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      1) Figure out what your health coverage insures.  If it is slim or nothing for a home birth or midwifery care, go over your finances and consider what you can afford (keeping in mind that some midwives offer income based sliding scales as well as payment plans.).

2)  Interview Midwives and Doulas:

-It is good to interview several before deciding on one. In some areas home birth midwives may be scarce so it will be easy to find their names and plenty of reviews. In other areas, there may be a lot of midwives that service the area and it is a good idea to do lots of research, read reviews, along with speaking with them in person. A good way to find positively reviewed midwives and doulas is on birth community sites that have forums for specific locations (IE: mothering.com offers “tribes” that connect you to mothers in your area of the world).  Most midwives and doulas offer a free consultation before they become “yours”.

               Examples of what to ask at a Midwife consultation:

                - Who certifies you? Are you a CPM, CNM?

                - What is your training background?

                - What is your educational background?

                - Why did you become a midwife?

                - How long have you been in practice?

                - What is your whole cost, do you offer a sliding scale?

                - What is your transfer rate?

                - Do you do any “routine” screenings, tests, etc and how do you process them?

                - Do you have any hospital affiliation?

                - For what reasons would you suggest I don’t deliver at home or need a transfer?

                - What equipment do you come with to a birth (and in case of emergency)?

                - Do you bring a nurse or apprentice to births?

                - Do you offer birth tub rentals if I desire a water birth?

               

                Examples of what to ask at a Doula consultation:

                -Who certifies you? (CAPPA, DONA, CBI, BAI, etc)

                -What techniques do you use to help me cope with labor/birth?

                -How many times do we meet before/after birth?

                -How long will you stay with me during/after labor/birth?

                -How much is your whole cost and do you offer a sliding scale or bartering system?

                -Do you have a lending library or other resource rentals (birth tub, birth balls, etc)?

                -Can you help me write a birth plan?

                -Do you offer any other services (placenta encapsulation or preparation, childbirth classes, Blessingway hosting, etc)

3) Prepare yourself with information as you deem appropriate. There are lots of great books and resources to help you prepare for birth. Below is a list of books that may be worth a read:

                - “Ina May’s Guide To Childbirth” by Ina May Gaskin

                - “The Thinking Woman’s Guide To A Better Birth” by Henci Goer

                - “Childbirth Without Fear” by Dr. Grantly Dick Read

                - “Gentle Birth Choices” by Barbara Harper

                - “Homebirth” by Sheila Kitzinger

                - “Spiritual Midwifery” by Ina May Gaskin

                - “The Complete Book of Pregnancy and Childbirth” by Sheila Kitzinger

There are many, many wonderful home birth resources on the internet as well. As a pregnant woman it is best to work under the philosophy that images and words will greatly affect how you feel and view birth during this childbearing year. So, although there are plenty of things to discover on the world-wide web, discretion is always good. Some sites that I recommend are below (these sites have categorized headings so you can navigate what will be useful and what you wish to see and avoid what you wish not to see):

-          www.thebirthingsite.com

-          www.birthwithoutfearblog.com

-          www.mothering.com

-     www.birthingnaturally.net

-     www.givingbirthnaturally.com

Consider hiring a private childbirth educator (or speak with your Doula-they often offer crash courses in childbirth for their clients) to meet you and your partner in your home for a childbirth class. (Or even split the cost with an interested or other pregnant friend!) .  You could also find a class through hospitals or ask your midwife or doula if she knows and recommends any childbirth courses in your area or online.

Some find attending a natural childbirth class to be just what they need to feel comfortable with home birth while others find their own research and support of their doula and midwife to be enough to prepare. Whatever you choose to help inform yourself, do so at a level that is comfortable to you-over researching and under preparedness have both posed issues for pregnant mothers as our minds can be particularly vulnerable during this time. If you find the more you dig for information the more anxious you become (or the more tempted you are to absorb negative stories and visuals), take it down a notch, tell your support people and advert your attention back to the positive thoughts for YOUR birth.

4) Speak openly with your partner. Decide what your hopes and wishes are for who will be present at the birth of your child, what roles you hope them to play. Discuss your partners comfort levels and work together to become comfortable with your plans. Think about the possibility of having a water birth, what music you may want, anything special you wish to be used to enhance or mellow your birth environment, sit down and consider all the aspects you wish to cover in your birth plan, specifically what roles everyone will play.  Enjoy this part of the planning, find common grounds with those you intend to include and make sure the people who support you believe in the process.  Reading a book together or sharing helpful articles can be a nice way to bond while preparing for your home birth. If you intend to include your older children, introduce them at age appropriate levels to the idea of mommy having her baby at home. There are several children's books out there that talk about what they can expect. 

5) Make an “in case of emergency” transfer plan with your midwife and inform everyone that will be present of the plan.  Prepare a separate birth plan for the event of a transfer if you feel it suites to calm you.  Most midwives will have you fill out a form that will include what hospital you wish to transfer to if possible, ambulance service if you are rurally located, etc.

6) Trust in the process and have faith that you picked people who will support you. This step is consuming affirmations, day-dreaming, picturing your birth, connecting with your baby, enjoying the fact that you are going to join the ranks of every mother that has ever lived(for the first or subsequent time), as well as give birth in the comfort of your home like so many generations before us. Cool, huh? Remember, you are strong, you are capable, the hands around you offer healing knowledge and support, the space around you offers peace, and your baby knows how to be born just as you know how to birth him. Allow yourself to feel the spiritual aspect of your pending home birth and enjoy every second! 

Published in Birthing Places
Thursday, 30 January 2014 15:04

The History of Midwifery and Breech Birth

Babies have been brought into this world since the beginning of mankind. Even up until the time when my father was born in 1930 a majority of births in the US were still taking place at home. Within 10 years this had completely changed and led us to where we are now, with a majority of births taking place in the hospital. The reasons for this shift were numerous. Today many women sight “what if there is a complication?” as reasons to deliver in hospital. One of these “complications“ can be a baby in breech position.

 Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix and occurs in 3-4% of all deliveries. In 2010 ACOG (The American Congress of Obstetricians and Gynecologists) stated "The decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery. Obstetricians should offer and perform external cephalic version whenever possible. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. In those instances in which breech vaginal deliveries are pursued, great caution should be exercised, and detailed patient informed consent should be documented. Before embarking on a plan for a vaginal breech delivery, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity might be higher than if a cesarean delivery is planned."

According to a historical account of midwife Jane Sharp who wrote the Midwives Books in 1671, “if the head comes first, the birth is natural, but if it come any other way, the Midwife must do what she can to bring it to this posture. Sometimes the infant comes with the legs forwards, and both arms downwards close to the sides, this way the Midwife may endeavor to take it forth if it continue in the same posture, by annointing and gently handling the place; but if it is safer, if she can, to turn the legs upwards again by the Belly, that the head may first come down by the back of the womb for that is the natural way.” pg 155 The Midwives Book. Jane goes on to outline other ways to assist a breech baby and her writing shows that she was clearly experienced in helping assist at breech births and that it was part of a midwife’s job to know what to do to help at births were the babies present in breech position.  Given the frank discussion on how to handle a baby in breech position and the very specific instructions on how to assist at a birth like this, it is curious why “most countries now recommend planned cesarean sections in breech deliveries, which is considered safer than vaginal delivery.” (BMC Pregnancy Childbirth 2013,13(153)

First, let’s look at the numbers. According to Birth without fear, (original article here) ”Breech presentation occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22% of births prior to 28 weeks’ gestation to 7% of births at 32 weeks’ gestation to 1-3% of births at term. Which means that 96-97% of babies will turn head down prior to their birth (97-99% if born at term)." Remember, that the percentage of breech deliveries decrease with advancing gestational age. This information is very helpful to a mother who has been told at an early ultrasound that her baby is breech. She can know that very often these babies turn on their own by 32 weeks. Other factors that can play into the position of the baby, and are often screened for include, uterine malformations, the presence of fibroids, polyhydramnios, placenta previa, and multiple gestations may cause a baby to stay in the breech presentation, (Medscape.com). This information can be helpful in determining risks associated with vaginal delivery, for example placenta previa does cause major issues for a mother and baby and can play into why a baby continues to lie in breech position.

The question then becomes, what can we do to assist the baby in breech position? Gail Tulley of Spinning babies has been working for 10 years on techniques that can be used during pregnancy to help mothers achieve optimal fetal positioning in addition to turning breech babies head down prenatally. She outlines exercises for all mothers to perform and specific exercises for a mother with a baby in breech position. If the baby is in a persistent breech position and labor begins, the fear that many mothers hear about is the risk to the baby that the head will get stuck. British Midwife, Shawn Walker explains it this way, ”Some babies who are breech need help, more often than head-down babies. So having experienced support is crucial to the safety of breech birth. The head getting stuck is a terrible image, designed to terrify women, and probably the result of practitioners themselves feeling fearful or inadequate. I prefer to talk about the need for help because it creates an image that help is available, as it should be, but is realistic about the fact that occasionally some manual assistance is required."(3) Ina May Gaskin has posted videos and written books on delivering breech babies. Gail and Ina May both outline specific modern techniques that can be used to assist in a breech delivery. Some of these techniques mimic in some form the work of Jane Sharp and others techniques are completely different. Keep in mind that is the work of only two birth attendants in the US.

If the techniques are there, what about the outcomes for moms and babies? There have been several studies done comparing the results from breech babies born via c-section to those born vaginally. In 2000, a randomized multicultural trial called the Term Breech Trial (TBT) published its results. The trial followed 1042 women who were assigned to deliver vaginally or via cesarean for babies in breech presentation. The trial reported some significant differences in outcomes with lower perinatal and neonatal mortality, and lower serious neonatal morbidity in the group of mothers who had planned cesarean section vs those who delivered vaginally. This one study had a major impact on practices and the modern practice of delivering breech babies via cesarean section and even influence the ACOG statement on breech birth.

A Norwegian group looked at information on international breech births and obtained information on perinatal morbidity and mortality in term breech infants in Norway. “Their results showed a lower perinatal morbidity among infants born vaginally in breech presentation compared to both study groups of the TBT.  The mortality rate was .31% when corrected for lethal malformations and 0.09% after the additional correction for death before admission to the maternity clinic. This could be explained by close fetal monitoring, national procedures, and sufficient skills of obstetric staff, combined with a high quality neonatal service, in contrast to many of the participating clinics in the TBT.” (BMC Pregnancy Childbirth :2013, 13 (153) . Clearly there are many factors that play into the outcomes from breech deliveries.

In France, health care professionals have taken a different approach than doctors in the US. “French gynaecologists continue to perform vaginal breech deliveries. Through various observational studies, they have shown that their management approach, although different from the one used in North America, is safe.” (6). A majority of babies in breech position, some studies state as high as 54%, are still delivered vaginally in France and in Europe, namely the additional countries of Belgium, Ireland, Switzerland, and the Netherlands.This is because “French authors have questioned the selection of patients for vaginal breech delivery in the TBT. The reason for this is that only 9.8% of patients underwent pelvimetry, 68.7% were assessed by ultrasound, 57% were assessed during labor, and 33.4% had continuous fetal heart monitoring during labor. It should also be noted that 5.8% of fetuses were macrosomic. Finally, a slower progression of labor than the French standards was accepted in the TBT: minimum cervical dilatation of 0.5 cm per hour and maximum duration of pushing (active second stage) of 60 minutes. The analysis of perinatal deaths in the TBT was also criticized. ”Couple this information with the risks to the mother associated with cesarean birth and the Europeans have not been as quick to jump to cesarean birth for all babies in breech position.” (6) In France they go into very specific criteria for women that are selected eligible for vaginal delivery as well as specific conditions during labor. The difference boils down to not only the care the women received prenatally, the amount of information gained prenatally, but also the difference in care that women received while in labor with the key being the French standards for labor allowed for labor to progress slower than the standards used in TBT. Perhaps the women whose labors were called for cesareans in the TBT would have progressed and delivered vaginally if given more time.

In going back to what the ACOG said, ”The decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery.”The question then becomes, what has happened to the care providers that have the skill and expertise in vaginal delivery of the baby in breech presentation? Is it simply that in the time since 2010 and our comfort for using cesarean sections for any deviation from normal birth that we have lost the skilled care providers that we have had since at least the time of Jane Sharp in 1671 to deliver breech babies? And is it in for the best of all mothers and all babies to offer women only the choice to birth babies in the breech position via cesarean? Certainly more research can be helpful, but will we loose these skills before that research can be done or are the keys to successful vaginal birth for breech babies out there in historical texts and in the few hands of skilled care providers?

In thinking back to when I was an expectant mother, I clearly remember reading stories of babies born vaginally in breech position. In fact, one of the things that most drew me to midwifery and homebirth then was trusting the understanding midwives have for the different ways normal deliveries can look.  I was drawn to the skills that I had read midwives possessed in a time when many doctors were relying more on tools and machines which often denied a mother the ability to labor and birth normally under the guise of safety. I didn’t know the terms then, just what I wanted as a woman and mother for the birth of my child. Now I know about informed consent. I try to instill in my mama friends, the responsibility of every pregnant woman to be informed of her choices. When faced with a variation of normal (a baby in breech position) a mother deserves to have access to information about how breech deliveries are taking place all over the world, information about the risks and benefits to all approaches for delivery, and should dialogue with her caregiver about what the options for her delivery are. Birth is never a one size fits all. It really is about options and what the mother and her care giver decide together what is the best option for this birth.

References:

1. Vaginal Breech Delivery- results of a prospective registration study.

By Ingvid Vistatd, Miladad Cvancarova, Berit L. Hustad, Tore Hernriksen

BMC Pregnancy Childbirth. 2013;13(153)

http://www.medscape.com/viewarticle/810620

2. Jane Sharp: A Midwife of Renaissance England by Jane Beal, Midwifery Today Autumn 2013 pg 30-31

3. Spinning Babies: Breech; Bottoms Up, http://spinningbabies.com/baby-positions/breech-bottoms-up

4. Ina May Gaskin- Midwifery Today, http://midwiferytoday.tumblr.com/post/27135829808

5. http://birthwithoutfearblog.com/2011/09/06/breech-birth-statistics/

6. http://jogc.org/abstracts/full/201003_Obstetrics_5.pdf

Published in Birthing Facts

I remember the first birth I attended as a midwifery student. It was this mom’s first baby. At one point during transition, she was in the bath and she was moaning as loud as she could. I began to feel uneasy that she was experiencing so much pain. My instinct was to try and help her “calm down”. My preceptor however just sat with her and encouraged her to express herself. After the birth, I shared with the midwife that I was sorry this mom had struggled so much in the last stages of labor. My preceptor asked: “Do you think that because she was screaming she was not in control of her labor pain?” I was surprised by her question. Yes, I had to admit that I had thought that. But, in truth, this birthing mama had just followed her instincts and expressed each wave of contractions in her own unique way. She later confided in us that her moaning really helped get her through the birth pains.
Just over a year ago, I was a doula for a sweet young mom. She sailed through her induction and even invited her acupuncturist to the birth. As she pushed, she told us that her baby wasn’t moving down. The midwife kept telling her to push and that she was doing great. But, she continued to tell us that it wasn’t working. Her words were interpreted as discouragement. But this young mom was giving us important clues to her birth that we ignored. The birth ended in a shoulder dystocia, with an OB performing the McRoberts manoeuvre and giving her a huge cervical laceration. After the birth, the mom asked, “Why didn’t anyone listen to me?” She had pushed for so long without any real help. She gave us important clues that we ignored.

Are we really listening to birthing mothers? Do we misinterpret the sounds they make? Do we ignore the words they say? Are we missing important clues by assuming that birthing women are not in control or not able to participate in feeling their way through the birth process? Are we letting mothers down by not validating and encouraging verbal participation in their births (whether through sounds or words)? Have we forced birth sounds and birth words into a box so that we don’t truly hear what women are communicating at their births? Worst even, are we putting words into the birthing woman’s mouth?

In a recent discussion on The Birthing Site’s Facebook page, we were asking moms if they spoke words like “I can’t do this anymore!” at their birth. Many women said they did. But, what surprised me was that some women said they only spoke those words because they felt that’s what was expected of them, that they didn’t really mean it, that they didn’t really know why they spoke those words. Wow. Think about that. What are you saying at your births? What are you hearing at other women’s births? Have we lost the art of listening to birth and expressing birth? Are women feeling hindered to speak a unique and truthful birth language of sounds and words during childbirth?
We must not assume. We need to ask ourselves:

Does screaming at a birth really mean a loss of control?

Do words like “It doesn’t feel good, Ouch! Don’t make me do that!, I can’t do this anymore!, Don’t touch me!, I can’t feel the baby moving down!” really mean that mom is discouraged and can’t clearly express herself through the pain? Are her words evidence of cultural expectations?

I encourage you to give every birthing woman the gift of listening and believing. Be slow to assume and quick to learn about each woman’s unique birth language! Have confidence in your own birthing language and choose support people who will listen and believe!

Published in Julie-Anne's Blog

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