felt like my period was coming all day long. Around 2:00pm I started getting Braxton Hicks contractions along with the cramping. They were about 10 minutes apart so I drank a bunch of water and lay down. This didn’t help and they got a little closer together, but didn’t get stronger. I had an opera audition that evening at 7:30 and I was just hoping that they would go away before then. I got ready for the audition and contractions were still coming, now about every 6 minutes. I got to my audition and sang great, despite the fact I was having contractions every 4 or so minutes. As soon as I got home I called Dr. Shannon.  She said she would feel more comfortable if I went into Labor and Delivery and she would meet me there mostly because I was only 36 weeks. So my husband and I headed up to the hospital at about 10 pm.

Once at the hospital I was checked and monitored. I came in at 2cm and 90% effaced.  Dr. Shannon decided she would come check me in an hour and a half to see if I’d made progress. An hour and a half later I was 4cm and still 90% effaced. Since 4-5cm is generally considered active labor I was admitted and everyone seemed to think I was going to have a baby soon.

I tried to sleep that night, but was too excited. I kept waiting for contractions to intensify, but they seemed to be getting farther apart. At 6am Shannon checked me and I was almost 5cm and still 90% effaced. She could feel baby’s head, but it was still at a -2 station. So I stayed and waited some more. At noon my contractions had all but stopped and I had no more change. I felt fine and told them I was not going to have a baby today— I could just feel it. (Trust your body! You know it better than anyone!) I felt completely normal. Since I was only 36 weeks and we were still waiting on the results of the Group B Strep (GBS) test, I was sent home (yay!) and everyone expected to see me back in the hospital by the weekend or early that next week. I told baby to stay in until that Sunday when I would be 37 weeks, my doula would be back in town and my GBS results would be back (which turned out to be negative, thank goodness!)

So the weekend came and went. And the next week. And the next weekend. I was feeling uncomfortable, but still pretty good. I did my normal activities- yoga, grocery shopping, we went to an opera, out on a date. That Monday  I had my 38 week appointment. Everything was routine and I told Dr. Shannon I would probably see her the next Monday at my 39 week appointment. I decided not to be checked. I would have known if something had been happening!

Tuesday morning I woke up at 5:30 with contractions that felt different. Instead of just tightening my belly, they were really low and radiated into my back. They weren’t horribly painful, but definitely more than what I had felt previously. At 7:30am I told Nick I’d been having contractions for 2 hours and asked him if he’d mind waiting to go into work for a little bit. Around 8:30 my husband called our doula and asked if she could come over. My contractions were very regular- not too close together but averaged about every 8-12 minutes over the past 3 hours. Our doula arrived around 9am. I ate a bowl of cheerios with banana and just kind of walked around the house a little. The contractions started hurting a little more to the point where I had to stop and breathe through them, but they were still only about 45 seconds in length. I spent a lot of time on my birth ball, leaned over the foot of the bed. I had my labor playlist going and continued to eat light snacks- almonds, granola bar and juice.

Around noon my contractions started getting longer and more intense. I had to really concentrate on breathing through them and my husband kept counter pressure on my lower back since that’s where most of the pain seemed to be concentrated. They started making me break out in a sweat. At 1:00pm I asked Nick to make sure all our bags were packed and ready to go because when I decided to go to the hospital I didn’t want to be waiting around for things to be gathered and packed up. So he put everything in the car. I had a few more very intense contractions. They were still only about 8 minutes apart, but I decided I wanted to get to the hospital and settled in a room before things got really intense. Courtney brought up not finding out my dilation progress at the hospital. I liked the idea because I didn’t want to be discouraged or disappointed if I hadn’t progressed much in the past several hours. Dr. Shannon checked me upon arrival and told the nurses to get a room ready, so I knew I had progressed!

The next few hours I had no sense of time whatsoever. I tried hands and knees, but it was not comfortable for me. Even though most women say that lying down is the most painful, for me, side lying with two big pillows between my knees was the best position because in between contractions I could completely relax all my muscles. Through all my contractions at the hospital my husband applied counter pressure to my back. I’m not sure I could have made it through without that! The contractions for me felt like a radiating, almost burning pain through my low belly, hips and back. As they progressed they started taking my breath away and I had to regain control through each one and really focus on deep breathing and just concentrate on one contraction at a time.

At this point the only deviation from my birth plan happened. I had requested intermittent fetal monitoring and had to be on the monitor for 10 minutes once per hour. During one of those monitoring sessions the baby’s heart rate was not picking up (She was descending pretty far into my pelvis at so I’m not surprised!) but the OB on call rushed in in a panic (Dr. Shannon was not readily available) and checked me rather aggressively. She then informed me that I would have to be monitored for the rest of my labor. I was disappointed, but I was so focused on my contractions that I didn’t fight it too much. Once Dr. Shannon returned she was not alarmed in the least about the baby’s heart rate and said the baby was probably getting lower in the pelvis so it would be harder to pick up the heart beat, but the rate had been steady and healthy for hour so far, so there was really no cause for concern.

They brought Maria to my chest for skin-to-skin as soon as she was born.

The next thing I remember was yelling out, “I’m pushing!” I could not stop myself.  Dr. Shannon checked me and I was 9cm with a little bit of a lip left before I was complete. My doula helped me do some quick exhalations to counter against the urge to push, but still helped me bear down. After the next contraction I was complete and was given the ok to push. I was still on my side and my husband and doula supported my leg so I could open my pelvis.  Once I pushed her head out, the rest of her slid out easily. My doula and Dr. Shannon said she came flying out! Her fast exit caused a long, but shallow 2nd degree tear (which I did not feel). I found out later that I only pushed for 20 minutes!

Our daughter, Maria Lorraine, scored a 9 out of 10 on her APGAR and was very alert. She latched on to the breast right away, which I think helped establish an easy time breastfeeding for both of us. She and I were not bloated or swollen at all, since I did not have any Pitocin. We enjoyed skin to skin contact for almost 2 hours before the doctors did their evaluation on her. Overall, I was more than pleased with how my natural childbirth went in a hospital setting. And remember that audition I sang while having Braxton Hicks contractions? I found out that night that I had gotten the role. :)

But afterwards it got me thinking. Since I was 36 weeks when I went in the first time and progressed to 4 cm rather quickly, but didn’t start active labor until 38 weeks, it really took 2 weeks to get from 4cm to 6cm! It made me wonder how many women in the hospital get Pitocin augmentation when their labor seems to be too slow for their doctors? Had I been 40 or 41 weeks the first time I went in and had a different doctor, I could have very easily been pressured into Pitocin when my labor “stalled.” I wonder how common it is to have a “long” labor, but no one ever knows because they are stuck to the clock and committed to making it happen on their own time table? It then took another 12 hours from the time my first real contractions started to the time I had my baby, even though I was starting at 4cm. It made me happy with my choices to not know my dilation, to labor at home for as long as I felt comfortable, and to have a family medicine physician who was supportive of natural childbirth! I was only in the hospital for 3 hours before I had Maria.

With such a positive experience, my confidence in my body’s ability to have a baby was boosted and I am actually looking forward to the next time I get to do it!

What do you think about Sarah’s story? What things did she do that boosted her chances of getting the birth she wanted? (I already think I know the answers, but I’m curious what you all think). Do you have any questions for Sarah?

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Waterbirth Part 1: How it Works

By Rebecca Dekker, PhD, APRN

This is my favorite waterbirth video. When I talk to nursing students about waterbirth, I love to show this video. It is a wonderful example of a calm, peaceful waterbirth. Oh, and it’s pretty G-rated for all you squeamish folks out there.

First of all, a disclaimer—after a very high-intervention (and low evidence-based) hospital birth with my first baby, I had a wonderful evidence-based home water birth with my second baby. I have to say—it was an amazing experience. Lifting my baby out of the water and onto my chest was one of the most exhilarating moments of my life.

When I was preparing for my home birth with my second baby, my midwife talked to us about the potential for having a waterbirth. Many of her clients choose to waterbirth, and she is very experienced at attending home waterbirths. I was interested in the possibility of a waterbirth, but I wanted to learn more. And Dan didn’t know that much about waterbirth either– he was a little skeptical about the safety and the logistics. So first we had to do some research.

As I did research on waterbirth, one of the best resources I found was the website for the organization Waterbirth International, founded by Barbara Harper. They have a great collection of evidence on water birth on their website. I also read several books on water birth—“The waterbirth book: Everything you need to know from the world’s renowned natural childbirth pioneer,” by Janet Balaskas and “Choosing waterbirth: Reclaiming the sacred power of birth” by Lakshmi Bertram. Some of the information below about the basics of waterbirth comes from these 3 sources.

So what keeps babies from breathing when they are born in the water? Johnson (1996), a physiologist, says that there are several safeguards that prevent this from happening. First, about 48 hours before spontaneous labor begins, prostaglandin levels are very high. This temporarily causes a slowing down or stopping of fetal breathing movements. Second, babies are born with naturally low oxygen levels (hypoxia). This temporarily stops breathing movements and causes the baby to swallow, instead of breathe or gasp. A third reason is the “dive reflex.” The throat of a newborn is covered all over with taste buds. When water hits the back of the baby’s throat, the taste buds sense the presence of water. The glottis (the valve that keeps fluids from going down into your lungs when you eat or drink) automatically closes and the water is swallowed instead of inhaled. So there is no way for water to go down “the wrong pipe.”

(**This paragraph has been changed 7/13/12 due to reader critique. Thank you, readers!!) The fourth and most important reason newborns can be safely born in the water is the temperature of the water. As long as the water temperature is about 37 degrees Celsius (same temperature the baby has been experiencing inside mom) that inhibits breathing. As soon as the baby reaches the cooler air temperatures, that is a powerful stimulant to breathe. This is one reason why it’s so important to regulate the temperature in a birthing tub.

So the main rules of thumb about waterbirth are

  1.  Bring the baby out of the water immediately.
  2. Water temperature should be the same as mom’s body temperature (approximately 98 degrees F or 37 degrees C).
  3. Water should cover the mom’s abdomen.
  4. Mom should get in the water when she is in active labor (5 cm or greater). It is okay to get in the tub earlier in order to relax, although it may slow down labor and the mom may need to get out for a while in order to move labor along.

So, those are the basics about how waterbirth works. So what did we decide to do?

Well, after I explained everything to Dan and showed him some of the resources, we decided we were open to having a waterbirth. So we rented a tub from our midwife. However, I wasn’t sure if I would actually give birth in the tub or not. You see, some of the books that I read said that some women naturally want to be in the water when they give birth. However, some women naturally have an urge to get out of the tub and give birth “on land.” I wanted to go with the flow and listen to my body. If I wanted to stay in the water when it was time to push, I would. If I wanted to get out, I would get out.

A few weeks before my estimated due date, we practiced blowing up the tub. We also bought a tarp to place underneath it and a brand new hose to fill it with. We bought a connector to attach the hose to our showerhead, so that we could use hot water from the bathroom and let it flow into the tub through the hose. I kept asking Dan to check the connection and make sure it worked. He kept saying, “Nah, it will work.” But I bugged him enough that he finally checked to make sure it would work. Good thing he did– because water sprayed EVERYWHERE all over the bathroom. He ended up having to come up with a totally different way to get hot water into the tub, and it involved running the hose from the hot water in the laundrey room in the basement up to the birthing room on the main floor.

The birthing tub set up in anticipation of our waterbirth

When I went into labor, one of the first things we did was turn up the heat on the water heater. We also made sure that I did not get into the tub until my midwife got there. If you are in active labor, being in the water can really speed things up, so you need to have your birthing attendant there. After she got to my house, my midwife gave me the okay to get in, even though I was in early labor. She told me, “I always regretted not spending enough time in my tub at my birth. So you go ahead and get in and enjoy yourself.”

Being in the tub felt wonderful. However, it was a lot of work to keep the water at the right temperature. Luckily, that was not my job. Our water heater ran out of hot water. My sister-in-law got to work in the kitchen, boiling huge vats of water so that the midwives could do a “bucket brigade” and bring water to heat up the tub. All that work was worth it, though, because being in the water was very relaxing for me. After a while, though, I felt like I was ready to get out. You know what? I just wasn’t really ready to be in the tub yet. I just felt like my pressure waves (i.e. contractions) were too easy, and that I would rather be on dry land for a while.

So I got out, took a nap, and a couple hours later got back in the tub when I was going through transition. It wasn’t long after that when I started pushing involuntarily. With the first involuntary push, I felt a “pop” and I knew that my water broke. Twenty two minutes later, Henry was born. I never got out of the tub– so he ended up being a waterbirth baby after all! When his head came out, my sister-in-law said it was so incredible to look down and see his little head underwater, with his eyes closed and his lips pouting. One more push and his body came out– and I reached down and pulled him up on my chest. We covered him with lots of towels and he sneezed a little bit.

Henry and me, moments after he was born in the water.

When you think about it, babies spend 9 months underwater inside your bag of waters in the uterus. So it really is no different for them in the warm water. They say water babies are incredibly calm at birth and do not cry or fuss very much at all. It is a very gentle, warm transition for them into the outside world. That was certainly true for my Henry. He was pink as all get out and breathing right away (Apgars were 10 and 10–perfect!!, but it took a while for him to cry. He was just happy, warm, and content. It was beautiful and peaceful.

Click here for a look at the scientific evidence that supports laboring in the water, and click here for a printable practice bulletin on the potential benefits/harms of actually giving birth in the water. In the meantime, have you ever wondered what it would be like to have a waterbirth? Do you have any questions about the logistics about having a waterbirth?

Reference:

Johnson, P. (1996). Birth under water- to breathe or not to breathe. British Journal of Obstetrics and Gynecology, 103, 202-208.

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