#9 | Birth Plan 101: Evidence Based Birth as the Safest, Smartest Approach

"Can I just say 'No' to an episiotomy? Do I have to give birth on my back? I want to be free to walk around in labor. I don't want to be hooked up to an IV. I believe in skin-to-skin contact immediately after birth." Do you ever feel like what you want - or don’t want - in your birth experience is at risk of not happening for you? This episode spells out the research on various Evidenced Based Birth practices so you can feel confident and comfortable in the choices you make around your birth experience. Grab a pen and your partner, and listen in because you don’t want to miss this essential information.

The evidence presented and statements made in this episode apply to normal, healthy, low-risk pregnant women seeking a low-intervention birth.  The statements made are supported by the American College of Nurse-Midwives. The commentary around the statements are our own opinions and are not medical advice. 

American College of Nurse Midwives

ACOG Committee Opinion #766: Approaches to limit intervention during labor & birth

Skin to skin care in preterm infants

Optimal Care in Childbirth: The Case for a Physiologic Approach

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Transcript

How do we know when to intervene and when not to intervene? So this is where evidence based practice comes into play, and we use the evidence to inform our decision about whether to intervene or not.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast.
 Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

So now let's get into what evidence based medicine means and in particular, what it means for evidence based birth practice. So there's basically two models of care that birth operates under. One is the medical management medical model, and the other is the physiologic process of birth. So the medical management model of care starts with the premise that pregnancy and birth are inherently difficult and potentially dangerous. Right? That's, that's the philosophy. That's the thinking. That's the education. That's the training that the medical management is coming at birth with. The physiologic care model believes that pregnancy and birth are healthy, normal, and will inherently go right if left undisturbed the vast majority of time. So there's a huge gap between these two models of care. And as a midwife, our practice our thinking, our training is all about the physiologic process of birth. We believe that birth is naturally going to go well, the vast majority of time and we have to trust that process. I can
hear everyone thinking right now. Is that approach riskier? to go into it trusting that it's going to go Well, I think the average person who's hearing this kind of thing for the first time is thinking, well, but what if something goes wrong?

Right, exactly. So that's where that's why we have evidence based practice. And that's why we have trained professionals to to monitor the birth process. But the problem is that it has become a practice of intervening in order to prevent something from going wrong as opposed to intervening when something actually does go wrong. That's the big distinction. Therefore, we need to use evidence based practice to inform our intervention as opposed to using intervention as the as the rule Okay, so let's get examples. So routine intervention is is the norm in birth today. So you walk in the door, you get the IV placed, you are having a prolong second stage, you get the tummy cut, you have one sign of fetal distress, and we're moving right toward c section. So how do we know when to intervene and when not to intervene? And what works and what doesn't. So this is where evidence based practice comes into play. And we use the evidence to inform our decision about whether to intervene or not, if that makes sense. So let me give you some examples. We regularly overuse interventions that are that are proven to not be helpful and we underused interventions that are proven to be helpful in that promote physiologic birth, which is promoting the natural normal process of birth. So for example, oral nutrition In labor, a woman should feel free to eat and drink and labor to promote a healthy birth process that is supported by good evidence that it's helpful, intermittent auscultation or listening to the baby's heartbeat intermittently as opposed to continually monitoring monitoring the baby skin to skin contact immediately after birth, delayed cord clamping vaginal birth after a cesarean section, these are all underused interventions that are supported by the evidence. So in addition to under using interventions that do promote physiologic birth, we often overuse interventions that are not helpful. For example, induction of labor at 41 weeks continuous fetal monitoring instead of the intermittent monitoring that we just mentioned, strict labor parameters that don't give women enough time to allow the natural process to take its course when everything is looking fine with the mom and the baby. So it is the it is the significant gap between these two models of care, the medical management of birth and the model of care that promotes physiologic birth that drives the need for evidence based practice. evidence based practice is the use of conscientious, judicious and explicit use of the current best evidence and making decisions about somebody care. And you should expect your provider to practice evidence based medicine. It should be the standard of practice. So both the acsm which is the American College of nurse midwives, and the a cog, which is the American College of Obstetricians and gynecologist have practice statements regarding evidence based medicine. or evidence based birth. So let's just touch on some of the ACM evidence based guidelines, women, families, partners, these are the things that you can go to your provider with, whether it's a midwife, or a doctor. And these are the things that you can ask for and that you can insist on because they are evidence based and they are the standard of practice. So I'm just going to run through them one, oral nutrition and hydration, meaning food and drink in labor are safe, and they actually optimize outcomes. So drink and eat, to comfort and labor.

To avoid the routine use of IV fluids. When you walk in that door, you can say no to the routine. IV it is evidence based, that it is not helpful to have the routine use of IV fluids And there are some risks, listening to the baby intermittently. Not being strapped to the continuous fetal monitor should be the standard of care. You do not have to have that monitor strapped on you the entire time you're in the Birthing Unit, or wherever you are listening to the baby at scheduled intervals with a handheld Doppler should be the standard of care. And this is not routinely practiced. So women, you need to speak up about this, because intermittent listening to the baby is evidence based and it is safe and it is far less cumbersome for you. I mean, having the monitor on the woman all the time allows for nursing staff to be in another room and feel that they are managing and overseeing this woman in labor, but it's a completely hands off approach and we know that support Women continuously in labor is majorly beneficial. I mean, just get this visual that we would like everyone who's supporting that woman to be surrounding her with their eyes on her. And now we have people whose eyes are on a computer printout. So when that print out is in the hospital rooms, imagine the temptation of the partner to be watching a computer printout and losing eye contact and losing that connection to the birthing mother because it's it's such a distraction. It's like you might as well have a movie playing in the room, but this is like, oh, what's happening? I'm watching it. Just watch her.

I think it also it's it's an institutional problem as well, because having that strip of continuous continuous monitoring of the baby's heart rate has been believed to be protective against malpractice because Oh, look, we have this whole strip. We can tell you how, you know we can track every second of how the baby was doing, but the evidence actually doesn't show That it's helpful against malpractice.

That's right. And there's one more point I'd like to make on this, that Imagine you're that loving, maybe even concerned partner, who's with the birthing mother, maybe it's let's say, it's her husband, let's say in the birthing room with her. And he's watching this thing printing. I have videos that I show in class where women are doing HypnoBirthing. And they're so relaxed. And you see that printout in one of the videos where the surge was very, very high, and she doesn't change at all. She's completely relaxed. She's breathing calmly. But imagine, if you put every partner in that situation, imagine the ones who will get nervous not based on anything she's doing. But based on what they see printing out, and imagine if they grip her hand tighter. Or they say, You're okay, I'm here, that energy isn't good for her because she'll pick up on that. So there are so many ways that this this isn't. Every intervention has effects and a downstream effect and these effects these emotional responses. Shouldn't be ignored either.

So it will be really interesting to see how labor management changes when intermittent listening to the baby truly becomes a standard of care.

So the basis for intermittent monitoring is for women who are having a natural birth, but we always have to be flexible in childbirth, we always have to be able to roll with the punches instead, we might go into birth saying I don't want continuous electronic fetal monitoring and then after 20 hours like what happened with you you know what I'm going to go for the epidural and okay i relinquish Now give me the monitor and you felt at peace with that of course there so yeah, it was it was a huge relief. And then it was amazing.

And it felt and it felt it felt a point not the epidural right like the the relinquishing to the monitoring suddenly felt like the right thing. It felt a very right thing to do. And it was never anti but it things were no longer going according to my plan. So I had to like adjust to the realities and yeah, so intermittent Monitoring leads us to the next evidence based practice statement from the ACM, that upright positioning and mobility are associated with decreased use of pain meds, decreased risk of sectarian section, less epidural use and fewer admissions to the Nick You are the intensive care unit for the baby. You can't have upright positioning and freedom of mobility when you are being continuously monitored. Therefore, intermittent monitoring, an upright position and mobility go together. So the more we can allow a woman to freely move her body, in the bed, to the toilet, in the shower, down the hall wherever she feels she needs to go to facilitate physiologic birth. We need to support that and the evidence is there to support that decision.

And no matter where you're giving birth, you can choose your own positioning because the most common question I get at this point when I'm Talking about this and teaching this is, well, they allow me to do that in the hospital. That's your room, when you're in the hospital, that is your birth always that is your baby always, you move if you want to move, no one can constrain you and keep you in the bed. If you don't want to be in the bed, if you do go for the continuous monitoring, as Tricia just said, you're going to be in the bed, but you can opt not to have continuous monitoring. And you should opt and you always can be in your own position. Even if the baby is coming out. They say okay, we're going to need you to lie back. It doesn't matter what they need you to do because Trisha just read you the research on this. You're safer being in the position that feels comfortable to you, which is hands knees for a lot of women are squatting and you can do that right on the bed. They will receive your babies safely. I have know a woman who she's on the news every night she took my class and she walked into a New York hospital and leaned against the bed. She just lowered her yoga pants and leaned against the bed standing up and what what did they do they there was nothing to be done. Everyone crouched round her kind of laughing a little bit, and just received her baby, she felt like standing. There's nothing to be done. So and that turned turns out lo and behold, that is a perfectly safe approach because she was upright as long as someone is receiving the baby, but, you know, they have to lose bodies. In that moment, we have to listen to our bodies throughout the whole birth process, and particularly in the moment that the baby is being born. All of those little tweaks of movement and that ability to be mobile is what allows and facilitates proper descent of the baby through the birth canal. Everybody, everybody's pelvis is a little bit different. And you have to sort of trust your intuition on how to tweak your body so that the baby best comes through in the best position and the baby's position will influence what's feeling right to you. Yeah, if you're suddenly turning to your left side, it's because the baby is getting pressure. You're getting your message from your body.

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If you are giving birth naturally is sometimes you suddenly get this feeling like you have to turn in other direction. You might be in a semi reclined position are on your hands and knees and suddenly you find yourself leaning toward the left. And that's because the baby is applying pressure somewhere. And it's giving you the message to create space where the baby needs space. It's like this beautiful dance between the mother and baby, they're feeling each other and they're moving together. So to force the mother into a single position is very limiting to the baby.

Absolutely. Which actually leads us to the next two points mobility in labor is associated with a shortened first stage okay. So that basically means that you want to be upright and mobile. also operate positioning during the second stage, which is the pushing stage is associated with less operative vaginal deliveries, meaning forceps and vacuum, fewer PCR dummies and a decreased abnormal fetal heart rate pattern. up right positioning that is not on your back. This
is such A strong case and a no brainer. Why are we doing it like this? Right? And didn't it all start with like a French doctor in the 1800s, who want a woman lying back with their legs up? Because it was so convenient, right? bright light on her right? was easier for the provider. Yes. And with that, yes. So it's still, in the face of the research that we have. We're still doing this and women are. The only way this is going to change is if we change that. And that's how all change happens. All good progress happens in any country. Because of people changing because of some kind of movement. We have. The hospitals aren't suddenly going to declare this before we do we have to go in and say I'm not birthing like that because I've done the research that isn't safer for me in my bed and the hospital bed and the hospital room isn't really set up to accommodate upright positioning it when you think when you visualize giving birth, based on whatever you see in the media or whatever you have witnessed you imagine a woman on her back in the bed. That is completely out. Opposite of upright positioning. So when you walk into a hospital room, you know, where's the birthing stool?

That's where you need to go. You know, I have a great visual that I share with my clients, and I'll make sure that we get it put up on our Instagram page. And it's a sketch of an elephant in labor lying on its spine with all four limbs directly up toward the sky. Right? You're making a face like it's absurd. But like you just said, If we think of a woman in labor, we picture her on her back because we've been conditioned to think that way. But mammals are not lying on their back, because we're beings of gravity. This is the gravity has everything to do with this situation. And I will just go further to add one of my own theories on one of my own comments that I always do. We gave birth out there we gave birth out in nature for hundreds of thousands of years. And we're prey out there. We are not predators. You put us in a jungle and we are up against them. With the jagged molars and the claws, and the strong Jaws, were out there giving birth, the last thing that prey does is expose their internal organs upward. We're always in protection mode curling inward. And when you feel anything abdominally, we always curl in. That's always the comforting way to move. So there's no part of us that would sprawl out. But even when you even think of how all of your ancestors gave birth out there, we forget about that. But if we trace every live birth from you, to your mother or to her, it goes to the beginning of time, and most of those women were out there somewhere. And their instinct would never have them exposing all of their organs when they're in any kind of vulnerable state.

And let's not forget about gravity and also the way that it opens the pelvis. All three of my children were born in the squatting position and I truly cannot imagine if somebody had forced me onto my back How I would have managed that. I think it would have been so awkward and uncomfortable, and it would have felt completely wrong to me. We scan our brains unfortunately, in the months after we give birth or anything we had, we wish we had done differently or anything we wish had gone differently. And one of those little things for me was that I was so comfortably in that tub on my I just followed my instinct on my hands and knees. I was so genuinely comfortable birthing my almost nine pound son and that first birth of mine, and moments before I birthed him. The midwife said okay, Cynthia, why don't you flip around now? And you know what, we're still are polite, lovely selves and labor. And I wish I hadn't been so polite. Because in my mind, I was complaining and whining a little bit like, Oh, no, do I have to, but I didn't say that out loud. I wish outloud I said I'm comfortable. I'm good. But I didn't I just said Oh, okay. Okay, I flipped around. And I did Don't like it much. And they did move me from one good position into another good position. It just wasn't the one that felt right to me. It was the semi reclining position, which is perfectly good for giving birth. And I birthed him, but I can't tell you how much I thought about that me like 100 times after he was born.

So what we really need is for women to feel free to birth in the position that they want so that the person catching their baby can get comfortable also in receiving the baby in any position. Let's look at another one. Continuous one on one support and labor is associated with decreased use of anesthesia, fewer sectarian sections, fewer operative deliveries and shorter labor's so what that means is the one on one supportive care that a woman gets in labor makes a tremendous difference in the outcome of her birth.

And I want to underscore The shorter labor is because we don't want women to believe that labor's are predestined. If we know we can alter the duration of your labor with something like one on one support, then we know there's an emotional component to labor. We already do know that for a fact, because it's all hormonal II driven with either endorphins like oxytocin or with catecholamines, like cortisol or adrenaline. But I just want everyone to really think about that. emotional support shortens labor, that's more evidence supporting what we talked about, that how you feel while you're giving birth, has a biophysical response on the birth itself, making birth more comfortable and safer.

That's what it's all about that continuous support is the thing that makes the woman feel safer while she's giving birth and feeling safe while you're giving birth is essential to the physiologic process working the way it should.

It's essential to your success. safest possible birth. Even if it's a C section, it's essential to your safest possible c section. It's always a core component of your safest possible birth.

So more doulas and midwives, more loving support and more loving supportive obstetricians  who will be there one on one throughout your entire labor who will not go home when the ship ends? which happened with exactly one of my client watch from the nurse's station watching your strip instead of you? Okay, cool. Do not rupture the membranes routinely. This I think is really is starting to shift I'm really I'm really anti me on me for no purpose am anti routine me automate. So you okay, I don't know what you're about to share. But can we can I tell you what, let's see.

All right, go ahead.

It's this is my understanding. Now tell me if there's anything that I'm missing or anything that's off. routine, me Atomy when you Ask a provider. Why are you giving this to me? What's the benefit? It's my understanding that by and large, the primary If not, the sole response is, oh, this will speed up your labor. Correct so far.

Now, I've read plenty of research on this. And much of it shows it's not speeding up labor. I did read some meta analysis that showed it sped up labor a little bit. I don't remember I don't even throw it a number, but it was a matter of minutes, not hours. And I if I had, we don't we are not going to have the answer, I guess. But if I had to theorize, I wouldn't be so surprised if it speeds up labor by a few minutes, because you're probably putting the baby in just a tad of distress. And the baby has to get out a little quicker. But there it's rife with risks, that water is a resource to the baby. And if you drain the water out, before the baby breaks that membrane in a natural way, or pushes through once you're 10 centimeters, the baby immediately loses that risk. And now has a more difficult time doing its most important job, which is to get into and stay in the optimal fetal position for birth.

Yes, they MDX tech clearly has a protective role throughout the entire pregnancy. And in the birth I think possibly where this came from was sometimes if the baby's head is not putting enough pressure on the cervix, and the bag of water is bulging through the cervix. The idea was that by breaking the bag of water, the head would engage with the cervix and put more pressure on it and help with dilating the cervix faster. And yes, there are certainly provider anecdotes of breaking the bag of water. And suddenly the woman dilates to 10 centimeters and gives birth but the routine use of this is greater risk than it is helpful. There are going to be some cases where it might help, but we cannot routinely recommend this. Also, the recommendation is to wait for women to begin spontaneously, bearing down to not force pushing before a woman really feels the urge and the desire to do so. So it has often been practice that when a woman reaches 10 centimeters, we would say great, it's time to push.

And regardless of what the woman was feeling at that time, you would start pushing. It's not time to push until you begin to feel that spontaneous urge And believe me, you will feel it.

And I have to say at this point, it breaks my heart when I hear about women who have the urge to push and they are told not to because the doctor isn't in the room.

I absolutely can't imagine having to resist that urge. It is such a powerful feeling and a feeling that is almost unstoppable.

And it feels very gratifying. It's a good feeling. It's relief. Yeah, it is an incredible relief and you can participate you get, you get a surge of adrenaline all of a sudden at the very end, and you get to use your muscles and bear down and feels. It feels gratifying.

Yes, a lot of women report that when they get to the second stage of labor, they finally feel relief. For that reason. Even though that feeling of the baby coming through the birth canal is so intense and can be far more intense than the sensation of a uterine contraction for some people. At least you're working with it and you're responding to your body and that feels relieving. So women, please do not feel that you have to start pushing wait for that spontaneous feeling wait for it to arrive in your body and when it does, you will know. Let's just touch on a episiotomy Oh, no more episiotomies . It is associated with increased risk of extended lacerations third and fourth degree. It is not ever to be used routinely, the list goes on and on of all the complications of episiotomy . All you need to know is there is no evidence to support its routine use. And it increases the likelihood of a deeper tear. I can't get over the irony of women being told we're going to cut you so that you don't tear.

It's unbelievable what what and we're like people are getting away with saying that the thinking was that episiotomy  was basically necessary some amount of opening of the parallel scan was necessary to get the baby out. Therefore if I cut you instead of letting you tear naturally which are going to do anyway, this is the thinking not the truth, right. The cut is easier to repair. It's cleaner. Now however, we know that when you cut something, it is far more likely to tear deeper after you've made that initial snip. Yeah, it's like if you take a sheet from your bed and you're, you're holding it taut, and you're pulling it and it's nice and taut and strong like the parent name is, but now someone comes along as you're doing that and they snip an inch down, they snip a little cut into that sheet and you keep applying pressure, it's going to tear deeper when women get to choose their own positions for birth, and there are many other factors involved, but let's just take that grand one. The majority of women don't tear at all. So don't fear tearing. If it happens, it happens. But many women don't ever tear
or if they do tear, it's a first degree tear that self resolves better to let the body do what the body needs to do and also to avoid aggressively touching or massaging the parent. Too much stimulation to the parent can cause irritation to the tissue, which can then make it more prone to tearing.

Does episiotomy  ever make sense and I think it's sometimes does, and is it not when you can visually see a woman tearing elsewhere and a place that will be more harmful to her than if you control the tear and relieve the pressure at the perineum? es, I do believe that there is a time and place where episiotomy  makes sense. It's it, they're few and far between and that is ultimately up to a provider. But certainly, if you have a baby in distress at the parent em, and it is not, you know, they're they're under significant distress. And you need to just make a move to get that baby out a little bit faster. That you know, that's a case where episiotomy  might be the appropriate thing to do. And once again, that's up to a provider, but what we're talking about is the routine use of  episiotomy must be stopped. Absolutely. So lastly, I just want to touch on newborn evaluation and skin to skin contact immediately after birth. Immediate skin to skin contact should be the standard Practice, it supports breastfeeding it supports thermo regulation of the infant and it is supports the initial mother baby attachment. This is all too often babies are birth shown to their mother and then taken away to the other side of the room to be immediately evaluated. There is no good reason that you can't evaluate that baby right there in the mother's arms.

A baby is always more likely to thrive and survive and restore to its proper temperature as well if it's skin to skin on the mom and if not on the mom then I'm the partner on the father on our on the partner skin to skin well the funny thing is we take these we take these babies over to the warmer so that they can thermo regulate and stay at the appropriate temperature when really the safest best place for the baby to thermoregulate is right there on the mother's chest. It is absolutely standard of practice, especially when it comes to preterm infants. They do So much better. They have such higher success rates when they are skin to skin with the mother almost 24 seven, it's labor intensive, but the improvement in the baby's well being is so significant that it's, it's a must do. So mothers, please do not allow separation of you and your baby even if your baby needs evaluating which they all get some amount of evaluating right after birth, but even if they need resuscitation, it's possible.

Babies belong skin to skin on the mom. And if for any reason not on the mom, then skin to skin on on the Father. On the partner.

That's right. If the mother is in a position where they are unable to hold their baby, then the baby should be skin to skin with the Father. Everyone has a right to the highest standard of care in pregnancy and birth and birth choices and your birth experience matter. A lot. So in this conversation we talked about evidence based practice. And we want you to take this information to make educated, informed and empowered choices so that you may have not only an effective birth, but a safe and satisfying experience. That leaves you feeling good about your choices and at peace. If you have a birth that you feel at peace with that covers everything. What else is there? Yeah, the baby is healthy, means you're healthy. It means you feel good about how things went. you participated in your care. You had an active role in it. It makes early parenthood a lot easier because there's less emotional and mental processing to go through.

It's not to say that 100% of births are going to go the way you want that. This is nature we're talking about. But we should feel that we have a right and even a responsibility to give ourselves a chance to have our best possible birth.

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